Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols

BACKGROUND

Pancreaticoduodenectomy (PD) is a technically complex operation, with a relatively high risk for complications. The ability to rescue patients from post-PD complications is as a recognized quality measure. Tailored protocols were instituted at our low volume facility in the year 2013.

AIM

To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.

METHODS

A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1, 2013 and June 30, 2023. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications, and the modified Clavien-Dindo classification was used to classify post-PD complications.

RESULTS

Over the study period, 113 patients at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56) underwent PDs at this facility. Major complications were recorded in 33 (29.2%) patients at a mean age of 53.8 years (SD: ± 7.9). Twenty-nine (87.9%) patients who experienced major morbidity were salvaged after aggressive treatment of their complication. Four (3.5%) died from bleeding pseudoaneurysm (1), septic shock secondary to a bile leak (1), anastomotic leak (1), and myocardial infarction (1). There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024).

CONCLUSION

This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD. Despite low volumes at our facility, we demonstrated that 87.9% of patients were rescued from major complications. We attributed this to several factors including development of rescue protocols, the competence of the pancreatic surgery teams and continuous, and adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.

A pilot randomized controlled trial comparing THUNDERBEAT to the Maryland LigaSure energy device in laparoscopic left colon surgery

BACKGROUND

The THUNDERBEAT is a multi-functional energy device which delivers both ultrasonic and bipolar energy, but there are no randomized trials which can provide more rigorous evaluation of the clinical performance of THUNDERBEAT compared to other energy-based devices in colorectal surgery. The aim of this study was to compare the clinical performance of THUNDERBEAT energy device to Maryland LigaSure in patients undergoing left laparoscopic colectomy.

METHODS

Prospective randomized trial with two groups: Group 1 THUNDERBEAT and Group 2 LigaSure in a single university hospital. 60 Subjects, male and female, of age 18 years and above undergoing left colectomy for cancer or diverticulitis were included. The primary outcome was dissection time to specimen removal (DTSR) measured in minutes from the start of colon mobilization to specimen removal from the abdominal cavity. Versatility (composite of five variables) was measured by a score system from 1 to 5 (1 being worst and 5 the best), and adjusted/weighted by coefficient of importance with distribution of the importance as follow: hemostasis 0.275, sealing 0.275, cutting 0.2, dissection 0.15, and tissue manipulation 0.1. Other variables were: dryness of surgical field, intraoperative and postoperative complications, and mortality. Follow-up time was 30 days.

RESULTS

60 Patients completed surgery, 31 in Group 1 and 29 in Group 2. There was no difference in the DTSR between the groups, 91 min vs. 77 min (p = 0.214). THUNDERBEAT showed significantly higher score in dissecting and tissue manipulation in segment 3 (omental dissection), and in overall versatility score (p = 0.007) as well as versatility score in Segment 2 (retroperitoneal dissection p = 0.040) and Segment 3 (p = 0.040). No other differences were noted between the groups.

CONCLUSIONS

Both energy devices can be employed effectively and safely in dividing soft tissue and sealing mesenteric blood vessels during laparoscopic left colon surgery, with THUNDERBEAT demonstrating some advantages over LigaSure during omental dissection and tissue manipulation.

CLINICALTRIAL

gov # NCT02628093.

Evidence Map of Pancreatic Surgery-A living systematic review with meta-analyses by the International Study Group of Pancreatic Surgery (ISGPS)

BACKGROUND

Pancreatic surgery is associated with considerable morbidity and, consequently, offers a large and complex field for research. To prioritize relevant future scientific projects, it is of utmost importance to identify existing evidence and uncover research gaps. Thus, the aim of this project was to create a systematic and living Evidence Map of Pancreatic Surgery.

METHODS

PubMed, the Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for all randomized controlled trials and systematic reviews on pancreatic surgery. Outcomes from every existing randomized controlled trial were extracted, and trial quality was assessed. Systematic reviews were used to identify an absence of randomized controlled trials. Randomized controlled trials and systematic reviews on identical subjects were grouped according to research topics. A web-based evidence map modeled after a mind map was created to visualize existing evidence. Meta-analyses of specific outcomes of pancreatic surgery were performed for all research topics with more than 3 randomized controlled trials. For partial pancreatoduodenectomy and distal pancreatectomy, pooled benchmarks for outcomes were calculated with a 99% confidence interval. The evidence map undergoes regular updates.

