A Soft Pancreatic Remnant is Associated with Increased Drain Fluid Pancreatic Amylase and Serum CRP Levels Following Pancreatoduodenectomy

The aim of this prospective study was to clarify differences in postoperative changes of serum or drainage fluid pancreatic amylase levels and serum C-reactive protein (CRP) levels between patients with a soft pancreatic texture and those with a hard pancreatic texture undergoing pancreatoduodenectomy (PD) with pancreaticogastrostomy. A total of 61 consecutive patients with resectable periampullary tumors undergoing PD were recruited. This population was divided into 27 patients with a hard pancreatic texture and 34 patients with a soft pancreatic texture. Drainage fluid total amylase or pancreatic amylase levels, serum total amylase or pancreatic amylase levels, and serum CRP levels were measured postoperatively. Clinicopathological data were also compared between two groups. Postoperative complications more frequently occurred in patients with a soft pancreatic texture compared with those with a hard pancreatic texture (P = 0.029). Serum or drainage fluid pancreatic amylase levels and serum CRP levels of patients with a soft pancreatic texture were significantly higher than those of patients with a hard pancreatic texture after PD on postoperative days 1 and 2 (P < 0.05). A soft pancreatic texture was identified as an only independent predictive factor of increased drainage fluid pancreatic amylase levels (P = 0.006) and serum CRP levels (P = 0.047). A soft pancreatic texture is closely associated with increased drainage fluid pancreatic amylase and serum CRP levels after PD. More careful post-PD management is needed for patients with a soft pancreatic texture. Presented at the 48th Annual Meeting of The Society for Surgery of the Alimentary Tract, Digestive Disease Week 2007, Washington, DC, May 19–23, 2007 (poster presentation).     

Do preoperative biliary stents increase postpancreaticoduodenectomy complications?

It has been suggested that the placement of endoscopic or percutaneous biliary stents prior to pancreaticoduodenectomy increases postoperative morbidity. A retrospective review of a prospectively collected database was performed. Patients undergoing preoperative biliary stenting were compared with patients who did not undergo stenting. In addition, outcomes after endoscopic and percutaneous stenting were compared. Patients who had undergone operative biliary bypass prior to pancreaticoduodenectomy were excluded from the analysis. Between January 1994 and December 1997,567 patients underwent pancreaticoduodenectomy without prior operative biliaty bypass. Preoperative biliary stenting was performed in 408 patients (72%), whereas the remaining 159 patients (28%) did not undergo biliary stenting. In the stented group, 64% had stents placed via a percutaneous approach and 36% had stents placed endoscopically. The stented patients were older (mean 63.1 years vs. 61.4 years; P = 0.05) and were more likely to be white (92% vs. 82%; P = 0.005). Those who had stents placed were more likely to have jaundice (67% vs. 38%; P < 0.0001) and fever (5% vs. 1%; P = 0.03) as presenting symptoms. There were no differences in multiple intraoperative parameters when the two groups were compared. Patients who had stems placed had a perioperative mortality rate of 1.7% compared to 2.5% in those who did not (P = 0.3). Although the overall complication rates were 3 5% in those who had stents placed and 30% in those who did not (P = NS), patients with stems experienced a significantly increased incidence of pancreatic fistula (10% vs. 4%; P = 0.02) and wound infection (10% vs. 4%; P = 0.02). The incidences of other postoperative complications were similar between the stented and unstented groups. Eight patients (3 %) in the percutaneously stented group developed significant hemobilia after stent placement, whereas none of the patients undergoing endoscopic stent placement developed hemobilia (P = 0.03). There were no statistical differences in other complications between the percutaneously and endoscopically stented groups. Preoperative biliary stenting did not increase the overall complication rate or mortality rate in patients undergoing pancreaticoduodenectomy. Stenting does appear to increase the rate of pancreatic fismla formation, possibly as a result of pancreatic inflammation related to the stenting procedure. Stenting also increases the rate of wound infection, likely secondary to contaminated bile (bactibilia) after instrumentation of the biliary tree. Preoperative biliary stenting is safe but should be used selectively because of the above-mentioned risks. The method of stenting should be based on local expertise. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, May 16–19, 1999, Orlando, Fla.     

