Second surgery after a pancreaticoduodenectomy in patients with periampullary malignancies

BACKGROUND/AIMS: Few case reports have previously documented a second surgery after pancreaticoduodenectomy due to recurrence or other reasons in patients with periampullary malignancies. The present report summarized the experience of this clinic with secondary surgery after Pancreaticoduodenectomy (PD). METHODOLOGY: During the past 7 years, 7 out of 95 patients with periampullary malignancies underwent a second surgery after pancreaticoduodenectomy at this institution. The clinical courses of these patients are presented and 2 interesting cases are shown in the present study. RESULTS: One patient with lower bile duct adenocarcinoma underwent a remnant splenopancreatectomy due to pancreatic recurrence 36 months after pancreaticoduodenectomy. The other patient with lower bile duct adenocarcinoma underwent a hepatectomy due to a solitary liver metastasis 47 months after a pancreaticoduodenectomy. These 2 patients have survived 4 and 13 months after the second surgery. In the 7 patients requiring secondary surgery, 5 underwent the procedure due to recurrent disease, and 4 of the 5 received the second surgery to remove the lesion. The mean interval between pancreaticoduodenectomy and the second operation was 32 months in the 5 patients with recurrent disease and 27 months in the all 7 patients. One of the 5 patients died of recurrent disease only 5 months after the second procedure because the surgery was a palliative bypass. However, the other 3 survived more than 1 year after the resection of the lesion at the recurrent site. CONCLUSIONS: The present study reports 2 rare cases with lower bile duct adenocarcinoma in which a recurrent tumor was removed after pancreaticoduodenectomy. In this study, 4 patients undergoing a curative re-operation survived more than 1 year after the surgery. The present study was small, but the findings are significant because of the scarcity of reports of patients undergoing secondary surgery after PD.     

Clinical impact of preoperative acute pancreatitis in patients who undergo pancreaticoduodenectomy for periampullary tumors

AIM: To investigate the impact of preoperative acute pancreatitis(PAP) on the surgical management of periampullary tumors.METHODS: Fifty-eight patients with periampullary tumors and PAP were retrospectively analyzed. Thirtyfour patients who underwent pancreaticoduodenectomy(PD) and 4 patients who underwent total pancreatectomy were compared with a control group of 145 patients without PAP during the same period.RESULTS: The preoperative waiting time was significantly shorter for the concomitant PAP patients who underwent a resection(22.4 d vs 54.6 d, p 0.001)compared to those who did not. The presence of PAP significantly increased the rate of severe complications(Clavien grade 3 or higher)(17.6% vs 4.8%, p = 0.019)and lengthened the hospital stay(19.5 d vs 14.5 d,p = 0.006). A multivariate logistic regression analysis revealed that PAP was an independent risk factor for postoperative pancreatic fistula(OR = 2.91; 95%CI:1.10-7.68; p = 0.032) and severe complications(OR =4.70; 95%CI: 1.48-14.96; p = 0.009) after PD. There was no perioperative mortality.CONCLUSION: PAP significantly increases the incidence of severe complications and lengthens thehospital stay following PD. PD could be safely performed in highly selective patients with PAP.     

Long survival in patients with bronchogenic carcinoma complicated by superior vena caval obstruction.

When superior vena caval obstruction complicates cancer of the lung; the prognosis is grave; 1 percent of such patients survive for one year. Improved palliation is reported from many radiation therapy centers using higher initial dose fractions and tumoricidal doses. We now report the findings in three patients with histologically confirmed bronchogenic carcinoma who had superior vena caval obstruction and who survived for nine years (two patients) and seven years (one patient). Aggressive therapy with irradiation seems to provide better palliation and may occasionally be associated with remarkably long survivals in this normally highly lethal disease.     

Thrombus removal with a temporary vena caval filter in patients with acute proximal deep vein thrombosis

Between September 1999 and January 2001 we performed thrombus removal with the use of a temporary vena caval filter in 11 patients who had acute iliofemoral venous thrombosis. To facilitate thrombus removal, 5 patients initially received catheter-directed thrombolytic therapy (thrombolysis group), and the other 6 received surgical thrombectomy (thrombectomy group). Residual thrombus was confirmed after initial catheter-directed thrombolysis in all patients in the thrombolysis group, and thrombolysis was continued in the ward. Bleeding complications subsequently occurred in 2 patients. In the thrombectomy group, 1 patient had residual thrombus just below the temporary filter, and a permanent vena caval filter was deployed for removal. Another patient had a residual thrombus in the superficial femoral vein, and rethrombectomy was performed. One patient in the thrombectomy group died of pneumonia. All other patients were discharged. There were no deaths from pulmonary thromboembolism in this series. Post-thrombotic syndrome occurred in 2 of the 5 patients in the thrombolysis group (40%) and in 3 of the 6 patients (50%) in the thrombectomy group. We conclude that a temporary vena caval filter is useful for the management of acute proximal deep vein thrombosis, especially when aggressive treatment is required.Presented at the 31st Annual Meeting of the Japanese Society for Cardiovascular Surgery, Yamaguchi, Japan, February 2001.     