RESULTS

Out of 30,860 articles reviewed, 328 randomized controlled trials on 35,600 patients and 332 systematic reviews were included and grouped into 76 research topics. Most randomized controlled trials were from Europe (46%) and most systematic reviews were from Asia (51%). A living meta-analysis of 21 out of 76 research topics (28%) was performed and included in the web-based evidence map. Evidence gaps were identified in 11 out of 76 research topics (14%). The benchmark for mortality was 2% (99% confidence interval: 1%-2%) for partial pancreatoduodenectomy and <1% (99% confidence interval: 0%-1%) for distal pancreatectomy. The benchmark for overall complications was 53% (99%confidence interval: 46%-61%) for partial pancreatoduodenectomy and 59% (99% confidence interval: 44%-80%) for distal pancreatectomy.

CONCLUSION

The International Study Group of Pancreatic Surgery Evidence Map of Pancreatic Surgery, which is freely accessible via www.evidencemap.surgery and as a mobile phone app, provides a regularly updated overview of the available literature displayed in an intuitive fashion. Clinical decision making and evidence-based patient information are supported by the primary data provided, as well as by living meta-analyses. Researchers can use the systematic literature search and processed data for their own projects, and funding bodies can base their research priorities on evidence gaps that the map uncovers.

Different types of pancreatico-enteric anastomosis

The pancreatico-enteric anastomosis has widely been regarded as the 'Achilles heel' of the modern day, single-stage, pancreatoduodenectomy (PD). A review of the literature was carried out to address the evolution of the pancreatico-enteric anastomosis following PD, the spectrum of anastomoses performed around the world, and finally present the current evidence in support of each anastomosis. Pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are the most common forms of pancreatico-enteric reconstruction following PD. There is no difference in postoperative pancreatic fistula (POPF) rates between PG and PJ, as well as individual variations, except in a high-risk anastomosis where performance of a PJ may be preferred. The routine use of glue, trans-anastomotic stents or omental wrapping is of no proven benefit. Externalised trans-anastomotic stents may have a role in mitigating the risk of a clinically relevant POPF in high-risk anastomoses. Pancreatico-enteric anastomosis is an important component of reconstruction following PD even though it is fraught with the risk of development of a POPF. Adherence to the tenets of anastomotic reconstruction and performance of a safe and reproducible anastomosis with a low clinically-relevant POPF rate remain the mainstay of achieving the best outcomes. Appropriate selection and opportune use of fistula mitigation strategies may help provide optimal outcomes when faced with the need to perform a high-risk pancreatico-enteric anastomosis.

Systematic Video Documentation in Laparoscopic Colon Surgery Using a Checklist: A Feasibility and Compliance Pilot Study

BACKGROUND

High-quality images can be readily captured during laparoscopic colon surgery, but there are no guidelines for documentation of these video data or how to best measure surgical quality from an operative video. This study evaluates the feasibility and compliance in documenting key steps during laparoscopic right hemicolectomy and sigmoid colectomy.

MATERIALS AND METHODS

A retrospective review of previously recorded videos of patients undergoing laparoscopic right hemicolectomy or sigmoid colectomy from September to December 2011 in a single institution was performed. Patients' demographics, intraoperative features, postoperative complications, and variables for video recording and editing were collected. Compliance of key surgical steps was assessed using a checklist by two independent surgeons.

RESULTS

Sixteen laparoscopic operations (seven right hemicolectomies and nine sigmoid colectomies) were recorded. Twelve (75%) were laparoscopic-assisted, and four (25%) were hand-assisted laparoscopic operations. Compliance with key surgical steps in laparoscopic right hemicolectomy and sigmoid colectomy was demonstrated in the majority of patients, with steps ranging in compliance from 42.9% to 100% and from 77.8% to 100%, respectively. The edited video had a median duration of 3 minutes 47 seconds (range, 1 minute 44 seconds-5 minutes 38 seconds) with a production time of nearly 1 hour and a resolution of 1440 × 1080 pixels.

CONCLUSIONS

Key surgical steps during laparoscopic right hemicolectomy and sigmoid colectomy can be documented and edited into a short representative video. Standardization of this process should allow video documentation to improve quality in laparoscopic colon surgery.

The impact of hereditary colorectal cancer on the Indian population

INTRODUTION

The incidence of colorectal cancer in India is lower compared to the Western world. In Western countries, most cases of colorectal cancer are sporadic and the hereditary variety accounts for only 10-15% of all cases. The aim of the present review is to determine the clinical and epidemiological characteristics of hereditary colorectal cancer in India.

