Pancreaticoduodenectomy for suspected periampullary cancers: the mimes of malignancy

Background:

Pancreaticoduodenectomies are often undertaken with suspicion of malignancy. We undertook this study to determine if and how unnecessary pancreaticoduodenectomies can be avoided.

Methods:

Data from patients undergoing pancreaticoduodenectomy were prospectively collected. Operative indications, including presenting symptoms and results with imaging, with or without biopsy, were reviewed.

Results:

From 1996 through to 2007, 551 patients underwent pancreaticoduodenectomy at our institution. Chronic pancreatitis was the operative indication in 3% of patients; premalignant/malignant lesions were present in 86% of patients. Eleven per cent of patients underwent ‘unnecessary’ pancreaticoduodenectomies with presumptive diagnoses of cancer but were without premalignant/malignant disease on final report by Pathology [pancreatitis in 63%, serous cystadenomas (<4 cm) in 14%]. Of the unnecessary resections, 20% had histories and imaging sufficient to diagnose pancreatitis, 18% had inaccurate preoperative brushings/biopsies ‘documenting’ cancer, 11% had clear misinterpretations of their imaging studies and 7% had inadequate preoperative evaluations. However, 45% had signs/symptoms of cancer with a pancreatic head mass/biliary stricture.

Conclusion:

Only a small minority of patients undergoing pancreaticoduodenectomy for suspicion of periampullary cancer do so unnecessarily. Preoperative review of biopsies, better considerations of pancreatitis and careful evaluation of imaging, particularly for cystic masses, will decrease unnecessary pancreaticoduodenectomies.     

Symptoms and life changes after total pancreatectomy: a qualitative study

BackgroundTotal pancreatectomy (TP) is a major surgical procedure that involves lifelong exocrine and endocrine pancreatic insufficiency. Qualitative evidence is sparse regarding patients' experiences after the operation. The aim of this study was to explore patients’ experiences of symptoms that occur after TP and how these symptoms affect their health and life situations.MethodsA qualitative design with prospective consecutive sampling and an inductive thematic analysis was used. Semistructured interviews were postoperatively performed at 6–9 months with 20 patients undergoing TP in two university hospitals in Sweden.ResultsTwo main themes emerged from the analysis: “Changes in everyday life” and “Psychological journey”. Patients experienced symptoms related to diabetes as the major life change after the operation, and they were also limited by symptoms of exocrine insufficiency, difficulties with food intake and physical weakness. In the psychological journey that patients underwent, the support received from family, friends and the health care system was important. Moreover, patients experienced a general need for more extensive information, especially regarding diabetes.ConclusionPatients experience a lack of sufficient support and education after TP, particularly concerning their diabetes. Further efforts should be undertaken to improve information and the organization of diabetes care for this patient group.     

Preoperative interleukin-2 immunotherapy in pancreatic cancer: preliminary results

BACKGROUND/AIMS: Cancer patients' immunodeficiency, made worse by surgery, represents a poor prognostic factor for postoperative complications and long-term survival. Interleukin-2 has been shown to contrast the immunodeficiency related to the tumor and surgical treatment. The aim of this study is to evaluate the effectiveness of preoperative immunotherapy with interleukin-2 in pancreatic cancer patients. METHODOLOGY: 19 patients with pancreatic cancer undergoing radical surgery were divided in 2 different groups. Group 1: 9 patients treated with preoperative Interleukin-2 (9 million IU of IL-2 s.c. for 3 consecutive days) followed by pancreaticoduodenectomy after 36 hours; group 2: 10 patients who underwent pancreaticoduodenectomy without any neoadjuvant treatment. Two groups were well matched for age, sex, stage of disease, preoperative tumor markers and preoperative hematological assessment. Inflammatory cells' infiltration on the resected specimens, pre- and postoperative blood lymphocyte counts were evaluated as well as postoperative complications and survival and compared between the groups. RESULTS: Hematological and histological findings showed no significant difference between the 2 groups. Postoperative complications were more frequent in the control than in the treated group (p<0.05). Two-year survival was 33% in the treated group compared with 10% in the control (p<0.05). CONCLUSIONS: Preoperative Interleukin-2 administration seems to achieve a positive effect on postoperative complications and survival in pancreatic adenocarcinoma.     

