Impact of portal vein infiltration and type of venous reconstruction in surgery for borderline resectable pancreatic cancer

BACKGROUND

The International Study Group of Pancreatic Surgery (ISGPS) recommends operative exploration and resection of pancreatic cancers in the presence of reconstructable mesentericoportal axis involvement. However, there is no consensus on the ideal method of vascular reconstruction. The effect of depth of tumour invasion of the vessel wall on outcome is also unknown.

METHODS

This was a retrospective cohort study of pancreaticoduodenectomy with vein resection for T3 adenocarcinoma of the head of the pancreas across nine centres. Outcome measures were overall survival based on the impact of the depth of tumour infiltration of the vessel wall, and morbidity, in-hospital mortality and overall survival between types of venous reconstruction: primary closure, end-to-end anastomosis and interposition graft.

RESULTS

A total of 229 patients underwent portal vein resection; 129 (56·3 per cent) underwent primary closure, 64 (27·9 per cent) had an end-to-end anastomosis and 36 (15·7 per cent) an interposition graft. There was no difference in overall morbidity (26 (20·2 per cent), 14 (22 per cent) and 9 (25 per cent) respectively; P = 0·817) or in-hospital mortality (6 (4·7 per cent), 2 (3 per cent) and 2 (6 per cent); P = 0·826) between the three groups. One hundred and six patients (47·5 per cent) had histological evidence of vein involvement; 59 (26·5 per cent) had superficial invasion (tunica adventitia) and 47 (21·1 per cent) had deep invasion (tunica media or intima). Median survival was 18·8 months for patients who had primary closure, 27·6 months for those with an end-to-end anastomosis and 13·0 months among patients with an interposition graft. There was no significant difference in median survival between patients with superficial, deep or no histological vein involvement (20·8, 21·3 and 13·3 months respectively; P = 0·111). Venous tumour infiltration was not associated with decreased overall survival on multivariable analysis.

CONCLUSION

In this study, there was no difference in morbidity between the three modes of venous reconstruction, and overall survival was similar regardless of tumour infiltration of the vein.

Major postoperative complications after pancreatic resection for P-NETS are not associated to earlier recurrence

BACKGROUND

The oncological impact of surgical complications has been studied in visceral and pancreatic cancer.

AIM

To investigate the impact of complications on tumour recurrence after resections for pancreatic neuroendocrine tumours.

METHODS

We have retrospectively analysed 105 consecutive resections performed at the Royal Free London Hospital from 1998 to 2014, and studied the long-term outcome of nil-minor (<3) versus major (≥3) Clavien-Dindo complications (CD) on disease-free (DFS) and overall survival (OS).

RESULTS

The series accounted for 41 (39%) pancreaticoduodenectomies, two (1.9%) central, 48 (45.7%) distal pancreatectomies, eight (7.6%) enucleations, four (3.8%) total pancreatectomies. Sixteen (15.2%) were extended to adjacent organs, 13 (12.3%) to minor liver resections. Postoperative complications presented in 43 (40.1%) patients; CD grade 1 or 2 in 23 (21.9%), grades ≥3 in 20 (19%). Among 25 (23.8%) pancreatic fistulas, 14 (13.3%) were grades B or C. Thirty-four (32.4%) patients developed exocrine, and 31 (29.5%) endocrine insufficiency. Seven patients died during a median 27 (0-175) months follow up. Thirty-day mortality was 0.9%. OS was 94.1% at 5 years. Thirty tumours recurred within 11.7 (0.8-141.5) months. DFS was 44% at 5 years. At univariate analysis, high-grade complications were not associated with shorter DFS (p = 0.744). At multivariate analysis, no parameter was independent predictor for DFS or OS. The comparison of nil-minor versus major complications showed no DFS difference (p = 0.253).

CONCLUSION

From our series, major complications after P-NETs resection are not associated to different disease recurrence; hence do not require different follow up or adjuvant regimens.