MATERIALS AND METHODS

A Medline search was conducted to review the literature published from India regarding colorectal cancer. The keywords used included India, colorectal cancer, hereditary nonpolyposis, and familial adenomatous polyposis. All relevant articles were reviewed and the characteristic features of this disease in Indian population were collated and presented.

RESULTS

Literature search revealed eighty two articles pertinent to India, of which only ten articles had relevant information on hereditary cancers. Although the overall incidence of colorectal cancer was low in both genders, there were a high proportion of patients developing colorectal cancer before the age of 45 years. Additionally, there was a higher proportion (10-15%) of hereditary nonpolyposis colorectal cancer cases, as confirmed by microsatellite instability.

CONCLUSION

The overall incidence of colorectal cancer is low in India. There is a tendency to affect a relatively younger age group, and we infer that the incidence of hereditary colorectal cancer is high and is similar to the Western countries.

Feasibility and Safety of Laparoscopic Colon Surgery Performed Under Intravenous Sedation and Local Anesthesia Using Microinvasive (<3 mm) Instruments: An Acute and Survival Study on Porcine Model

PURPOSE

The purpose of the study was to evaluate the feasibility and safety of performing laparoscopic intestinal surgery using local anesthesia and intravenous sedation with instruments <3 mm in diameter.

METHODS

Porcine model with acute (n = 2) and the survival studies (n = 8): all female pigs, weight (median 36.4 kg, range 33.2-38.4 kg). Surgeries were performed using only intravenous sedation with ketamine-midazolam and local anesthetic infiltration at the sites of trocar insertion, with airway protection. CO2 pneumoperitoneum was maintained using pressure of 3 to 5 mm Hg. Commercially available instruments, sizes <3 mm in diameter were used. Surgical steps were as follows: (a) exploration of all quadrants of the abdomen and pelvis, (b) "running" the entire length of small bowel, (c) dissection of bowel attachments to the peritoneal sidewall, and (d) creating a 2.5 cm enterotomy in the colon and suture repair of this defect.

RESULTS

All 10 surgeries were completed successfully. Animals tolerated the procedure well, with no requirement of intubation. There were no decrements in vital signs during pneumoperitoneum or surgery. Despite spontaneous respiration movements, all planned surgical maneuvers were feasible. The median length of operations was 74 minutes (range 56-165 minutes). All survival animals had an uneventful recovery; there were no infectious complications, oral intake and bowel function returned within 24 hours.

CONCLUSIONS

It appears feasible and safe to perform simple laparoscopic intestinal procedures using instruments <3 mm in diameter and low CO2 insufflation pressure under local anesthesia and intravenous sedation. This methodology holds promise in the development of new approaches to intestinal surgery and disease diagnosis.

The influence of obesity on short- and long-term outcomes after laparoscopic surgery for colon cancer: a case-matched study of 152 patients

BACKGROUND

Despite the increasing prevalence of obesity and colonic diseases, the impact of obesity on short-term and oncologic outcomes of laparoscopic colorectal surgery still remains unclear.

STUDY DESIGN

Seventy-six consecutive obese patients with body mass index (BMI) ≥30 kg/m(2) who underwent laparoscopic colectomy were matched with 76 nonobese patients with BMI <30 kg/m(2). Perioperative parameters and oncologic outcomes were analyzed in the two groups.

RESULTS

Obesity was associated with greater operative time (obese vs nonobese, 182 ± 59 vs 157 ± 55 min, P = .0084) and multivariate analysis identified BMI (hazard ratio 2.11, 95% confidence interval 0.64-3.56, P = .0049) as an independent predicting factor for operative time together with cancer location (hazard ratio 28.6, 95% confidence interval 14.62-42.51, P < .0001). Obesity had no adverse influence on overall morbidity (25 vs 21%, P = .563), however, or postoperative duration of stay (median 6.0 vs 5.5 days, P = .22). Furthermore, the rate of conversion to open procedure was similar between the two groups (9 vs 9%, P > .99). Regarding oncologic outcomes, there was no statistical difference in overall and disease-free survival between the two groups (5-year overall survival rate 86 vs 89%, P = .72, 5-year disease survival rate 70 vs 77%, P = .70).

CONCLUSION

Laparoscopic colonic resection, when performed for selected patients, appears to be a safe and reasonable option in obese patients with colon cancer resulting in similar short-term and oncologic outcomes as nonobese patients.

Experience of a specialist centre in the management of anastomotic sinus following leaks after low rectal or ileal pouch-anal anastomosis with diverting stoma

AIM

The natural history and appropriate management of anastomotic sinus has not been clearly defined. The aim of this study was to evaluate the incidence, management and outcomes of anastomotic sinus.