Arterial and vena caval resections combined with pancreaticoduodenectomy in highly selected patients with periampullary malignancies

BACKGROUND/AIMS: To obtain a margin-negative resection and increase the indication for resection of periampullary malignancies, pancreaticoduodenectomy with a SM-PVR (superior mesenterico-portal vein resection) has been performed. However, an arterial resection, other vascular resections except SM-PVR (e.g., an inferior vena caval resection), or a metastatic tumor resection combined with pancreaticoduodenectomy has yet to be fully elucidated because of the high risk of postoperative complications and extremely poor long-term survival in patients undergoing these exceptional procedures. The present report focused on highly selected patients undergoing an arterial resection or a vena caval resection associated with pancreaticoduodenectomy. METHODOLOGY: Besides 31 patients with periampullary tumors undergoing pancreaticoduodenectomy associated with SM-PVR in our department, a group of 4 patients underwent arterial resections and another patient underwent pancreaticoduodenectomy combined with a resection of liver metastasis together with an inferior vena caval resection. These five patients were reported in the present study. RESULTS: A 27 year-old-woman presented pancreatic ductal adenocarcinoma of the pancreatic head and a liver metastasis in which involvements of the superior mesenterico-portal vein and the inferior vena cava were shown. Pancreaticoduodenectomy was performed with SM-PVR associated with a left hemihepatectomy combined with a segment 1 resection and an inferior vena caval resection. The patient did not present severe postoperative complications and experienced a good quality of life during 16 months after surgery. Four other patients underwent arterial resections. These arterial resections were performed only when a margin-negative resection was feasible. The superior mesenteric artery was resected and reconstructed with a Goretex graft in one patient. The right hepatic artery was resected and reconstructed with a saphenous graft in two patients. The other patient underwent a resection of the common hepatic artery and reconstruction was performed with the splenic artery. Three of the four patients presented postoperative complications but were conservatively treated. Two patients are still alive 25 months and 8 months after surgery. One patient died of sepsis 5 months after surgery, and the other died of cancer progression 19 months after surgery. CONCLUSIONS: The indication for retropancreatic arterial resection associated with pancreaticoduodenectomy should be carefully evaluated only when a margin-negative resection can be achieved. An appropriate bypass method of arterial reconstruction should be selected because a direct end-to-end anastomosis is not always feasible. Hepatectomy for metastases of pancreatic ductal carcinoma should be also regarded as an exceptional procedure.     

Evidence against routine scheduling of surveillance bronchoscopy after stent insertion

STUDY OBJECTIVES: To determine whether routine scheduling of surveillance flexible fiberoptic bronchoscopy is warranted within 2 to 3 months after silicone stent insertion for central airway obstruction. DESIGN: Retrospective cohort study. SETTING: University medical center. PATIENTS: All patients with silicone stents placed for benign or malignant tracheobronchial obstruction during a 3-year period. METHODS: Incidence of stent-related complications, new respiratory symptoms, and need for therapeutic bronchoscopic intervention were noted in patients undergoing surveillance bronchoscopy (SFFB) and emergency bronchoscopy (EFFB), defined as flexible fiberoptic bronchoscopy prompted by onset of new symptoms before the date of scheduled SFFB. RESULTS: One hundred one silicone stents were inserted in 88 patients (47 with cancer, 41 with benign disease). Eighteen patients died within 2 months and had no bronchoscopy. Seventy patients underwent either SFFB or EFFB. Stent-related complications were detected in 9 of 31 asymptomatic patients (29%) undergoing SFFB; all had received tumor-specific therapy after stent insertion (in 7 of 8 patients [88%] reporting new respiratory symptoms at the time of SFFB, and in 26 of 31 patients [84%] undergoing EFFB). Overall, stent-related complications were detected in nine asymptomatic patients (10% of total), of which only four patients (5% of total, but 13% of all asymptomatic patients) required therapeutic interventions. CONCLUSION: Routine SFFB within 2 to 3 months after stent insertion did not detect a high incidence of stent-related complications among patients without new respiratory symptoms.     