Preoperative Biliary Drainage Increases Infectious Complications after Hepatectomy for Proximal Bile Duct Tumor Obstruction

Background  The role of preoperative biliary drainage before liver resection in jaundiced patients remains controversial. The objective of this study is to compare the perioperative outcome of liver resection for carcinoma involving the proximal bile duct in jaundiced patients with and without preoperative biliary drainage. Methods  Seventy-four consecutive jaundiced patients underwent hepatectomy for carcinoma involving the proximal bile duct from January 1989 to June 2006 and their data were retrospectively analyzed. Fourteen patients underwent biliary drainage before portal vein embolization and were excluded from the study. Thirty patients underwent biliary drainage before hepatectomy and 30 underwent liver resection without preoperative biliary drainage. All patients underwent resection of the extrahepatic bile duct. Results  Overall mortality and operative morbidity were similar in the two groups (3% vs. 10%, p = 0.612 and 70% vs. 63%, p = 0.583, respectively). The incidence of noninfectious complications was similar in the two groups. There was no difference in hospital stay between the two groups. Patients with preoperative biliary drainage had a significantly higher rate of infectious complications (40% vs. 17%, p = 0.044). At multivariate analysis, preoperative biliary drainage was the only independent risk factor for infectious complication in the postoperative course (RR = 4.411, 95%CI = 1.216-16.002, p = 0.024). Even considering patients with preoperative biliary drainage in whom the bilirubin level went below 5 mg/dl, the risk of infectious complications was higher compared with patients without biliary drainage (47.6% vs. 16.6%, p = 0.017). Conclusions  Overall mortality and morbidity after liver resection are not improved by preoperative biliary drainage in jaundiced patients. Prehepatectomy biliary drainage increases the incidence of infectious complications.     

Presence of white bile in malignant biliary obstruction is associated with poor prognosis: personal preliminary observations

Objective The chemical composition and clinical significance of white bile in patients with malignant obstructive jaundice were evaluated in a prospective study. Materials and methods 115 consecutive patients with inoperable malignant biliary obstruction underwent endoscopic placement of 10 Fr straight, plastic biliary stents, Amsterdam-type. Bile was aspirated during the endoscopic procedure and a blood sample was taken. Patients were divided into two groups: those with white bile and those with yellow bile. The groups were compared for decremental fall in bilirubin, cholangitis after stent insertion, and survival. Results Thirty-five patients (15 men, 20 women; mean age 54 years) underwent endoscopic drainage for malignant obstruction (29 hilar, 6 distal bile duct). Eighteen patients had white bile. Refractory jaundice (p  > −0.025) was seen in nine (50%) patients with white bile compared with three (17.6%) patients with yellow bile; mean difference −42.2 (95% CI [−62.4, −22.0]) and −45.7 (95% CI [−72.0, −19.4]), respectively. The bilirubin (0.49 mg/L) and bile acid (14.6 mmol/L) concentrations in white bile were significantly less than bilirubin (41.9 mg/L) and bile acid (62.2 mmol/L) concentrations in yellow/black bile. Cholangitis developed in 66.6% of patients with white bile compared with 35% of those with yellow/black bile (OR 3.67: 95% CI [0.74, 19.25]). Kaplan–Meier curves showed that median survival was shorter in patients with white bile (36 [23–60] vs 75 [35–220] days) (p = 0.004, log rank test), which was significant even after adjusting for potential confounders with Cox proportional hazards regression. Conclusion White bile is largely devoid of bilirubin and bile acids. The presence of white bile was associated with significantly worse survival in patients with malignant biliary obstruction.     

