Postoperative pancreatic fistula after pancreatic resection

BACKGROUND

The failure of pancreatic anastomosis after the proximal pancreaticoduodenectomy (PD) and the failure of pancreatic stump after the distal pancreatectomy with a resulting postoperative pancreatic fistula remain the most feared complications after pancreatic resection. Surgeons have been trying to find a reliable reconstructive technique of pancreatic anastomosis for decades.

METHODS

A literature search was performed to January 2020. Studies giving a detailed description of the pancreatic anastomosis after open PD and pancreatic stump closure techniques after the distal pancreatectomy were included. The aim of this study was review reported data derived from meta-analyses concerning the incidence of POPF according to the International Study Group of Pancreatic Surgery. A comparison of various surgical techniques and their impact on POPF incidence was made.

RESULTS

In the group of clinically relevant POPF (CR- POPF), a well established difference between the patients undergoing POPF-associated interventional drainage or reoperation was observed. Meta-analyses showed that the patients with CR- POPF were statistically more likely to have a small duct size, soft gland texture, particular pancreatic neoplasms and an excessive intraoperative blood loss.

CONCLUSION

Grade C POPF following PD, although uncommon, occurs with a defined incidence and is associated with a substantial morbidity, prolonged hospitalization, delayed recovery and a significant mortality. According to the results of various meta-analyses, pancreatogastrostomy and pancreatojejunostomy seemed to be comparable anastomotic techniques following PD (Ref. 54).

Ampullary cancer in a patient with familial adenomatous polyposis - a rare case report and current status of management

Familial adenomatous polyposis (FAP) is an inherited autosomal dominant disorder. Extracolonic manifestations are seen quite often. As prophylactic colectomy has become a standard care in FAP patients, the concerns over the development of associated extracolonic malignancies have become more prevalent. The authors report a case of a patient with the history of subtotal colectomy because of FAP with the development of adenocarcinoma of papilla of Vater twenty-six years later. A radical procedure in form of proximal pancreaticoduodenectomy was indicated. Variable endoscopic surveillance protocols and treatment strategies have been proposed concerning the management of duodenal and periampullary lesions. In case of periampullary malignancies, the radical surgical resection offers the only chance for cure and the only option that may safeguard the long‑term survival (Fig. 2, Ref. 30). Keywords: ampulla of Vater, bile duct, obstructive jaundice, pancreatoduodenectomy, periampullary tumors.

Gastric cancer with liver metastasis

Surgical treatment of gastric cancer with liver metastasis (GCLM) is currently a frequent topic of discussion at professional surgical symposia. There is a low number of patients and a lack of large clinical multi-center studies describing the benefits of this treatment approach. The article describes a patient with GCLM, growing through stomach wall serosa, invading the spleen hilum, distal part of pancreas with metastasis to S7 of the right liver lobe. The patient had total gastrectomy performed with D2 lymphadenectomy, distal pancreatectomy with splenectomy, resection of diaphragm and RFA of the metastatic lesion in S7 of the liver. Post-surgery course was free of complications, followed by adjuvant chemotherapy. 2 years after the surgery, the patient is in full remission, free of any relapse. Liver resection or RFA is not commonly used in the gastric cancer with liver metastasis (GCLM). At present, there is no direct marker available to define the degree of biological aggressiveness of the tumor (indicating or contra-indicating the surgical treatment), therefore we are left to rely on indirect prognostic factors: cancer invasion in the gastric wall serosa, presence of 3 and more liver metastases, size of metastasis exceeding 50 mm (Fig. 2, Ref. 13).

Surgical management of breast cancer liver metastases

We analyzed the treatment results in patients who underwent hepatic resection for breast cancer liver metastases(BCLM).Between 1/2003 and 12/2012, 15 patients underwent hepatic resection for BCLM. All primary breast tumors were diagnosed as invasive breast cancer. Synchronous BCLM ocurred in 2 patients and 13 patients presented with metachronous BCLM. Median age of patients at the time of BCLM diagnosis was 51 years(range from 31 to 73 years). All resections were considered as R0. From among 15 resections we performed 10 major hepatic resections according to Couinaud classification(≥3 segments) and the rest were minor ones. There was no postoperative mortality within 60 days . All postoperative complications were managed conservatively. Median hospital stay was 10,5 days, ranging from 7-14 days.Standard therapy for patients with BCLM remains systemic chemo- and hormonal therapy. Hepatic resection as a part of multimodal treatment in tertiary HPB centers can offer in a selected group of patients a safe option for improved survival. Keywords: breast cancer, liver metastases, hepatic resection.