Complications and chemotherapy have little impact on postoperative quality of life after pancreaticoduodenectomy – a cohort study

BackgroundWith the poor prognosis of pancreatic cancer and the high rate of postoperative complications after pancreaticoduodenectomy, it is important to evaluate how the operation affects patients’ quality of life.MethodsThis single-centre study included all patients undergoing pancreaticoduodenectomy from 2006 to 2016. Quality of life was measured with two questionnaires preoperatively, and at 6 and 12 months postoperatively. Comparisons between groups were made using a linear mixed models analysis.ResultsOf 279 patients planned for pancreaticoduodenectomy, 245 underwent the operation. The postoperative response rates were all 80% or more. Differences were found in one domain between the early and late time periods and three domains between patients receiving and not receiving adjuvant chemotherapy. No significant differences were found between patients with and without severe postoperative complications. However, the demographic variables of age group, sex, preoperative diabetes and smoking all exerted a significant impact on postoperative quality of life.ConclusionWhile little or no impact was shown for the factors of postoperative complications, time period and adjuvant chemotherapy, demographic data, such as age, sex, preoperative diabetes and smoking, had considerable impacts on postoperative quality of life after pancreaticoduodenectomy.     

A non-randomized comparative study of laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy

Background/Aims: Laparoscopic surgery for periampullary disease is still a challenging operation. The aim of this study was to compare the perioperative outcomes of patients undergoing conventional pancreaticoduodenectomy (PD) with the outcomes of those undergoing laparoscopy-assisted PD. Methodology: A retrospective analysis was conducted on 51 consecutive patients who underwent laparoscopy-assisted or open PD for periampullary disease. Results: There were no significant differences in the preoperative demographic or clinical data of the two study groups. Although there were no significant differences in the operative time between the two study groups, blood loss in the laparoscopy-assisted PD group was significantly smaller than that in the open PD group. There were no significant differences in the occurrence of postoperative complications between the two groups. Conclusions: Laparoscopy-assisted PD is a feasible and safe surgical procedure that provides the advantages expected from a minimally invasive surgery including less blood loss.     

Prevalence of pancreatic exocrine insufficiency after pancreatic surgery measured by 13C mixed triglyceride breath test: A prospective cohort study

BackgroundPatients undergoing pancreatic surgery are at risk of pancreatic exocrine insufficiency (PEI) and needing pancreatic enzyme replacement therapy (PERT).MethodsThis study included 254 patients undergoing pancreatic surgery for oncologic indications. A¹³C mixed triglyceride breath test was performed immediately preoperative and postoperative. This test analyzes the pancreatic remnant lipase activity measuring ¹³CO₂ in breath samples after a test meal with 1.3-distearyl-(¹³C-Carboxyl)octanol-glycerol. Cumulative percent dose recovery after 6 h of less than 23% confirms PEI. In addition, PEI was compared between pathology subgroups.ResultsIn 197 patients undergoing pancreaticoduodenectomy, cPDR-6h decreased significantly from a median of 32.84% before to 15.80% after surgery (p < 0.0001). This decrease in exocrine function was significant in all pathology subgroups except in pancreatic neuroendocrine tumors. Exocrine function decreased most in pancreatic ductal adenocarcinoma (PDAC). In addition, the percentage of patients needing PERT because of PEI increased from 25.9% to 68.0% postoperative (p < 0.001). Overall, patients with an MPD diameter of more than 3 mm had a higher risk of developing postoperative PEI: 62.7% compared to 37.3% (p = 0.009), OR = 3.11.In contrast, the majority of the 57 patients undergoing a distal pancreatectomy did not experience any significant change in exocrine function.ConclusionsThe vast majority of patients undergoing pancreaticoduodenectomy for oncologic indications experience a significant drop in exocrine function, are at high risk of developing pancreatic exocrine insufficiency and consequently need to be treated with pancreatic enzyme replacement therapy. Therefore, systematic screening for pancreatic exocrine insufficiency is needed after pancreaticoduodenectomy.     

