Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Gallbladder primary well-differentiated neuroendocrine tumor: A misdiagnosed case

INTRODUCTION

Gallbladder (GB) Well-Differentiated (WD) Neuroendocrine Tumor (NET) are extremely rare tumors. They represent only about 0.5 % of all Neuroendocrine Neoplasms (NENs). Most GB-NETs are diagnosed after cholecystectomy. They are often misdiagnosed and have good prognosis.

CASE PRESENTATION

We share our experience of a 42-year-old woman operated on for symptomatic cholelithiasis. We discover on the anatomopathological piece that it was a Grade 1 NET of the GB. Staging scans and octreotide-scans were normal: there is no distant or nodal metastasis. This tumor was classified as T1bN0M0. After multidisciplinary team discussion, additional treatment is deemed unnecessary. She didn't receive any treatment after the surgery. At one year after the cholecystectomy, she is symptom free and there is no sign of recurrence.

DISCUSSION

The diagnosis of GB-WD NET is difficult at the first evaluation. Surgical management for GB cancer has shown increased survival rates, a similar strategy seems reasonable for GB-NETs. Patients with Grade,1 well-differentiated GB-NETS have an excellent prognosis overall.

CONCLUSION

Research is required to facilitate earlier diagnosis and to develop management guidelines for GB-NETs.

Rupture of a liver hydatid cyst into the right portal vein leading to right portal vein thrombosis: a case report and literature review

Hydatid disease (HD) is a worldwide parasitic disease. HD is endemic in many sheep- and cattle-raising areas, with a high prevalence of 5% to 10% in the Mediterranean region. Fistulation of liver hydatid cysts (LHC) in the bile ducts is the most common complication, followed by rupture of cysts in the peritoneal and thoracic cavities. Vascular complications are a rare complication of HD. We describe the case of a 70-year-old woman who was admitted with the chief complaint of pain in the abdominal right upper quadrant for 6 months. Abdominal computed tomography revealed a large LHC in the right liver that had ruptured into the right portal vein branch, with venous thrombosis. Intraoperatively, the right portal vein was opened longitudinally, and the hydatid contents were evacuated. Right hepatectomy was performed to completely excise the LHC. The penetration of a cyst into an adjoining vessel is very rare, and portal vein invasion by HD is extremely rare, with only 10 cases published in the literature, to the best of our knowledge.

Quality of life in Tunisian colorectal cancer patients: a cross-sectional study

PURPOSE

Quality of life (QOL) of colorectal cancer (CRC) patients has been little studied in Tunisia. The aim of this work was to evaluate the QOL of CRC patients and to identify factors that may influence it.

METHODS

A cross-sectional, study spread was made over a period of 6 months on patients with CRC treated in the department of Medical Oncology of Farhat Hached University Hospital of Sousse. The EORTC questionnaires translated and validated in Arabic (QLQ-C30 and QLQ-CR29) were used.

RESULTS

142 patients diagnosed with colon or rectal cancer were enrolled. The overall QOL score was 58.5 ± 29.1. The emotional and sexual functional dimensions were the most affected, especially in women and patients under 50 years of age. QOL scores were higher in patients who were in complete remission (71.4 ± 24.7) and in good general condition (63.7 ± 26.6) physical activity may have a significant influence on all functional dimensions of QOL (p < 0.001). Fatigue was significantly (p < 0.001) more present when there was a sedentary lifestyleradiotherapy, palliative chemotherapy (1st and 2nd line) and targeted therapy.

CONCLUSION

Evaluating quality of life of patients with colorectal cancer in Tunisia is necessary especially those under 50 years old and in women. Laparoscopic surgery with restoration of intestinal continuity, less toxic palliative chemotherapy protocols, more accessibility to new radiotherapy technics will improve QOL of CRC patients. Physical activity and nutrition support are also essential in promoting QOL of these patients.

Radical versus conservative surgical treatment of liver hydatid cysts: A paired comparison analysis

BACKGROUND

The management of liver hydatid cysts (LHC) is complex and includes surgery, percutaneous drainage, chemotherapy and observation. Broadly, there are two types of surgical treatment for LHC - conservative surgery (CS) and radical surgery (RS). The purpose of this study was to compare the outcome of RS and CS.

METHODS

Data from all patients with LHC treated in Sahloul Hospital, between January 2000 and December 2019, were retrieved. To minimize selection bias, paired comparison analysis (PCA) was performed.