Prognosis of Resected Ampullary Adenocarcinoma by Preoperative Serum CA19-9 Levels and Platelet-Lymphocyte Ratio

Background  The objective of this study was to evaluate whether preoperative CA19-9 levels and the platelet–lymphocyte ratio (PLR) might reflect prognostic indices for resected ampullary adenocarcinoma. Materials and Methods  Data were collected prospectively over a 10-year period for consecutive patients undergoing pancreatoduodenectomy for malignancy. Results  Both preoperative PLR and CA19-9 results were available in 52 cases of resected ampullary adenocarcinoma. Preoperative CA19-9 levels of ≤150 kU/l (or ≤300 kU/l in the presence of bilirubin levels >35 μmol/l) and a PLR of ≤160 were found to represent the optimal cut-off values to risk stratify patients. If both levels were elevated (n = 8), patients had a median overall survival of 10.1 months. If either CA19-9 or PLR were elevated individually (n = 23), patients had a median survival of 25.2 months. For cases where both levels were less than the cut-off values (n = 21), the median overall survival time was not reached but was greater than 60 months (log rank, p < 0.001). This preoperative risk stratification was found to remain a significant independent predictor of survival on multivariate analysis (Cox, p = 0.001) alongside resection margin status (p = 0.002) and tumor size (p = 0.051). Conclusions  Preoperative CA19-9 and PLR both merit further evaluation as prognostic indices in resected ampullary adenocarcinoma.     

Surrogate Markers of Resectability in Patients Undergoing Exploration of Potentially Resectable Pancreatic Adenocarcinoma

Despite extensive preoperative staging, a significant number of pancreatic cancers are unresectable at surgical exploration. Patients undergoing pancreatic exploration with a view to resection were studied and comparisons are then made between those undergoing resection and a bypass procedure to identify surrogate markers of unresectability. One hundred thirteen consecutive patients underwent pancreatic exploration for head-of-pancreas (HOP) adenocarcinoma with curative intent. Fifty-five underwent pancreaticoduodenectomy and 58 underwent a bypass procedure. Student’s t test, receiver operator characteristics (ROC) and logistic regression were used to compare the predictive value of preoperative patient variables collected retrospectively. The bypass group had a significantly higher median CA19.9 than the resection group (P = 0.003). Platelet count and neutrophil–lymphocyte ratio (NLR) were also significantly different (P = 0.013 and P = 0.026, respectively). ROC analysis indicated that age ≤65, platelet count >297 × 10⁹/l, CA19.9 ≤473 Ku/l, and CA19.9–bilirubin ratio were predictive variables for resectable disease. NLR and CA19.9–bilirubin ratio had specificity values of 92.9 and 97.0%, respectively. From logistic regression, a raised CA19.9 was found to be an independent risk factor for unresectable disease (P = 0.031). A significant proportion of patients with HOP adenocarcinoma are understaged preoperatively. Preoperative serology including platelet count, NLR, CA19.9, and CA19.9–bilirubin ratio may be used as additional discriminators of resectability particularly for high-risk patients.     

对比观察超声引导下经皮经肝胆管穿刺引流术与经皮经肝胆囊穿刺引流术姑息治疗晚期恶性梗阻性黄疸

目的比较超声引导下经皮经肝胆管穿刺置管引流术(PTBD)及经皮经肝胆囊穿刺置管引流术(PTGD)姑息治疗晚期恶性梗阻性黄疸的价值。方法纳入79例晚期恶性梗阻性黄疸患者,其中47例共接受120次超声引导下PTBD(PTBD组),32例共接受39次PTGD(PTGD组)。比较PTBD组和PTGD组手术操作时间、黄疸减退情况、胆道出血和胆汁外漏发生率及引流管有效带管时间。结果两组黄疸减退情况、胆道出血和胆汁外漏发生率差异均无统计学意义(P均0.05);PTBD组手术操作时间为(7.07±2.24)min,PTGD组操作时间为(5.94±2.03)min,差异有统计学意义(P=0.02)。PTBD组有效带管时间为(100.56±11.31)天,PTGB组为(63.58±6.23)天,差异有统计学意义(P0.001)。结论对晚期恶性梗阻性黄疸患者,超声引导下PTBD带管时间长,相对PTGD更为适用。     

