Living Donor Liver Transplantation Combined with Whipple’s Procedure for Metastatic Gastrinoma: a Clinical Case with 5 Years Follow-Up

Introduction: Most patients with gastro-enteropancreatic neuro-endocrine tumours present with liver metastases at the time of diagnosis. As metastases are usually widespread in the liver, though remain confined to this organ for long periods of time, liver transplantation could be in some cases a possible treatment option. Material and methods: We herein report the case of a 24-year-old male with Zollinger-Ellison syndrome, who was referred to our department after having had a right hepatectomy for metastatic lesions, followed by chemotherapy. At that time, the site of the primary tumour was undefined. Following the diagnosis of a primary gastrinoma in the pancreatic head after selective angiography of the pancreatic vessels with hormonal sampling tests in our institution, the decision was made to offer a living donor liver transplantation (LDLT).

Results: A right lobe LDLT was carried out together with a Whipple’s procedure. The operation was uneventful and five years later the patient remains in an excellent clinical condition, although with a suspicion of relapsed gastrinoma. Discussion: according to the literature, some conditions, such as the 1-step combined surgery, gastrinoma primary tumour and duodeno-pancreatical localisation are considered as poor prognostic factors, whereas young age and tumour expression of Ki-67 < 5% are linked to a more favourable outcome. We think that in cases of long-lasting stability of the disease under chemotherapy, together with the presence of a low Ki-67 expression index, such a treatment could be proposed to young and symptomatic patients, provided the resection of the primary tumour is feasible. Long-term survival may be achieved in metastatic gastro-enteropancreatic neuro-endocrine tumours after LDLT combined with Whipple’s procedure, despite tumour relapse.     

Minimally Invasive Mandible Reduction Using Lee’s Rasp &; Saw

Mandible reduction is one of the most well-known facial contouring procedures used to reduce the size of the face for Asian patients, and many studies have been conducted. However, these studies have largely included only exposure by the intraoral incision, which can be accompanied by serious emergency situations and complications. Difficulties in mandible reduction can be encountered during the process of maintaining visual sight for the approaching saw. In maintaining the visual field, the patient’s mouth should be widely stretched while the incision and periosteal elevation is extended largely around the entire mandible. This occasionally has been related to serious emergency situations such as airway obstruction caused by edema and massive bleeding. The authors have tried to solve these difficulties with the help of new surgical equipment, which includes a bone dust–collecting rasp with simultaneous suction and irrigation known as Lee’s Rasp & Saw. The “minimally invasive” surgical technique can be used with this new rasp and saw. Rasping is performed through a 4- to 6-mm stab incision like other endoscope-assisted techniques so soft tissue injury is minimized and the operation procedures are simplified. The authors have applied this new surgical method to more than 260 male and female patients, and their experience has been satisfying in terms of decreased complications and reduced operation times. This report describes the external approach only. The authors are evaluating this new method using an intraoral approach as well, and the results are as good as those for the external approach.     

‘Stent in a Stent’—An Alternative Technique for Removing Partially Covered Stents Following Sleeve Gastrectomy Complications

Endoscopic stenting is a relatively new technique for the treatment of post sleeve gastrectomy complications. Partially covered stents are used in this method to minimise the risk of migration but they are associated with difficulties with removal. Patients requiring emergency stenting following sleeve gastrectomy underwent insertion of a partially covered metallic stent. One month later, if the stent was not easily removable, a fully covered overlapping stent was inserted and the patient was readmitted 2 weeks later for removal of both stents. Four patients required stenting following sleeve gastrectomy leaks, and one patient required stenting for a stricture. In these cases, a ‘stent in a stent’ technique was used for removal. This technique allows the safe removal of partially covered stents inserted following sleeve gastrectomy complications.     

Treatment of Bowler’s Neuroma with Digital Nerve Translocation

Bowler’s thumb presents as paresthesias or a neuroma involving the ulnar digital nerve of the thumb. Over 95 million people enjoy bowling worldwide with nearly 3 million certified league bowlers in the United States. While the incidence of Bowler’s thumb is unknown, it is an unrelenting nuisance for bowlers, and symptoms can be severe enough to prevent further sport participation. The condition can be managed nonoperatively with rest and splinting, but successful nonoperative treatment frequently requires discontinuation of bowling. The pressure on athletes to resume sports participation sooner and the possibility of nonoperative treatment failure mandate the need for development of a dependable surgical procedure for this condition. We present a case report of a successful surgical treatment by transposing the ulnar digital nerve dorsal to the adductor pollicis. The patient returned to manual labor and resumed bowling and is symptom free 3 years postsurgery.     

Editorial Commentary: Which Procedure Contributes to Best Outcomes After Arthroscopic Reduction and Minimally Invasive Surgery for Ankle Fractures?

The algorithm of arthroscopic reduction and minimally invasive surgery (ARMIS) can decrease the incidence of complications and reoperations, in spite of longer operative times and higher doses of irradiation for the patients with a supination–external rotation ankle fracture. At the present time, however, we cannot identify which procedure contributes to improved outcomes with use of the ARMIS algorithm.     