RESULTS

A total of 914 patients were included in this study. RS and CS were performed in 284 and 630 patients, respectively. After PCA, 206 patients were included in each group. The incidence of intraoperative bleeding was significantly higher in the RS group. The overall morbidity was significantly lower in the RS group. Thity-four patients developed recurrence with significantly higher recurrence in CS group.

CONCLUSION

RS is associated with fewer postoperative complications and lower recurrence rate compared to CS. RS may be the preferred procedure for LHC if the expertise is available.

Surgical management of giant hepatic hemangioma: A 10-year single center experience

Background

Hepatic hemangiomas are the most typical benign mesenchymal lesions of the liver. Most of these lesions are asymptomatic. Giant hepatic hemangiomas (GHH) (>10 cm) are often symptomatic and require surgical intervention. This study aimed to describe the clinical findings, risk factors, diagnostic approach and management of GHH.

Methods

We performed a retrospective analysis of patients with GHH treated at our hospital from January 2008 to December 2018. The medical records of each patient were reviewed to obtain the clinical and surgical data.

Results

Twelve patients with GHH were treated during the study period. 9 were female and 3 were male. The mean age of diagnosis was 48,2 years. The most common presenting symptom was abdominal pain. Eight patients presented an abdominal mass. Indications for surgical resections were rupture (n = 2), Kasabach-Merritt syndrome (n = 1) and abdominal pain (n = 9). Right hepatectomy was done in four patients, left lobectomy in four patients, and enucleation in four patients. Embolization was performed in 4 patients, but due to the persistence of symptoms or bleeding, surgery was indicated. The mean operative time was 3.5 h, and median blood loss was 870 ml. The median hospital stay was 5.3 days. For four patients, we registered postoperative complications causing death in one case. All alive patients were asymptomatic at a median follow-up of 55 months.

Conclusion

Despite limitations and alternative modalities, surgery remains the only effective curative treatment for GHH.

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Hepatic hemangiomas are the most common benign tumors of the liver with the incidence of 0.4–20%.

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Giant hepatic hemangiomas (GHH) are usually responsible for overt clinical symptoms and complications.

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Management of liver hemangiomas ranges from close observation to surgery depending upon the site, size and symptoms.

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Surgical resection is indicated in patients with abdominal complaints or complications, or when diagnosis remains inconclusive.

[Left paraduodenal hernia: a rare cause of acute intestinal obstruction]

La hernie para duodénale gauche est une hernie interne congénitale qui se complique rarement par une occlusion intestinale aiguë et qui peut mettre en jeux le pronostic vital par ischémie des anses. Nous rapportons un cas d’un jeune homme de 28 ans pris en charge pour un syndrome occlusif. Le scanner abdominal a objectivé une occlusion intestinale aiguë haute, l’exploration peropératoire a trouvé des anses jéjunales incarcérées dans une hernie para duodénale gauche. Le collet a été fermé et les suites opératoires étaient simples. En conclusion, la hernie para duodénale gauche, est souvent diagnostiquée lors d’une complication, son traitement est chirurgical et préférentiellement par laparoscopie.

Ectopic pancreas: A rare cause of occult gastrointestinal bleeding

Ectopic pancreas (EP) is a rare entity characterized by the development of pancreatic tissue in areas other than the pancreas. We present the case of a 16-year-old female with a heterotopic pancreas in the jejunum revealed by occult gastrointestinal bleeding. Contrast-enhanced computed tomography (CT) of the abdomen revealed a 2 × 3 cm enhancing nodular jejunal mass suspicious of a neuroendocrine or gastrointestinal stromal tumor. Octreoscan was planned but the patient presented in the emergency department with fever and sudden onset severe abdominal pain. The patient underwent emergency laparotomy. On abdominal exploration, appendicular perforation was present for which appendectomy and peritoneal lavage were performed. The small jejunal lesion seen on CT was identified during surgery and segmental jejunal resection with end-to-end anastomosis was performed. The histopathological examination of the jejunal mass revealed the presence of pancreatic acini and ductal structures without islets of Langerhans in the submucosa of the small intestine covered by normal mucosa. At the last follow-up of eight months after surgery, the patient is symptom-free and the abdominal CT is normal. Preoperative diagnosis of EP requires high clinical suspicion and should be included in the differential diagnosis while treating patients with gastrointestinal bleeding or gastrointestinal mass on CT.

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Ectopic pancreas (EP) is a rare entity characterized by the development of pancreatic tissue in areas other than the pancreas.

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It is often asymptomatic and mostly detected incidentally on surgery for other disease or on autopsy.

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The most common sites of EP are stomach and small intestine but it can be found in the esophagus, ileum, and biliary tree.