Long-term survival after pancreaticoduodenectomy in patients with ductal adenocarcinoma of the pancreatic head

Background: Pancreatic ductal adenocarcinoma(PDAC) has the worst prognosis of all malignant tumors due to unavailable screening methods, late diagnosis with a low proportion of resectable tumors and resistance to systemic treatment. Complete tumor resection remains the cornerstone of modern multimodal strategies aiming at long-term survival. This study was performed to investigate the overall rate of long-term survival(LTS) and its contributing factors. Methods: This was a retrospective single-center analysis of consecutive patients undergoing pancreaticoduodenectomy(PD) for PDAC between 2007 and 2014 at the St. Josef Hospital, Ruhr University Bochum, Germany. Clinical and laboratory parameters were assessed and evaluated for prediction of LTS with Cox regression analysis. Results: The overall rate of LTS after PD for PDAC was 20.4%(34/167). Median survival was 24 months regardless of adjuvant treatment. Carbohydrate antigen 19-9 levels, tumor grade, lymph vessel invasion, perineural invasion and reduced general condition were significantly associated with LTS in univariate analysis( P 0.05). Serum levels of carbohydrate antigen 19-9, American Joint Committee on Cancer stage, tumor grade, abdominal pain, male, exocrine pancreatic insufficiency and duration of postoperative hospital stay were independent predictors of cancer survival in multivariable analysis. Conclusions: Cancer related characteristics are associated with LTS in multimodally treated patients after curative PDAC surgery.     

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (FNA) of liver lesions.

BACKGROUND: Endoscopic ultrasonography (EUS) is not traditionally thought to be clinically applicable in liver imaging. EUS-guided fine-needle aspiration of the liver has not been well described. METHODS: A prospective study was conducted in which 574 consecutive patients with a history or suspicion of gastrointestinal or pulmonary malignant tumor undergoing upper EUS examinations underwent EUS evaluation of the liver. Fourteen (2.4%) patients were found to have focal liver lesions and underwent EUS-guided fine-needle aspiration. RESULTS: The median largest diameter of the liver lesions was 1.1 cm (range 0.8 to 5.2 cm). The mean number of passes was 2.0 (range 1 to 5 passes). All fine-needle passes yielded an adequate specimen. One of the 14 patients underwent EUS-guided fine-needle aspiration of 2 liver lesions. Fourteen of the 15 liver lesions sampled by means of EUS-guided fine-needle aspiration were malignant and one was benign. Before EUS, computed tomography (CT) depicted liver lesions in only 3 of 14 (21%) patients. Seven of 14 patients had a known cancer diagnosis. For the other 7, the initial diagnosis of cancer was made by means of EUS-guided fine-needle aspiration of the liver. There were no immediate or late complications. CONCLUSIONS: EUS can detect small focal liver lesions that are not detected at CT. Findings of EUS-guided fine-needle aspiration can confirm a cytologic diagnosis of liver metastasis and establish a definitive M stage that may change clinical management.     

Choosing the right survey—patient reported outcomes in esophageal surgery

Patient reported outcomes (PROs) fulfill a crucial and unique niche in patient management, providing health-care providers a glimpse into their patients’ health experience. This is of utmost importance in patients with benign and malignant disorders of esophagus requiring surgery, which carries significant morbidity, in part due to a high burden of symptoms affecting health-related quality of life (HRQOL). There are a variety of generic and disease-specific patient reported outcome measures (PROMs) available for use in esophageal surgery. This article provides a broad overview of commonly used HRQOL instruments in esophageal surgery, including their utility in comparative effectiveness research, prognostication and shared decision-making for patients undergoing surgery for benign and malignant disorders of the esophagus.     