Outcome after pancreaticoduodenectomy for T3 adenocarcinoma: A multivariable analysis from the UK Vascular Resection for Pancreatic Cancer Study Group

BACKGROUND

Most resectable pancreatic cancers are classified as T3, including those involving the porto-mesenteric vein. Survival and perioperative morbidity for venous resection have been found to be comparable to standard resection. We investigate factors associated with short and long term outcomes in pancreaticoduodenectomy with (PDVR) and without (PD) venous resection exclusively for T3 adenocarcinoma of the head of the pancreas.

METHODS

This is a UK multicenter retrospective cohort study assessing outcomes in patients undergoing PD and PDVR. All consecutive patients with T3 only adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. Multivariable logistic and proportional hazards regression analyses were performed to determine the association between the surgical groups and in-hospital mortality (IHM) and overall survival (OS).

RESULTS

1070 patients were included of whom 840 (78.5%) had PD and 230 (21.5%) had PDVR. Factors independently associated with IHM were a high creatinine (aHR 1.14, p = 0.02), post-operative bleeding (aHR 2.86, p = 0.04) and a re-laparotomy (aHR 8.42, p = 0.0001). For OS, multivariable analyses identified R1 resection margin status (aHR 1.22, p = 0.01), N1 nodal status (aHR 1.92, p = 0.0001), perineural invasion (aHR 1.37, p = 0.002), tumour size >20mm (aHR 0.63, p = 0.0001) and a relaparotomy (aHR 1.84, p = 0.0001) to be independently associated with overall mortality.

CONCLUSION

This study on T3 adenocarcinoma of the head of the pancreas suggests that IHM is strongly associated with perioperative complications whilst OS is affected by histological parameters. Detailed pre-operative disease evaluation and advances in oncological treatment have the potential to improve OS.

Coil migration--a rare complication of endovascular exclusion of visceral artery pseudoaneurysms and aneurysms

INTRODUCTION

We describe a case of metallic, angiographic coil migration, following radiological exclusion of a gastroduodenal artery pseudoaneurysm secondary to chronic pancreatitis.

PATIENTS AND METHODS

A 55-year-old man presented to the out-patient clinic with chronic, intermittent, post-prandial, abdominal pain, associated with nausea, vomiting and weight loss. He was known to have chronic pancreatitis and liver disease secondary to alcohol abuse and previously underwent angiographic exclusion of a gastroduodenal artery pseudoaneurysm. During subsequent radiological and endoscopic investigation, an endovascular coil was discovered in the gastric pylorus, associated with ulceration and cavitation. This patient was managed conservatively and enterally fed via naso-jejunal catheter endoscopically placed past the site of the migrated coil. This patient is currently awaiting biliary bypass surgery for chronic pancreatitis, and definitive coil removal will occur concurrently.

CONCLUSIONS

Literature review reveals that this report is only the eighth to describe coil migration following embolisation of a visceral artery pseudoaneurysm or aneurysm. Endovascular embolisation of pseudoaneurysms and aneurysms is generally safe and effective. More common complications of visceral artery embolisation include rebleeding, pseudoaneurysm reformation and pancreatitis.

Review article: surgical, neo-adjuvant and adjuvant management strategies in biliary tract cancer

BACKGROUND

The majority of patients with cholangiocarcinoma present with advanced, irresectable tumours associated with poor prognosis. The incidence and mortality rates associated with cholangiocarcinoma continue to rise, mandating the development of novel strategies for early detection, improved resection and treatment of residual lesions.

AIM

To review the current evidence base for surgical, adjuvant and neo-adjuvant techniques in the management of cholangiocarcinoma.

METHODS

A search strategy incorporating PubMed/Medline search engines and utilising the key words biliary tract carcinoma; cholangiocarcinoma; management; surgery; chemotherapy; radiotherapy; photodynamic therapy; and radiofrequency ablation, in various combinations, was employed.

RESULTS

Data on neo-adjuvant and adjuvant techniques remain limited, and much of the literature concerns palliation of inoperable disease. The only opportunity for long-term survival remains surgical resection with negative pathological margins or liver transplantation, both of which remain possible in only a minority of selected patients. Neo-adjuvant and adjuvant techniques currently provide only limited success in improving survival.