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EP should be included in the differential diagnosis while treating patients with gastrointestinal bleeding or gastrointestinal mass on CT.

Osteoclastic giant cell tumor of the pancreas with synchronous jejunal gastrointestinal stromal tumor: A case report

Osteoclastic giant cell tumor of the pancreas is a rare aggressive tumor, counting for 2–7% of all pancreatic cancers. Surgery is considered the most appropriate treatment. We report a case of a 84-year-old man with incidentally detected 11cm tumor in the pancreatic tail and another 6 cm tumor located in the jejunum on abdominal computed tomography. The patient underwent distal pancreatectomy with splenectomy along with segmental resection of the tumor bearing part of the jejunum. On histological examination, osteoclast-like giant cells with some areas of metaplastic bone were observed which confirmed the diagnosis of osteoclastic tumor of the pancreas. The jejunal tumor was strongly c-kit positive on immunohistochemistry which confirmed the diagnosis of GIST. On the last follow up at 2 years after surgery, there is no evidence of recurrence or distant metastasis. Pancreatic OGCT has a better prognosis after resection than pancreatic adenocarcinoma. Its co-existence jejunal GIST, as seen in the index case, has not been reported in the English literature till date.

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Osteoclastic giant cell tumor of the pancreas is a rare aggressive tumor, counting 2–7% of all pancreatic cancers.

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Surgery is considered the most appropriate treatment.

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Pancreatic OGCT has a better prognosis, after resection than pancreatic adenocarcinoma.

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Its co-existence jejunal GIST, as seen in the index case, has not been reported in the English literature till date.

Solid pseudopapillary neoplasm of the pancreas: a report of 10 cases and literature review

BACKGROUND

Solid pseudopapillary tumour of the pancreas (SPTP) is a rare pancreatic tumour characterized by a non-specific clinical presentations and vague radiologic features. The aim of this study is to identify these tumours from other pancreatic neoplasms because complete resection is curative in most cases and provides long-term survival.

METHODS

A retrospective analysis of patients operated for SPTP between January 2000 and December 2018 was conducted. The collected data included age, gender, clinical findings, laboratory tests, radiological findings, anatomopathological examination, immunohistochemistry results, surgical treatment, mortality, morbidity and recurrence.

RESULTS

Ten cases of SPTP have been diagnosed between January 2000 and December 2018 representing 5.1% of all pancreatic tumours operated during this period (male/female: 2/8; median age 41.2 years; range 19-78 years). The most common symptom was abdominal pain and physical examination was normal in four of 10 cases. The most common tumour localization was the tail of the pancreas. The main tumour size was 7.2 cm (range 2-15 cm). One patient had abdominal disseminated disease. Surgical interventions were distal pancreatectomy in five cases, enucleation in one case, cephalic duodeno-pancreatectomy in two cases, central pancreatectomy in one case and pancreatic biopsy in one case. Only one patient received adjuvant chemotherapy. During follow-up, one patient died after 12 months and another developed unique hepatic metastasis that was resected.

CONCLUSION

Although it is delayed in diagnosis, the overall prognosis of these tumours remains good even with local recurrence and metastasis. Complete surgical resection is the treatment of choice even in cases of recurrence.

Factors predicting recurrence after curative resection for rectal cancer: a 16-year study

BACKGROUND

The recurrence after curative surgery of the rectal adenocarcinoma is a serious complication, considered as a failure of the therapeutic strategy. The aim of this study was to identify the different prognostic factors affecting the recurrence of adenocarcinoma of the rectum.

METHODS

A retrospective analysis of patients operated for adenocarcinoma of the rectum between January 2000 and December 2015 was conducted. The study of the recurrence rate and prognostic factors was performed through the Kaplan Meier survival curve and the Cox regression analysis.

RESULTS

During the study period, 188 patients underwent curative surgery for rectal adenocarcinoma, among which 53 had a recurrence. The recurrence rate was 44.6% at 5 years. The multivariate analysis identified four parameters independently associated with the risk of recurrence after curative surgery: a distal margin ≤ 2 cm (HR = 6.8, 95% CI 2.7-16.6, 6), extracapsular invasion of lymph node metastasis (HR = 4.4, 95% CI 1.3-14), tumor stenosis (HR = 4.3, 95% CI 1.2-15.2), and parietal invasion (pT3/T4 disease) (HR = 3, 95% CI 1.1-9.4).

CONCLUSION

The determination of the prognostic factors affecting the recurrence of rectal adenocarcinoma after curative surgery allows us to define the high-risk patients for recurrence.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03899870 . Registered on 2 February 2019, retrospectively registered.