Visceral Pseudoaneurysm Embolisation Using ‘Ping-Pong’ Technique: Importance of Dual Arterial Catheterisation to Prevent Rupture

Supracolic peri-pancreatic visceral pseudoaneurysms combine the challenges of difficult location for open surgical repair with unpredictable risk of fatal exsanguination. Endovascular embolisation is a well-established method of safely decompressing these lesions using a variety of thrombogenic agents. A single catheter technique is commonly employed to achieve this outcome. However, there is also a risk of iatrogenic rupture during these procedures as a result of occlusion of one vessel allowing pressure to rise through any other vessel(s). Thus a thorough understanding of the flow dynamics prior to and during occlusion is essential for safe decompression. We report the adaptation of dual arterial catheter technique in treating these lesions in an 80-year old man with a large, leaking peripancreatic visceral pseudo-aneurysm. Our technique of alternating between intervention and observation of effect allows greater control of the potentially unpredictable haemodynamic situation.     

Treatment of Peyronie’s Disease: 2012 Update

Peyronie’s disease (PD) is the occurrence of a fibrous inelastic scar of the tunica albuginea of the penis. It is a relatively common disorder among men, with a reported prevalence of 3% to 8%. It is often associated with penile pain, anatomical deformities in the erect state, and difficulty with intromission. Because the exact pathophysiology of PD remains unknown and standards for evaluating or reporting treatment outcomes are unclear, research on effective therapies has been limited. The benefits of nonsurgical treatment options are conflicting and further controlled studies are required before any therapy can be fully recommended. The success of surgery has been well documented; however, surgery is invasive and costly and carries potential side effects. Patients who report stable disease that has been present for longer than 12 months and who experience penile deformity preventing satisfactory sexual intercourse are best suited for surgery. Additionally, failed conservative management and a patient’s preference for definitive correction are important additional indications for surgical treatment.     

Subclinical Intestinal Inflammation in Patients with Crohn’s Disease Following Bowel Resection: A Smoldering Fire

Background/Aims  

Fecal lactoferrin is the direct expression of intestinal inflammation in Crohn’s disease (CD). The aim of this study was to analyze the in vivo intimate correlation between intestinal and systemic inflammation in CD patients in clinical remission following bowel resection. The secondary end point was to evaluate the prognostic value of lactoferrin levels and serum cytokines in terms of need of surgery for recurrence in these patients.     

Minimally Invasive Approach for Spleen-Preserving Distal Pancreatectomy: a Comparative Analysis of Postoperative Complication Between Splenic Vessel Conserving and Warshaw’s Technique

Background

Spleen-preserving distal pancreatectomy with Warshaw’s technique (WT) was reported to have higher spleen-related complication. The aim of this study was to evaluate the postoperative complication between the splenic vessel-conserving technique (SVC) and the WT when they were performed by the minimally invasive approach.

Methods

From January 2006 to June 2015, data of the patients who had laparoscopic or robotic-assisted spleen-preserving distal pancreatectomy for benign or borderline malignant tumors were retrospectively reviewed. Patients were divided into SVC and the WT group for comparison.

Results

Of the 89 patients who had the spleen-preserving distal pancreatectomy, 63 were SVC, whereas 26 were WT. The CT scans showed that patients who had WT were found to have higher rate of splenic infarction (P?<?0.001) and had significantly higher rate of collateral vessel formation at 1 year (P?<?0.001). All the splenic infarctions were low grade and asymptomatic which resolved spontaneously. None of the patients with collateral formation experienced gastrointestinal bleeding. The postoperative complication of SVC and WT did not differ significantly.

Conclusion

SVC and WT were found to have comparable outcome. Both techniques can be used to achieve higher spleen-preserving rate.

     

Treatment of Morton’s neuroma: A systematic review

Background

The treatment of Morton’s neuroma (MN) can be operative, conservative and infiltrative. Our aim was the evaluation of evidence on outcomes with different types of conservative, infiltrative and surgical treatment in patients affected by primary MN.

Minimally Invasive Parathyroidectomy Using the Lateral Focused Miniincision Approach: Is There a Learning Curve for Surgeons Experienced in the Open Procedure?

BACKGROUND: Minimally invasive parathyroidectomy (MIP) has gained acceptance as the standard of care for management of primary hyperparathyroidism in which a single adenoma can be localized. The aim of this study was to determine if there is a learning curve for MIP using the lateral focused miniincision approach performed by surgeons experienced in open parathyroidectomy. STUDY DESIGN: This is a retrospective case series comprising all parathyroid operations undertaken by three surgeons in the University of Sydney Endocrine Surgical Unit from 2003 to 2005. Outcomes of the experienced surgeon were compared with those of the two surgeons commencing practice. RESULTS: There were 699 parathyroidectomies performed in the Unit during the 36-month period (experienced surgeons: 438 versus commencing physicians: 261). Of the parathyroidectomies performed, 57% done by experienced surgeons were minimally invasive compared with 38% of those performed by surgeons commencing practice (p < 0.001). There were no differences in the number of complications (p = 0.21), conversions to open exploration (p = 0.6), and cure rates (p = 0.9) in the MIP patients in both groups. The initial (first 131 patients) and subsequent (next 130 patients) parathyroidectomy experiences of surgeons commencing practice were examined. In the initial experiences, 28% of the cases were minimally invasive compared with 48% in the subsequent experiences (p < 0.001). There were no differences in the number of complications (p = 0.3), conversions to open exploration (p = 0.9), and cure rates (p = 0.9). CONCLUSIONS: For surgeons experienced in open parathyroidectomy, there is no technical learning curve using the lateral focused miniincision technique for MIP. There is, however, a learning curve for patient selection.