Preoperative cholangitis is an independent risk factor for mortality in patients after pancreatoduodenectomy for pancreatic cancer

ObjectivesPreoperative biliary stenting is required for patients with obstructive jaundice from pancreatic adenocarcinoma who are receiving neoadjuvant chemotherapy. While in most patients this approach results in durable biliary drainage, some patients develop cholangitis during neoadjuvant treatment. Further, several studies have shown that preoperative cholangitis in patients with hepatobiliary malignancies can result in substantially unfavorable outcomes. The aim of this study was to evaluate the impact of preoperative cholangitis in patients who underwent pancreaticoduodenectomy after completing neoadjuvant chemotherapy.MethodsParticipants: all adult patients (n = 449) diagnosed with pancreatic adenocarcinoma from January 1st, 2013 to March 31st, 2018 who pursued treatment at the Massachusetts General Hospital were screened. Of these 449 patients, 97 met final inclusion criteria of receiving neoadjuvant chemotherapy with intent to pursue curative surgery. Data were collected via retrospective chart review including baseline characteristics, survival, episodes of preoperative cholangitis, and surgical complications.ResultsIn patients completing successful pancreaticoduodenectomy surgery, preoperative cholangitis is associated with increased mortality (HR 2.67, 95% CI:1.16–6.13). This finding is independent of postoperative outcomes or tumor recurrence rate. The presence of cholangitis did not impact completion of neoadjuvant chemotherapy (92% vs 85%, p = 0.5) or ability to proceed to surgery (76% vs 75%, p = 1.0). Preoperative cholangitis was not associated with postoperative morbidity (42.1% vs 45.1%, p = 1.0).ConclusionsOne episode of cholangitis during neoadjuvant chemotherapy is associated with increased mortality following successful pancreaticoduodenectomy, independent of immediate postoperative outcomes or tumor recurrence. Preoperative cholangitis does not affect ability to pursue neoadjuvant chemotherapy or complete successful surgery. Patients who develop cholangitis during the neoadjuvant chemotherapy treatment phase may reflect a distinct phenotype of patients with PDAC with a complex and more challenging clinical course.     

Long-term Outcomes and Prognostic Factors of Elderly Patients with Hepatocellular Carcinoma Undergoing Hepatectomy

Objective  The present study aimed to evaluate the long-term outcomes and prognostic factors of elderly patients with hepatocellular carcinoma (HCC) undergoing hepatectomy. Material and Methods  From January 1983 to December 2006, 2,283 patients with HCC received hepatectomy in Sun Yat-sen University Cancer Center. The clinicopathological data and treatment outcomes of 67 elderly HCC patients (elderly group, ≥70 years of age) and 268 patients (control group, <70 years of age) who were selected randomly from the 2216 younger patients were compared retrospectively. Results  The elderly HCC patients had lower hepatitis B surface antigen-positive rate (P < 0.001), lower rate of marked α-fetoprotein elevation (P = 0.004), higher infection rate of hepatitis C virus (P = 0.010), more preoperative comorbidities (P < 0.001), higher rate of tumor encapsulation (P = 0.040), and better overall survival rate (P = 0.017); whereas there were no significant differences between these two groups in other factors, including gender ratio, liver function, accompanying cirrhosis, pathological tumor–node–metastasis (pTNM) staging, satellite nodules, vascular invasion, tumor rupture, resection margin, intraoperative blood loss, incidence of postoperative complications, hospital mortality, and disease-free survival rate. Multivariate analysis showed that pTNM staging was an independent prognostic factor of long-term survival in elderly patients with HCC. Conclusion  HCC in the elderly was less HBV-associated, less advanced, and less aggressive. Hepatectomy for selected elderly patients with HCC possibly have a better curative effect compared with younger patients. For the elderly patients without preoperative comorbidities or with controlled comorbidities, hepatectomy is a safe and effective treatment. pTNM staging is the only independent predictor of postoperative overall survival in elderly HCC patients.     