METHOD

The medical records of all patients who underwent a low anterior resection (LAR) or an ileal pouch-anal anastomosis (IPAA) with a diverting loop ileostomy (LI) and with contrast enema performed before planned stoma closure between 2001 and 2011 were retrospectively reviewed. The radiological features of the sinus tract, treatment and outcome of anastomotic sinus were studied.

RESULTS

Twenty patients (8.2%) were found to have anastomotic sinuses out of the total of 244 patients who had undergone LAR (n = 146) or IPAA (n = 98) with LI. Of these, 13 (65%) had prior symptomatic leaks, while seven did not. Twelve patients (60%) were found to have simple sinus tracts, while eight had complex sinuses (associated with either pelvic cavities or severe strictures). Five patients with simple tracts were treated with observation alone. Fifteen patients underwent surgical interventions. Overall, with a median follow-up of 28 (6-73) months, 16 patients (80%) had resolution of their sinuses. All of 12 patients (100%) with simple sinus tracts and four of eight patients (50%) with complex sinuses underwent successful stoma reversals after 8 (3.5-24) months following the initial surgery (P = 0.01).

CONCLUSION

Patients with simple tracts are significantly more likely to have complete resolution of sinuses than patients with complex sinuses. Persistent sinus associated with either a pelvic cavity or severe stricture despite surgical intervention is likely to lead to a permanent stoma.

Identifying specific surgical tools and methods for laparoscopic colorectal operations in obese patients

OBJECTIVE

Laparoscopic operations for obese patients remain challenging due to technical difficulties at operation as well as higher comorbidities and high risk of postoperative complications. The aim of this study is to identify specific surgical tools and methods for laparoscopic colorectal operations for obese patients, applying knowledge of previous literature as well as our expertise in both laparoscopic and bariatric operations.

CONCLUSIONS

Current knowledge of bariatric surgery is invaluable in establishing a "customized" approach for laparoscopic colorectal operations in obese patients. The instruments routinely used during surgery on patients with normal body mass index (BMI) should often be modified and substituted according to the patient's BMI. We believe such an approach will prove beneficial to surgeons performing laparoscopic operations on obese patients.

Evolution of pancreatoduodenectomy in a tertiary cancer center in India: improved results from service reconfiguration

BACKGROUND

Pancreatic cancer incidence in India is low. Over the years, refinements in technique of pancreatoduodenectomy (PD) may have improved outcomes. No data is available from India, South-Central, or South West Asia to assess the impact of these refinements.

PURPOSE

To assess the impact of service reconfiguration and standardized protocols on outcomes of PD in a tertiary cancer center in India.

METHODS

Three specific time periods marking major shifts in practice and performance of PD were identified, viz. periods A (1992-2001; pancreaticogastrostomy predominantly performed), B (2003-July 2009; standardization of pancreaticojejunal anastomosis), and C (August 2009-December 2011; introduction of neoadjuvant chemo-radiotherapy and increased surgical volume).

RESULTS

500 PDs were performed with a morbidity and mortality rate of 33% and 5.4%, respectively. Over the three periods, volume of cases/year significantly increased from 16 to 60 (p < 0.0001). Overall incidence of post-operative pancreatic anastomotic leak/fistula (POPF), hemorrhage, delayed gastric emptying (DGE), and bile leak was 11%, 6%, 3.4%, and 3.2%, respectively. The overall morbidity rates, as well as, the above individual complications significantly reduced from period A to B (p < 0.01) with no statistical difference between periods B and C.

CONCLUSION

Evolution of practice and perioperative management of PD for pancreatic cancer at our center improved perioperative outcomes and helped sustain the improvements despite increasing surgical volume. By adopting standardized practices and gradually improving experience, countries with low incidence of pancreatic cancer and resource constraints can achieve outcomes comparable to high-incidence, developed nations.

SYNOPSIS

The manuscript represents the largest series on perioperative outcomes for pancreatoduodenectomy from South West and South-Central Asia - a region with a low incidence of pancreatic cancer and a disproportionate distribution of resources highlighting the impact of high volumes, standardization and service reconfiguration.

Complications as indicators of quality assurance after 401 consecutive colorectal cancer resections: the importance of surgeon volume in developing colorectal cancer units in India

BACKGROUND

The low incidence of colorectal cancer in India, coupled with absence of specialized units, contribute to lack of relevant data arising from the subcontinent. We evaluated the data of the senior author to better define the requirements that would enable development of specialized units in a country where colorectal cancer burden is increasing.