晚期壶腹周围癌的胆胰管双支架治疗

目的探讨晚期壶腹周围癌患者胆管和胰管双支架治疗的临床价值。方法36例经病理学和（或）临床诊断为晚期壶腹周围癌患者,影像学表现为胰管和胆管均有狭窄,经内镜先在胰管内置入Teflon塑料支架,然后胆道内置可膨胀式金属支架,不成功者改经皮经肝胆管内置入金属支架进行引流。观察支架置放前后患者的血清肝生化指标、胰酶水平和临床表现。结果36例置入胰管塑料支架均顺利,29例内镜置人金属胆道支架成功,7例（2例Billroth1I术后）因导丝插入胆管困难改为经皮经肝胆管内支架置入。支架置放后肝ALT、AST、ALP、r-谷氨酰转肽酶以及总胆红素、直接胆红素均有明显的下降;15例出现血淀粉酶和血脂肪酶的升高,但经过治疗后均恢复正常;腹痛缓解率82．4％（28／34）,腹泻改善有效率达88．2％（15／17）。结论胆、胰管联合支架可以解除壶腹周围癌患者的胆、胰管恶性狭窄与梗阻,安全有效。     

Recurrent venous thromboembolism in patients with and without anticoagulation after inferior vena caval filter placement.

AIM: The aim of this study was to compare the rate of recurrent venothromboembolic (VTE) events and factors contributing to VTE events in patients with inferior vena caval (IVC) filters on chronic anticoagulation to those in whom anticoagulation was discontinued. METHODS: Retrospective cohort study of 353 patients who received IVC filters between 1986 and 2002. RESULTS: Anticoagulation status was available for 304 patients (132 on coumadin anticoagulation therapy and 172 who did not receive any anticoagulation therapy) whose IVC filters were placed within 30 days of their qualifying thromboembolic event. Two-year event-free survival for the anticoagulated group was 80.6% (95% confidence interval--CI--76.9, 84.3] and was 67.8% (95% CI 63.2, 72.3) for the non-anticoagulated group. Patients who had Greenfield filter had a higher, but not statistically significant different, rate of recurrence compared to those with other types of filters (hazard ratio 1.4; 95% CI 0.9, 2). The rate of recurrent VTE events was independent of age, gender, smoking status, or underlying medical condition. CONCLUSIONS: Among those with IVC filters, long-term anticoagulation therapy prolonged event-free survival for up to 2 years but did not prevent recurrent VTE events.     

ERCP in patients with periampullary diverticulum

BACKGROUND/AIMS: Duodenal diverticula, discovered incidentally in patients during endoscopic retrograde cholangiopancreatography, are usually asymptomatic, but can be the source of significant morbidity. The aim of this study was to evaluate the indications for endoscopic retrograde cholangiopancreatography, the course of this procedure and complications after this procedure in patients with periampullary diverticulum. METHODOLOGY: Clinical, laboratory, ultrasonographic, and endoscopic retrograde cholangiopancreatography data of 626 patients from a single endoscopy center were retrospectively analyzed. RESULTS: The periampullary diverticulum was identified in 72 patients (11.5%). The difficulty in cannulation of papilla of Vater was encountered in 57 patients (79.2%) with diverticulum compared to 54 patients (9.7%) without diverticulum (P < 0.001). Cannulation of common bile duct was successful in 592 patients (94.6%). Cannulation of common bile duct failed in 8 patients (11.1%) with diverticulum compared to 26 patients (4.7%) without diverticulum (P = 0.046). Patients without diverticulum (n = 168, 31.9%) had two-times more often dilated common bile duct > or = 6 mm without stone on ultrasound compared to patients with diverticulum (n = 12, 17.6%) (P = 0.017). Patients with diverticulum presented 1.8-times more often with retained stone in the common bile duct than patients without diverticulum (16.7% vs. 9.7%). 17.3% of patients developed post-endoscopic retrograde cholangiopancreatography complications, which did not significantly differ in both groups. However, the patients who presented with retained common bile duct stones had higher post-endoscopic retrograde cholangiopancreatography complications (P = 0.011). CONCLUSIONS: Cannulation of the common bile duct is more difficult in patients with periampullary diverticulum and requires more skills. Periampullary diverticulum is also associated with higher risk of retained stones in the common bile duct which may lead to higher post-endoscopic retrograde cholangiopancreatography complication rate.     