CONCLUSIONS

The development of novel strategies and treatment techniques is crucial. However, the shortage of randomised controlled trials is compounded by the low feasibility of conducting adequately powered trials in liver surgery, due to the large sample sizes that are required.

Splenic injury following colonoscopy--an underdiagnosed, but soon to increase, phenomenon?

INTRODUCTION

We present a case of splenic rupture in a 71-year-old woman admitted 6 days following a diagnostic colonoscopy. She underwent an open splenectomy and made a delayed, but complete, recovery. We proceeded to perform a retrospective review of all relevant literature to assess the frequency of similar post-colonoscopy complications.

MATERIALS AND METHODS

Using relevant keywords, we identified 63 further PubMed reports of splenic injury associated with colonoscopy that were reported in English.

FINDINGS

We have described only the fourth report of splenic injury secondary to colonoscopy from a UK centre. Literature review reveals a mean age of 63 years and a female preponderance for this complication. Most patients present on the day of their colonoscopy with abdominal pain, anaemia, elevated white cell count and Kehr's sign. CT is the investigation of choice and splenectomy the definitive management of choice. Most patients make a routine recovery, with mortality rates of approximately 8%. There is likely to be an under-reporting of this complication from UK-based centres, with the majority of reports originating from Europe and US. This points to a possible under-diagnosis or under-recognition of this potentially fatal complication. The incidence of such post-colonoscopic complications may increase with the forthcoming introduction of the National Bowel Cancer Screening Programme.

The management of multi-site, bleeding, visceral artery pseudoaneurysms, secondary to necrotising pancreatitis

We present the case of a 45-year-old man, who presented to his local casualty department with severe epigastric pain following an alcohol binge, and was subsequently diagnosed with acute pancreatitis. Pancreatic necrosis with multiple collections ensued, necessitating transfer to an intensive care unit (ITU) in a tertiary hepatopancreaticobiliary centre. Initially, the patient appeared to slowly improve and was discharged to the ward, albeit following a prolonged ITU admission. However, during his subsequent recovery, he suffered multiple episodes of haematemesis and melaena associated with haemodynamic instability and requiring repeat admission to the ITU. Computerised tomographic angiography, followed by visceral angiography, was used to confirm the diagnosis of multisite visceral artery pseudoaneurysms, secondary to severe, necrotising pancreatitis. Pseudoaneurysms of the splenic, left colic and gastroduodenal arteries were sequentially, and successfully, radiologically embolised over a period of 9 days. Subsequent sequelae of radiological embolisation included a clinically insignificant splenic infarct, and a left colonic infarction associated with subsequent enterocutaneous fistula formation. The patient made a prolonged, but successful, recovery and was discharged from hospital after 260 days as an in-patient. This case illustrates the rare complication of three separate pseudoaneurysms, secondary to acute pancreatitis, successfully managed radiologically in the same patient. This case also highlights the necessity for multidisciplinary involvement in the management of pseudoaneurysms, an approach that is often most successfully achieved in a tertiary setting.

Clinical presentation and pathophysiology of meatal stenosis following circumcision

OBJECTIVE

To describe the clinical presentation and pathophysiology of meatal stenosis occurring after circumcision.

PATIENTS AND METHODS

The clinical presentation and operative findings are reported in 12 children who presented with meatal stenosis over a period of 3 years.

RESULTS

The cardinal symptoms of meatal stenosis were penile pain at the initiation of micturition (12 of 12), narrow, high velocity stream (8 of 12) and the need to sit or stand back from the toilet bowl to urinate (6 of 12). Following surgical correction with meatotomy there was no recurrence of stenosis after a mean follow-up of 13 months. Traumatic meatitis of the unprotected post-circumcision urethral meatus and/or meatal ischaemia following damage to the frenular artery at circumcision are suggested as possible causes of meatal stenosis.

CONCLUSION

Preservation of the frenular artery at circumcision, or the use of an alternative procedure (preputial plasty), may be advisable when foreskin surgery is required, to avoid meatal stenosis after circumcision.