METHODS

We retrospectively analyzed data of 401 consecutive colorectal resections from a prospective database of the senior author. In addition to patient demographics and types of resections, perioperative data like intraoperative blood loss, duration of surgery, complications, re-operation rates and hospital stay were recorded and analyzed.

RESULTS

The median age was 52 years (10-86 years). 279 were males and 122 were females. The average duration of surgery was 220.32 minutes (range 50-480 min). The overall complication rate was 12.2% (49/401) with a 1.2% (5/401) mortality rate. The patients having complications had an increase in their median hospital stay (from 10.5 days to 23.4 days) and the re-operation rate in them was 51%. The major complications were anastomotic leaks (2.5%) and stoma related complications (2.7%).

CONCLUSIONS

This largest ever series from India compares favorably with global standards. In a nation where colorectal cancer is on the rise, it is imperative that high volume centers develop specialized units to train future specialist colorectal surgeons. This would ensure improved quality assurance and delivery of health care even to outreach, low volume centers.

Managing leaks following anterior resections: a new classification system

BACKGROUND/AIMS

Anastomotic leak rates following rectal resections and anastomosis stand at 2.9-15.3%, with an attendant mortality rate of 6- 39.3%. The aim of our study was to identify those patients who had developed an anastomotic leak, and evaluate the indications for re-exploration as well as study the impact of covering colostomies on the subsequent outcome.

METHODOLOGY

We analyzed 266 consecutive anterior resections for rectal cancer performed at a single institution between 1st September 2002 and 31st December 2006.

RESULTS

Twenty-one anastomotic leaks were encountered in 266 resections. Covering colostomies were performed in 56% (151/266) of the patients. Out of the 21 patients who developed a leak, 9 had a covering colostomy (42.8%). In this group, 3 of patients (33%) could be managed without surgical re-exploration, while all the 12 patients without a covering colostomy had to undergo a reexploration. With our new classification system for anastomotic dehiscence, the clinical decisions appear to follow a predictable pattern. There were 4 deaths (1.5%). However, the mortality rate in the patients undergoing surgical re-exploration for complications was 16.6% (3/18).

CONCLUSIONS

This large study provides an insight into the potential advantages of covering colostomies wherever indicated following anterior resections. With our new and effective classification system for clinical leaks, the management road map can be simplified and standardized.

Sentinel lymph node biopsy in gastrointestinal malignancies-where do we stand?

Sentinel lymph nodes (SLNs) are the nodes in direct communication with the primary tumor and are therefore the first group of nodes to be involved in lymphatic metastasis. Though the role of SLN biopsy is well established in cancers of the breast and melanoma, its role in gastrointestinal malignancies is still evolving and controversial. In this paper, the literature is reviewed with respect to the status of SLN biopsy in gastrointestinal malignancies.

Laparoscopic surgery for colorectal cancers: Current status

Laparoscopy was introduced more than 15 years ago into clinical practice. However, its role in colorectal surgery was not well established for want of better skills and technology. This coupled with high incidences of port site recurrences, prevented laparoscopic surgery from being incorporated into mainstream colorectal cancer surgery. A recent increase in the number of reports, retrospective analyses, randomized trials and multicentric trials has now provided sufficient data to support the role of laparoscopy in colorectal cancer surgery. We, thus, present a review of the published data on the feasibility, safety, short - and long-term outcomes following laparoscopic surgery for colorectal cancers. While the data available strongly favors the use of laparoscopic surgery in colonic cancer, larger well powered studies are required to prove or disprove its role in rectal cancer.

Laparoscopy in pancreatic tumors

Recently, increasing number of manuscripts - original articles and case reports have attempted to provide evidence of the forays of minimal access surgery into pancreatic diseases. Many, based on the lack of Level I evidence, still believe that laparoscopy in pancreatic surgery is experimental. This article attempts to look into data exploring the existing use of minimally invasive surgery in pancreatic disease to answer a vital question - what does the evidence say on the current status of laparoscopic surgery in pancreatic tumors.

Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes

PURPOSE

During pancreatoduodenectomy (PD), two techniques have been described to dissect the head of pancreas, viz. the superior mesenteric artery (SMA) approach by dissecting the uncinate process and the uncinate process first approach.

METHODS

Forty-four consecutive patients, who underwent PD between June 2009 and April 2010, were analyzed. Thirty patients underwent the SMA first approach along with uncinate dissection (group 1), while 14 patients underwent the uncinate process first approach (group 2).