Effect of early enteral combined with parenteral nutrition in patients undergoing pancreaticoduodenectomy

AIM:To investigate the effect of early enteral nutrition(EEN)combined with parenteral nutritional support in patients undergoing pancreaticoduodenectomy(PD).METHODS:From January 2006,all patients were given EEN combined with parenteral nutrition(PN)(EEN/PN group,n=107),while patients prior to this date were given total parenteral nutrition(TPN)(TPN group,n=67).Venous blood samples were obtained for a nutrition-associated assessment and liver function tests on the day before surgery and 6 d after surgery.The assessment of clinical outcome was based on postoperative complications.Follow-up for infectious and noninfectious complications was carried out for 30 d after hospital discharge.Readmission within 30 d afterdischarge was also recorded.RESULTS:Compared with the TPN group,a significant decrease in prealbumin(PAB)(P=0.023)was seen in the EEN/PN group.Total bilirubin(TB),direct bilirubin(DB)and lactate dehydrogenase(LDH)were significantly decreased on day 6 in the EEN/PN group(P=0.006,0.004 and 0.032,respectively).The rate of gradeⅠcomplications,gradeⅡcomplications and the length of postoperative hospital stay in the EEN/PN group were significantly decreased(P=0.036,0.028and 0.021,respectively),and no hospital mortality was observed in our study.Compared with the TPN group(58.2%),the rate of infectious complications in the EEN/PN group(39.3%)was significantly decreased(P=0.042).Eleven cases of delayed gastric emptying were noted in the TPN group,and 6 cases in the EEN/PN group.The rate of delayed gastric emptying and hyperglycemia was significantly reduced in the EEN/PN group(P=0.031 and P=0.040,respectively).CONCLUSION:Early enteral combined with PN can greatly improve liver function,reduce infectious complications and delayed gastric emptying,and shorten postoperative hospital stay in patients undergoing PD.     

Fever and abdominal mass in a 74-year-old man with long-standing vena caval obstruction

Stenographic reports of weekly clinicopathologic conferences held in Barnes and Wohl Hospitals are published in each Issue of the Journal. Members of the Departments of internal Medicine, Radiology, and Pathology of the Washington University School of Medicine participate jointly in these conferences. Kenneth M. Ludmerer, M.D., and John M. Kissane, M.D., are the editors of this feature.     

A pancreaticoduodenectomy is acceptable for periampullary tumors in the elderly,even in patients over 80 years of age

Background

Although the mortality rates for pancreaticoduodenectomy have been reported to be low for periampullary tumors at high-volume centers, postoperative results still remain unclear for elderly patients over 80 years of age.

Methods

This was a retrospective study of patients who underwent a pancreaticoduodenectomy and consisted of 335 patients who were treated for periampullary tumors between January 1994 and August 2008. The main outcomes were postoperative complications, mortality, and the length of hospital stay among the elderly patients, and they were analyzed in three groups: elderly patients over 80 years old, septuagenarians, and those under 70 years of age.

Results

The performance status of elderly patients was lower than that of the patients under 70 (P < 0.05), and the elderly had a higher American Society of Anesthesiologists physical status classification score (P < 0.001) as well as low hemoglobin and serum albumin levels (P < 0.01 and P < 0.001, respectively). The incidence of delayed gastric emptying in the elderly was higher; however, there was no significant difference. The other outcomes in the elderly group were similar to those of the other groups.

Conclusions

Pancreaticoduodenectomy was considered to be a feasible surgical procedure for elderly patients who had a good performance status.     

Cardiac lymphoma associated with superior vena caval syndrome and cardiac tamponade: case history

A sixty-three-year-old patient with malignant histiocytic lymphoma of the heart presented with both superior vena cava syndrome and cardiac tamponade. A two-dimensional echocardiogram showed a large tumor mass in the right atrium and pericardial effusion with right ventricular compression. Superior and inferior vena cavagrams disclosed a lobulated tumor located in the right atrium that extended into and obstructed the superior vena cava. After the pericardial effusion was drained and the diagnosis was established, the patient was irradiated and given chemotherapy with resolution of the tamponade and superior vena cava obstruction.