Surgical management of breast cancer liver metastases

We analyzed the treatment results in patients who underwent hepatic resection for breast cancer liver metastases(BCLM).Between 1/2003 and 12/2012, 15 patients underwent hepatic resection for BCLM. All primary breast tumors were diagnosed as invasive breast cancer. Synchronous BCLM ocurred in 2 patients and 13 patients presented with metachronous BCLM. Median age of patients at the time of BCLM diagnosis was 51 years(range from 31 to 73 years). All resections were considered as R0. From among 15 resections we performed 10 major hepatic resections according to Couinaud classification(≥3 segments) and the rest were minor ones. There was no postoperative mortality within 60 days . All postoperative complications were managed conservatively. Median hospital stay was 10,5 days, ranging from 7-14 days.Standard therapy for patients with BCLM remains systemic chemo- and hormonal therapy. Hepatic resection as a part of multimodal treatment in tertiary HPB centers can offer in a selected group of patients a safe option for improved survival.

Radionavigated detection of sentinel nodes in breast carcinoma--first experiences of our department

INTRODUCTION

Biopsy and histological evaluation of sentinel lymphatic node limits the axillary node dissection only in cases of positive histological finding and decreases the occurrence of postoperative complications related to the axillary node dissection.

METHODS

We used radiotracer SentiScint, Medi-Radiopharma Ltd, Hungary and preoperatively administered blue dye--Blue Patenté V, Guebert, Aulnay-Sous-Bios, France. 11 (18%) patients were subdued to deep peritimorous application of radiotracer, 10 (16.4%) to sub/intradermal application over the lesions and n 40 (65.6%) patients the application was sub/intradermal and periareolar. The patients underwent an operation protocol of corresponding quadrantectomy, radionavigated blue-dye sentinel node biopsy and axillary dissection.

RESULTS AND CONCLUSIONS

From May 2006 to June 2008, we examined 61 patients with breast carcinoma. They underwent radionavigated and blue-dye sentinel node biopsy. We detected 57 (93.4%) sentinel nodes with preoperative scintigraphy, of which only 51 (83.6%) were detected peroperatively and underwent histological evaluation. In six (9.8%) cases, the "frozen cut" histology of the primary lesion had shown a benign lesion; hence no sentinel node biopsy or axillary disection was performed. 12 (19.7%) of 51 histologically evaluated sentinel nodes had metastatic invasion. We retrospectively compared the histological fund in sentinel and axillary nodes in patients with metastatic sentinel nodes. In 6 (16.6%) cases, the sentinel node was positive of metastatic invasion but axillary nodes were histologically negative, in 6 (16.6%) cases the sentinel node and axillary nodes were positive for metastatic invasion. We observed falsely negative findings in 3 (8.3%) patients with negative histological fund in the sentinel node, but positive axillary nodes (Tab. 3, Fig. 2, Ref. 11). Full Text (Free, PDF) www.bmj.sk.

Radical D2 surgery for patients with gastric cancer

The authors analyzed and prepared a report concerning 18 radical surgeries for gastric cancer that were performed between 1999-2001. Overall, 55 operation were performed, 32 radical, 18 palliative and 5 explorative laparatomies. D2 resections were performed 18 times, while D1 type 14 times. The group undergoing D2 surgery comprised of 10 men and 8 women with average age of 64.3. D2 resection included partial (8 times), or total (10) gastrectomy and lymfadenectomy of perigastric nodes, supra and infrapyloric nodes and nodes along common hepatic artery, truncus coeliacus, lienal artery, left paracardial nodes and removing capsula of pancreas. Splenectomy was performed twice. On average, 37.5 lymphnodes were removed for every operation (25-69). Operative mortality was none (0%) and morbidity was 22%. As of January 1, 2002 relaps was noted in six patients, and 5 patients died.

CONCLUSION

D2 resection surgeries performed by an experienced surgeon show low morbidity as well as better outcome and higher perspective for long-term survival in patients with gastric cancer. (Tab. 1, Ref. 19.).

[Radical treatment of rectal cancer]

The authors present an account on radical resections of the rectum in 73 patients during 1991-1995. A radical operation with excision of the mesorectum was performed 69 times, local excisions 4 times. Five-year survival was recorded in 57.90% patients, local relapses were recorded in 10.14% patients. Remote metastases or generalization of the disease was found in 18.84% patients. Adjuvant treatment was administered to 74% patients.