RESULTS

There were 30 male and 14 female patients. The median age was 51 years (range 19-76 years). Median intraoperative blood loss in group 1 was 800 ml, while that in group 2 was 600 ml. A mean of 0.52 units of blood were transfused in group 1 (range 0-3) compared to 0.2 units in group 2 (range 0-1). The median operative time in group 1 was 457.5 min and the median operative time was 450 min in group 2. Complication rate was 40% and 14.3% in groups 1 and 2, respectively. Median duration of hospital stay was 14 days in group 1 and 12.5 days in group 2. Median nodes resected in group 1 were 8 (range 0-26), while in group 2 they were 9 (range 2-14). Resection margins were positive in two cases (one in each group). There were two mortalities in group 1 and no mortalities in group 2. None of the above differences were significant.

CONCLUSIONS

SMA first is a safe technique. It compares well with the uncinate first approach in terms of operative time, blood loss, number of lymph nodes retrieved, margin positivity and operative morbidity. Both techniques may be useful in situations such as a large uncinate process tumor or when superior mesenteric vein/portal vein/superior mesenteric artery involvement is suspected or present. Further studies, evaluating data related to specific predefined uncinate tumors, would be the next logical step in further defining the precise role of these techniques.

Endoscopic fixation of the rectum for rectal prolapse: a feasibility and survival experimental study

BACKGROUND

In recent years, there has been considerable interest in developing technology as well as techniques that could widen the therapeutic horizons of endoscopy. Rectal prolapse, a benign localized condition causing considerable morbidity, could be an excellent focus for new endoscopic therapies. The aim of this study was to assess the feasibility and safety of endoluminal fixation of the rectum to the anterior abdominal wall, after pushing it up inside the body, using an in vivo animal model.

METHODS

We performed an in vivo comparative surgical study in a porcine model, including laparoscopic mobilization of the rectum and posterior rectopexy (standard surgical method) or endoluminal tacking of the rectum. After proving feasibility in ex vivo and acute studies, we performed a survival study to evaluate the safety of endoluminal tacking of the mobilized rectum to the anterior abdominal wall. The main outcome measures were successful completion of the tasks, maintenance of the fixation, complications associated with the methods, and survival studies including histopathological examinations of the fixation sites.

RESULTS

There were two groups: laparoscopic rectopexy (8 animals) and endoluminal fixation of the rectum to the anterior abdominal wall (10 animals). There were no differences between these two groups in their postoperative recovery. The group with the endoluminal fixation was found to have adequate attachment of the rectum to the anterior abdominal wall (measured attachment pressure in the endoluminal group = 6.06 ± 0.52 ft-lb, in the control group = 4.86 ± 2.00 ft-lb) on both gross and microscopic evaluation.

CONCLUSION

Endoscopic fixation of the mobilized rectum is feasible and safe in this model and in the future may provide an effective alternative to current treatment options for rectal prolapse.

Evaluating the vascularity of intestinal anastomoses--can narrow band imaging play a role?

A variety of factors are critical for the success of bowel anastomoses. The most crucial patient factor is adequate vascularity of the bowel ends which are to be anastomosed. Currently, intraoperative features such as healthy looking bleeding edges of the bowel are considered to be signs of adequate vascular supply. However, once the anastomosis is performed, external appearances may not be reliable. In order to improve evaluation of the bowel as well as the anastomosis, our group has adopted the routine use of post-anastomosis intraoperative colonoscopy. Intraoperative colonoscopy provides vital information regarding the integrity of the anastomosis (leak testing) and also visualizes the mucosa of the bowel. Narrow Band Imaging (NBI) is a novel real-time imaging technique which is an integral component of many modern colonoscopes. We hypothesize that NBI assessment of vascularity at the time of intestinal anastomosis can improve safety and reduce the risks of anastomotic complications following surgery.

Letter 1: Randomized clinical trial of laparoscopic versus open left colonic resection (Br J Surg 2010; 97: 1180-1186)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

Does pancreatic ductal anatomy play a role in determining outcomes of pancreatic anastomoses?