Influence of bactibilia after preoperative biliary stenting on postoperative infectious complications

The aim of this study was to correlate the bactibilia found after preoperative biliary stenting with that of the bacteriology of postoperative infectious complications in patients with obstructive jaundice. One hundred thirty-eight patients (83% malignant and 17% benign etiologies) with obstructive jaundice had both their bile and all postoperative infectious complications cultured. Eighty-six (62%) had preoperative biliary stents (stent group) and 52 (38%) did not (no-stent group). There were no differences for age, sex, incidence of malignancy, type of operation, estimated blood loss, transfusion requirements, hospital length of stay, morbidity, or mortality rates between the two groups. Of 31 infectious complications, 23 were in the stent group and eight were in the no-stent group (P > 0.05), but only 13 (42%) infectious complications had bacteria that were also cultured from the bile. Only wound infection (P = 0.03) and bacteremia (P = 0.04) were more likely to occur in stented patients. Taken together, these data show that preoperative biliary stenting increases the incidence of bactibilia, bacteremia, and wound infection rates but does not increase morbidity, mortality, or hospital length of stay. Jaundiced patients can undergo preoperative biliary stenting while maintaining an acceptable postoperative morbidity rate.     

Efficacy of preoperative endoscopic nasobiliary drainage for hilar cholangiocarcinoma

Background/Purpose  Although percutaneous transhepatic biliary drainage has previously been recommended as a primary preoperative step, endoscopic nasobiliary drainage (ENBD) is prevalent as an alternative procedure. Few reports assess the efficacy and safety of ENBD in a substantial patient cohort. Methods  Of 116 patients with hilar cholangiocarcinoma who underwent surgery, 62 (43 men and 19 women, median age 69 years) underwent preoperative ENBD. After classification of lesions according to Bismuth–Corlette (B–C) criteria, we evaluated efficacy and safety with respect to B–C type. Results  Patients were classified as B–C types I (n = 5), II (n = 21), IIIa (n = 23), IIIb (n = 5), and IV (n = 8). Preoperative single ENBD was effective in 46/62 patients (74%) including 5/5 (100%) B–C type I, 20/21 (94%) type II, 16/23 (70%) type IIIa, 4/5 (80%) type IIIb, and 1/8 (13%) type IV. Sixteen cases (26%) required additional drainages with ENBD or endoscopic biliary stenting (EBS) in 8/16 (50%), and with PTBD in 8/16 (50%). Mild acute pancreatitis (n = 1, 2%), segmental cholangitis (n = 2, 3%), and acute cholangitis with catheter obstruction (n = 7, 11%) occurred with ENBD. Conclusions  Preoperative single ENBD in the future remnant lobe is effective treatment for B–C type I–III hilar cholangiocarcimona. Preoperative ENBD was rarely complicated with segmental cholangitis.     

Hepatic Resection for Hepatocellular Carcinoma with Obstructive Jaundice due to Biliary Tumor Thrombi