Idiopathic segmental infarction of the omentum mimicking acute appendicitis: A case report

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Omentum infarction occurs due to torsion, infections and vascular thrombosis.

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Primary idiopathic segmental omental infarction is rare.

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Clinically it is difficult to differentiate from acute appendicitis.

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Idiopathic omental infarction should be included in the differential diagnoses while treating patient with acute abdomen.

Introduction

Omentum is a well vascularized organ. Omentum infarction is uncommon. Most of the cases are secondary due to torsion, intra-abdominal infections and vascular thrombosis. Primary idiopathic segmental omental infarction is rare.

Presentation of case

A 26-year-old male presented with acute onset right iliac fossa pain mimicking acute appendicitis. On radiological imaging, early acute appendicitis was suspected. On diagnostic laparoscopy, appendix appeared normal and there was idiopathic infarction of a part of the greater omentum lying close to the cecum. Patient underwent laparoscopic appendectomy with excision of the diseased segment of the omentum and had uneventful recovery.

Conclusion

Idiopathic omental infarction should be included in the differential diagnoses while treating patient with acute abdomen.

Gallbladder volvulus: A case report and review of the literature

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Gallbladder volvulus (GV) is a rare disease with less than 400 cases reported in the English literature.

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Preoperative diagnosis is a major challenge with only 4 cases being diagnosed on radiology.

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Critical constellation of presenting symptoms and signs along with radiology can help in timely diagnosis of GV.

Introduction: Gallbladder volvulus (GV) is a rare disease with less than 400 cases reported in the English literature. The pre-operative diagnosis of GV is difficult as none of the imaging modalities are accurate. Once diagnosed, the mainstay of treatment is emergency surgical derotation and cholecystectomy.

Presentation of case: A 83-old lady presented with right upper quadrant pain and fever for 3 days. Abdominal imaging revealed the presence of a distended, floating gallbladder located outside its normal fossa with thickened non-enhancing wall and a twisted pedicle suggestive GV. The patient underwent emergency laparotomy because the laparoscopic approach was refused by the anesthetist due to the history of pulmonary emphysema. Intraoperatively, the gallbladder was found be gangrenous and rotated in anti-clockwise direction around the cystic pedicle. The gallbladder was de-rotated followed by cholecystectomy.

Discussion: GV is an uncommon cause for abdominal pain and occurs due to rotation of gall bladder on its mesentery along the axis of the cystic duct and the cystic artery. Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging. This case is one of the rare cases diagnosed with pre-operative imaging. It is often misdiagnosed as acute cholecystitis before surgery. However, critical constellation of presenting signs and symptoms along with radiological findings may guide the surgeon to accurate and timely diagnosis of GV before surgical intervention.

Conclusion: Although rare, it is important to consider GV as a differential diagnosis in an elderly patient with acute cholecystitis.

Isolated Roux loop pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: A case-control study

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Pancreaticojejunostomy is commonly used in the reconstruction after pancreaticoduodenectomy, but the incidence of POPF remains high.

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There are a number of theoretical advantages to the isolated Roux loop pancreaticojejunostomy reconstruction, mainly related to the physical separation of bile acids and the pancreaticojejunostomy.

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The use of an isolated Roux loop pancreaticojejunostomy seems to be associated with decrease in the rate of postoperative PF in patients undergoing PD.

Objectives

The aim of this study was to compare the postoperative outcomes of isolated Roux loop pancreaticojejunostomy (IPJ) and conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy (PD).

Methods

Data of patients who underwent IPJ were compared with those of a pair-matched equal number of patients undergoing CPJ. The matching was performed according to age, gender, nature of the lesion indicating PD and the texture of the pancreas. The primary outcome was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality.

Results

Seventy patients treated by PD (35 patients in each group) were included in the study. The two groups were comparable with regards to the pre-operative and intra-operative parameters. Postoperative pancreatic fistula developed in 10 out of 35 patients in the CPJ group and 3 out of 35 patients in the IPJ group (p =  0.031). Nine CPJ patients and one IPJ patient had POPF of type B or C (p =  0.006). Re-laparotomy was significantly more frequent in the CPJ group (11.1% versus 34.6%; p = 0.04). Time to resumption of oral feeding was shorter in the IPJ group (p =  0.001).

Conclusions

The use of IPJ is associated with decrease in the rate of postoperative PF in patients undergoing PD. In addition, patients with IPJ reconstruction have lesser need for re-laparotomy and early resumption of oral feeding.