Pancreatoduodenectomy (PD) is the surgical procedure performed for cancers of the head of the pancreas. Despite a substantial reduction in mortality rates following PD, morbidity remains high secondary to major post-operative complications. Post-operative pancreatic fistula (POPF), the commonest major complication following PD, results from the failure of the pancreato-enteric anastomosis. There appears to be a correlation between intrinsic pancreatic features like the texture of the gland and duct size and the outcome of the pancreatic anastomosis. Based on current clinical research data, we propose a new hypothesis called the "pancreatic ductal anatomy" concept. We hypothesize that morphological variations, anomalies or aberrations of the main pancreatic duct play a role in the outcome of the pancreatic anastomosis, irrespective of its type. The consequence of aberrant ductal anatomy is that certain areas of the remnant pancreas remain either undrained or partially drained, or have blocked ductules/ducts. This results in localized obstructive pancreatitis causing an inflammatory reaction which jeopardizes the anastomosis. We also propose two maneuvers which could possibly play a role in predicting potential problems and also planning the surgical resection and reconstruction in order to reduce the incidence of POPF. The first modality is the use of pre-operative magnetic resonance imaging (MRI) of the pancreatic duct, and the second maneuver is the gentle cannulation test of the pancreatic duct with a soft, narrow tube following transection of the pancreatic neck. These factors would alert the surgeon about potential ductal variations and could facilitate the surgical approach.

The vascular stapler in uncinate process division during pancreaticoduodenectomy: technical considerations and results

BACKGROUND

Few studies describing the use of stapling devices for uncinate process division during pancreaticoduodenectomy (PD) have data regarding outcomes. Our aim is to discuss our technique and the peri-operative outcomes with the use of the linear vascular stapler for division of the uncinate process during PD.

MATERIALS AND METHODS

19 consecutive patients who underwent stapler division of the uncinate process ('stapler' group) were compared to 20 consecutive patients operated without stapler ('no-stapler' group).

RESULTS

The overall surgical morbidity in the no-stapler group was 25% (5/20) and 31.6% (6/19) in the stapler group (p = 0.731). The mean blood loss in the no-stapler group was 1,077.5 +/- 594 ml compared to 778 +/- 302 ml in the stapler group (p = 0.113). The mean operative duration was 498 +/- 105 min in the no-stapler group and 490 +/- 60 min in the stapler group (p = 0.773). The average number of lymph nodes retrieved was 6.1 +/- 3 in the no-stapler group versus 5.9 +/- 4 in the stapler group (p = 0.627). Neither group had positive resection margins.

CONCLUSION

Stapler division of the uncinate process for selected periampullary tumours compares well with the conventional method, has comparable peri-operative outcomes without compromising oncological radicality and has the potential to simplify uncinate resection.

Hormones and gallbladder cancer in women

Epidemiological evidence suggests that the incidence of gallstone disease and gallbladder cancer is higher in women. We analyzed the literature on estrogen and progesterone receptor expression in gallbladder cancer in women. A systematic search was done using Medline, Embase, and Cochrane Central Register of Controlled Trials for the years 1983-2009. The search terms used included 'gallbladder', 'gallstone', 'oestrogen/estrogen', 'progesterone', 'cancer', 'cholelithiasis', 'hormone,' and 'motility'. Hormone receptor expression in gallbladder cancer was analyzed in 11 studies of which immunohistochemistry was used in 10 and enzyme immunoassay in one study. Sample sizes varied 141. Estrogen and/or progesterone receptor expression was detectable in gallbladder cancer tissue samples in nine studies, whereas four studies failed to confirm these findings. The data on the association of hormone receptor expression to tumor differentiation is contradictory and needs further evaluation.

Systematic review: should routine resection of the extra-hepatic bile duct be performed in gallbladder cancer?

BACKGROUND/AIM

Complete surgical resection is associated with improved outcomes in gallbladder cancer. Whether the extra-hepatic bile duct (EHBD) should be routinely excised for gallbladder cancer is unclear.

OBJECTIVE

To analyze literature concerning EHBD excision to determine if it is associated with survival advantage and hence can be routinely recommended.

MATERIALS AND METHODS

A systematic search using Medline, Embase, and Cochrane Central Register of Controlled Trials for the years 1988-2008.

RESULTS

EHBD excision was reported to be performed routinely for T1-4 in some studies, while others reported resection to facilitate lymph node clearance or if the EHBD was grossly involved by disease that remained otherwise resectable. While one study demonstrated 100% survival in T1 disease, other reports do not demonstrate any survival benefit of EHBD excision in T1 disease. Four studies (level IV-V) demonstrated 60% to 90% five-year survival for routine excision in T2 disease, while three other studies demonstrated no survival advantage but increased morbidity due to the procedure. In T3/4 disease, one study (level IV-V) demonstrated a benefit in T4 disease only, and another study (level IV-V) reported a survival advantage in patients in whom the bile duct was not involved; five other studies showed no impact of routine EHBD excision on survival but reported morbidity following anastomotic leaks.