Hepatocellular carcinoma (HCC) with obstructive jaundice due to biliary tumor thrombi is uncommon, and few studies have examined the outcome of hepatectomy for HCC with this unusual entity. This study examined the clinicopathologic factors influencing the outcomes of 17 HCC patients with obstructive jaundice due to biliary tumor thrombi undergoing hepatectomy. The clinical features of 17 HCC patients with obstructive jaundice due to biliary tumor thrombi (group A) undergoing hepatectomy from 1986 to 1998 were reviewed. The clinical features and factors influencing the outcome of 555 HCC patients without biliary tumor thrombi (group B) undergoing hepatectomy were used for comparison. Of 572 patients with surgically resected HCCs, 17 (3.0%) were classified into group A. Right upper quadrant pain, physical signs of jaundice, low albumin level, elevated bilirubin level, small tumor size, more vascular invasion, and tumor rupture were characteristic of group A patients. Multivariate stepwise logistic regression analysis revealed no independently significant factor differentiating group A patients from group B patients. The disease-free survival was similar between the group A and B patients, although group B patients exhibited significantly better overall survival (p = 0.014). Vascular invasion may adversely influence overall survival in group A patients undergoing hepatic resection (p = 0.0709). When feasible, hepatic resection is the preferred treatment for HCC patients with obstructive jaundice due to biliary tumor thrombi. It can achieve a disease-free survival comparable to that of HCC patients without biliary tumor thrombi. However, HCC patients with biliary tumor thrombi had significantly worse overall survival than did those without biliary tumor thrombi, especially those with concomitant vascular invasion.     

Photodynamic therapy for cholangiocarcinoma

The prognosis of nonresectable cholangiocarcinoma is dismal, and in Bismuth type III and IV tumors relief of jaundice is seldom achieved, despite successful endoprosthesis insertion. Therefore, we evaluated additional photodynamic therapy in patients who failed to respond to endoprostheses insertion. All patients showed good clinical results in regard to jaundice, quality of life; and survival time (median, 439 days). Before initiating a randomized multicenter trial we wanted to evaluate these preliminary results in a greater number of patients. Twenty-one patients underwent photodynamic therapy in addition to endoscopic drainage. The hematoporphyrin derivative Photofrin was infused intravenously (2 mg/kg body weight), and intraluminal photoactivation was performed 2 days later. Bilirubin decreased from a mean level of 201.26 ± 189.25 μmol/l after stenting alone to 68.87 ± 78.27 μmol/l (P = 0.0051), and the Karnofsky index improved from 49.04% ± 28.79% to 72.85 ± 19.01 (P = 0.003). Thirteen patients have died and 8 patients are still alive, with a follow-up period of 82–739 days. The 6-month survival time is 95%. Similar results were obtained by another group, with 75% overall (stage M1 and M0) survival after 6 months and beyond 80% for stage M0. Other authors treated 7 patients and saw a remarkable reduction of bile duct stenosis and bilirubin decrease in all patients. Received: September 5, 2000 / Accepted: October 26, 2000     

The Impact of Obesity on Outcomes Following Pancreatectomy for Malignancy

Background  Obesity has previously been shown to correlate with higher stage and decreased survival in pancreatic cancer. The aim of this study was to determine the impact of obesity on operative outcomes, recurrence, and overall survival. Methods  A review of our 1345 patient prospective hepatopancreaticobiliary database was performed to identify patients undergoing pancreatic resection from January 1991 to August 2008 for adenocarcinoma. Obesity was defined as a body mass index (BMI) > 30 kg/m². Data was analyzed using Wilcoxon, t test, and chi-square methods. Survival was analyzed using log-rank analysis. Postoperative complications were assessed using a 5-point scale. P < .05 was considered significant. Results  Of 306 patients undergoing pancreatic resection for pancreatic adenocarcinoma examined, 68 were defined as obese. There was no significant difference seen in length of stay, operative time, tumor size, or node status. Obese patients had a higher operative blood loss (median 650 vs. 400 mL, P = .0008). Obese patients were more likely to suffer postoperative complications (67.6% vs. 50.4%, P = .01). There was no significant difference seen in disease-free survival or overall survival (22.1 months for obese vs. 25.6 months for nonobese, P = .5; 19.8 months for obese vs. 23.5 months for nonobese, P = .46). Conclusion  Obese patients had a higher rate and greater severity of postoperative complications, with increased operative blood loss. However, obese patients did not demonstrate any significant difference in specific oncologic factors or survival. These data suggest an equivalent biologic effect of obesity on pancreatic cancer survival.     

The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy

BACKGROUND:

The benefit of preoperative biliary drainage in jaundiced patients undergoing pancreaticoduodenectomy for a suspected malignancy of the periampullary region is still under debate. This study evaluated preoperative biliary drainage in relation to postoperative outcomes.

STUDY DESIGN:

At the Academic Medical Center, Amsterdam, the Netherlands, a cohort of 311 patients undergoing pancreaticoduodenectomy from June 1992 up to and including December 1999 was studied. Of this cohort 21 patients with external or surgical biliary drainage were excluded and 232 patients who had received preoperative internal biliary drainage were divided into three groups corresponding with severity of jaundice according to preoperative plasma bilirubin levels: < 40 μM (n = 177), 40 to 100 μM (n = 32), and > 100 μM (n = 23) were designated as groups 1, 2, and 3, respectively. These groups were compared with patients who underwent immediate surgery (n = 58) without preoperative drainage.

RESULTS:

The median number of stent (re)placements was 2 (range 1 to 6) with a median drainage duration of 41 days (range 2 to 182 days) and a stent dysfunction rate of 33%. Although patients in group 1 were better drained than patients in groups 2 and 3 (median reduction of bilirubin levels 82%, 57%, and 37%, respectively, p < 0.01), there was no difference in overall morbidity among the drained groups (50%, 50%, and 52%, respectively). There was no significant difference in overall morbidity between patients with and without preoperative biliary drainage (50% and 55%, respectively).

CONCLUSIONS:

Preoperative biliary drainage did not influence the incidence of postoperative complications, and although it can be performed safely in jaundiced patients it should not be used routinely.     

Clinical Significance of Microvessel Count in Patients with Metastatic Liver Cancer Originating from Colorectal Carcinoma

Background  Microvessel count (MVC) has been correlated with patient prognosis in hepatocellular carcinoma. We investigated whether MVC assessed by staining with CD34 antibody was associated with disease-free and overall survival in patients with metastatic liver cancer (MLC). Methods  We examined relationships between MVC and clinicopathologic factors or postoperative outcomes in 139 MLC patients who underwent hepatectomy between 1990 and 2006. CD34 expression was analyzed by the immunohistochemical method. Results  MVC was associated with fibrous pseudocapsular formation on histological examination. By means of the modern Japanese classification of liver metastasis, poorer survival was associated with higher score, poorly differentiated adenocarcinoma, higher preoperative carcinoembryonic antigen (CEA) level, fibrous pseudocapsular formation, and smaller surgical margin. Shorter disease-free survival was associated with higher score when the Japanese classification of liver metastasis was used, multiple or bilobar tumor, regional lymph node metastasis in primary colon carcinoma, preoperative CEA level, fibrous pseudocapsular formation, and smaller surgical margin (<5 mm). Higher MVC (≥406/mm²) was associated with decreased disease-free and overall survival by univariate analysis (P = .034 and P = .021, respectively), and higher MVC represented an independently poor prognostic factor in overall survival by Cox multivariate analysis (risk ratio, 2.71; P = .023) in addition to histological differentiation. Conclusions  Tumor MVC seems to be a useful prognostic marker of MLC patient survival.     

Preoperative Liver Function Tests and Hemoglobin will Predict Complications Following Pancreaticoduodenectomy

Introduction  Previous studies identified an association between dilated pancreatic and biliary ducts and lower rates of pancreatic leak after pancreaticoduodenectomy, but it remains unclear whether elevated liver function tests are also associated with lower rates of complications. The purpose of this study was to determine if preoperative liver function tests are associated with postoperative complications. Materials and Methods  We identified 452 patients who received a pancreaticoduodenectomy from 1990–2007. Clinicopathological data was collected for each patient, and regression analyses were performed to identify predictors of postoperative complications. Results  Of the patients studied, 289(64%) experienced no postoperative complications. In univariate analysis, patients with a low or normal preoperative aspartate aminotransferase (p = 0.03) or alkaline phosphatase(p = 0.03), had higher rates of complications. Multivariate analysis confirmed an elevated alkaline phosphatase was associated with a lower incidence of complications (OR = 0.56, p = 0.02), while preoperative anemia was found to be a predictor of complications following pancreaticoduodenectomy(OR = 2.01, p = 0.02). Conclusion  Anemic patients and those with normal liver function tests were more likely to experience complications after pancreaticoduodenectomy. This may represent extent of disease and tumors not causing biliary or pancreatic dilatation, respectively. Precautions, such as intraoperative ductal stents, should be considered when operating on this group of patients to minimize complications. Presented at the 49th Annual Meeting of the Society for Surgery of the Alimentary Tract, May 17–21, 2008. San Diego Convention Center, San Diego, California.     