CONCLUSIONS

Available evidence does not support routine resection of EHBD in gallbladder cancer. EHBD excision should be performed in the presence of specific indications, viz., to achieve an R0 resection of the primary tumor and/ or to aid complete lymph node dissection that would compromise the EHBD by devascularization.

Surgery for malignant liver tumors

Recent decades have witnessed an increase in liver resections. There is a need for an update on factors related to the management of liver tumors in view of newer published data. A systematic search using Medline, Embase, and Cochrane Central Register of Controlled Trials for the years 1983-2008 was performed. The IHPBA classification provides a suitable nomenclature of liver resections. While one randomized trial has provided an objective time of 30 min as optimal for intermittent pedicle occlusion, another randomized study has demonstrated the feasibility of performing liver resections without pedicle clamping. A randomized trial has demonstrated the benefit of clamp crushing over newer techniques of liver transection. Cohort studies support anatomical resections when feasible in terms of outcomes. Nonrandomized studies also support nonanatomical and ablative therapies in patients with cirrhosis and small remnant livers. A randomized trial has shown comparable long-term outcomes of radiofrequency ablation (RFA) and surgery for tumors < 5 cm. No randomized trials comparing laparoscopy and open surgery exist. Surgery remains an important treatment modality for malignant hepatic neoplasms. While anatomical resections provide improved survival, the choice of nonanatomical versus anatomical resections should be individualized taking into account factors such as cirrhosis and function of the liver remnant. A clear margin of resection is essential in all surgically resected cases. RFA is emerging as a useful, often complimentary tool, to surgery when dealing with complex tumors or tumors in patients with a poor liver function. Laparoscopic ultrasonography is useful in staging and performance of RFA.

Tumors of the Pancreatic Body and Tail

Tumors of the pancreatic body and tail are uncommon. They have a propensity to present late and often attain a large size with local invasion before they produce any clinical symptoms. The current review aims at comprehensively analysing these tumors with respect to their pathology, presentation, the investigation of these tumors, and finally the latest trends in their surgical and medical management.

A cystic hepatic lesion: when to worry?

A 16-year old female presented to hospital with abdominal pain. Features on computed tomography raised the possibility of biliary cystadenoma or cystadenocarcinoma. She underwent a liver resection, and histopathology confirmed a serous biliary cystadenoma. This case is presented to highlight the radiological features of this uncommon pre-malignant condition as well as to summarize a management algorithm for cystic liver lesions.

Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study

BACKGROUND

There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres.

MATERIALS AND METHODS

Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India.

RESULTS

Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9-54). The median number of PDs per surgeon per year was 16 (range 7-38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2-5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3-32.2%), and the median post-operative duration of hospital stay was 16 days (range 4-100 days).

CONCLUSIONS

This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.

Vascular anomalies encountered during pancreatoduodenectomy: do they influence outcomes?

BACKGROUND

Because of the potential risk of hemorrhage or ischemia, the presence of vascular anomalies adds to the surgical challenge in pancreatoduodenectomy (PD).

OBJECTIVE

To analyze the literature concerning the influence of aberrant peripancreatic arterial anatomy on outcomes of PD.

MATERIALS AND METHODS

A systematic search using Medline and Embase for the years 1950-2008.

RESULTS

The most common aberration in hepatic arterial anatomy is the replaced right hepatic artery. Other vascular abnormalities such as replaced common hepatic artery with a hepatomesenteric trunk and celiomesenteric trunk and arcuate ligament syndrome leading to celiac artery stenosis are also associated with post-PD complications. Damage to the biliary branches of the hepatic arteries increases the risk of postoperative biliary anastomotic leak.

CONCLUSION

The most common abnormalities of the hepatic vasculature include a replaced RHA, replaced LHA, and accessory RHA or LHA. Celiac artery stenosis secondary to median arcuate ligament compression may also be encountered. Every attempt should be made to preserve the aberrant vessel unless their resection is oncologically indicated. Routine preoperative computerized tomography angiography helps to identify the hepatic vascular anatomy and thereby prepares the surgeon to better deal with the vascular anomalies intraoperatively. Increased awareness of the vascular anatomy would decrease the chances of intraoperative vascular injury and consequent postoperative complications such as biliary anastomotic leaks as well as the chances of postoperative hemorrhage.

Small intestinal tumours

Small bowel neoplasms continue to be an enigma to the clinicians. The insidious onset, the subtlety of the signs, the lack of definitive pre-operative diagnostic tests with often variable efficacies makes them difficult to diagnose. Small bowel consciousness is crucial in diagnosing and treating these tumours. This review aims to increase awareness of small bowel tumours in terms of epidemiology, diagnosis and treatment.