Primary and overall success rates for clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts

Background  Internal drainage of pancreatic pseudocysts can be accomplished by traditional open or minimally invasive laparoscopic or endoscopic approaches. This study aimed to evaluate the primary and overall success rates and clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts. Methods  Records of 83 patients undergoing laparoscopic (n = 16), endoscopic (n = 45), and open (n = 22) pancreatic cystgastrostomy were analyzed on an intention-to-treat basis. Results  There were no significant differences (p < 0.05) in the mean patient age (years), gender, body mass index (BMI) (kg/m²), etiology of pancreatitis (% gallstone), or size (cm) of pancreatic pseudocyst between the groups. Grade 2 or greater complications occurred within 30 days of the primary procedure for 31.5% of the laparoscopic patients, 15.6% of the endoscopic patients, and 22.7% of the open patients (nonsignificant differences). The follow-up evaluation for 75 patients (90.4%) was performed at a mean interval of 9.5 months (range, 1–40 months). The primary compared with the overall success rate, defined as cyst resolution, was 51.1% vs. 84.6% for the endoscopic group, 87.5% vs. 93.8% for the laparoscopic group, and 81.2% vs. 90.9% for the open group. The primary success rate was significantly higher (p < 0.01) for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups (nonsignificant differences). Primary endoscopic failures were salvaged by open pancreatic cystgastrostomy (n = 13), percutaneous drainage (n = 3), and repeat endoscopic drainage (n = 6). Conclusions  Laparoscopic and open pancreatic cystgastrostomy both have a higher primary success rate than endoscopic internal drainage, although repeat endoscopic cystgastrostomy provides overall success for selected patients.     

Outcomes of metastatic breast cancer patients in relationship to disease‐free interval following primary treatment of localized disease; a pooled analysis of two clinical trials

The aim of the current study is to assess the impact of disease‐free interval (DFI) following treatment of primary localized breast cancer on the outcomes of patients with subsequent metastatic breast cancer treated with first‐line docetaxel chemotherapy. This study is a combined analysis of patient‐level raw data of 604 metastatic breast cancer patients referred for docetaxel first‐line chemotherapy in two clinical trials. Overall survival and time to progression were evaluated according to DFI through Kaplan‐Meier analysis. Multivariate analysis of factors affecting overall survival and time to progression was then conducted through Cox regression analysis. For the overall cohort, shorter DFI is associated with worse overall survival (P < 0.0001). When classified by the hormone receptor status, the shorter interval was associated with worse overall survival in both hormone receptor positive and negative patients (P = 0.009; P = 0.018; respectively). Likewise, shorter DFI is associated with shorter time to progression (P < 0.0001) in the overall cohort. When classified by the hormone receptor status, the shorter interval was associated with shorter time to progression for hormone receptor negative but not positive patients (P = 0.001; P = 0.070; respectively). In multivariate Cox regression analysis, the following factors were associated with worse overall survival: shorter DFI (P < 0.0001), poorer ECOG performance score (P = 0.008) and lower body mass index (P = 0.018). Likewise, in multivariate Cox regression analysis, the following factors were associated with shorter time to progression: shorter DFI (P < 0.0001) and hormone receptor negative status (P = 0.025). Shorter DFI was associated with worse overall survival and shorter time to progression among patients receiving first‐line docetaxel chemotherapy.