Impact of preoperative chemoradiotherapy on survival in patients with resectable pancreatic cancer

AIM:To explore whether preoperative chemoradiation therapy improves survival of patients with pancreatic cancer undergoing resectional surgery. METHODS:Forty-seven patients with a malignant pancreatic tumor localized in the head or uncinate process of the pancreas underwent radical pancreaticoduodenectomy. Twenty-two received chemoradiation therapy (gemcitabine and radiation dose 50.4 Gy) before surgery (CRR) and 25 patients underwent surgery only (RO). The study was non-randomised. Patients were identified from a prospective database. RESULTS:The median survival time was 30.2 mo in the CRR group and 35.9 mo in the RO group. No statistically significant differences were found in subclasses according to lymph node involvement,TNM stages,tumor size,or perineural invasion. The one,three and five year survival rates were 81%,33% and 33%,respectively,in the CRR group and 72%,47% and 23%,respectively,in the RO group. In ductal adenocarcinoma,the median survival time was 27 mo in the CRR group and 20 mo in the RO group. No statistically significant differences were found in the above subclasses. The one,three and five year survival rates were 79%,21% and 21%,respectively,in the CRR group and 64%,50% and 14%,respectively,in the RO group. The overall hospital mortality rate was 2%. The morbidity rate was 45% in the CRR group and 32% (NS) in the RO group. CONCLUSION:Major multicenter randomized studies are needed to conclusively assess the impact of neoadjuvant treatment in the management of pancreatic cancer.     

Is gastric cancer a new indication for surveillance colonoscopy? Colon cancer is increased in gastric cancer patients]

BACKGROUND/AIMS: It has been reported that the risk of gastric polyp is increased in various colonic polyposis syndromes or in series of patients with sporadic colonic polyps. However, there are only a few large case controlled studies of colon cancer incidence in gastric cancer patients who underwent colonoscopy. The aims of this study were to determine the incidence of colorectal neoplasm and to evaluate the necessity of colonoscopic surveillance in patients with gastric cancer. METHODS: We performed colonoscopy in 105 patients with gastric cancer who agreed to undergo colonoscopy before or after 6 months from gastric resection between January 2002 and December 2004 in Kangbuk Samsung hospital. As a control group, 269 consecutive, age and sex matched patients without gastric neoplasm on gastroscopy who underwent colonoscopy within 6 months for the evaluation of various gastrointestinal symptoms during the year 2004 were included. Endoscopic reports and pathological results were reviewed retrospectively. RESULTS: In the patient group, adenomatous polyps were diagnosed in 24/105 patients (22.9%) and colorectal adenocarcinoma in 10/105 patients (9.5%). In the control group, adenomatous polyps were diagnosed in 78/269 patients (29.0%) and colorectal adenocarcinoma in 2/269 patients (0.7%). The incidence of colorectal adenocarcinoma between the patient group and control group showed significant differences (odds ratio 11.04, p=0.003). CONCLUSIONS: The risk of colorectal adenocarcinoma increases significantly in patients with gastric cancer. We suggest that the patients with gastric cancer might carry a high risk for colorectal cancer whom require surveillance colonoscopy.     

Bowel habits in hemorrhoid patients and normal subjects

OBJECTIVES: Bleeding, pain, soiling, and prolapse are the classic symptoms in hemorrhoid disease, but the patients sometimes report a variety of other symptoms. Little is known about functional bowel symptoms in patients with hemorrhoids and few studies have previously addressed this subject. The aim of this study was to compare patients with hemorrhoids with a control population regarding functional bowel symptoms and anorectal complaints. METHODS: One hundred consecutive patients who participated in a randomized study on hemorrhoidectomy completed a validated questionnaire on bowel and anorectal functional symptoms. Two hundred age- and gender-matched population based control subjects, and 100 gender-matched consecutive patients undergoing an orthopedic procedure served as two control groups, and completed the same questionnaire. RESULTS: Bowel frequency was the same in all three groups, but only 37% of the patients described their bowel movements as normal, compared to 55 and 67% of the controls (p < 0.001). Up to 37% of the patients reported bloating, compared to 18 and 26% in the control groups. Abdominal pain associated with bowel evacuation was experienced by 34% of the patients but in 3 and 5% of the controls (p < 0.001). Excessive straining, feeling of incomplete evacuation, and repeated toilet visits were significantly more usual in the patients. Reduced feeling of well being and disturbed social life caused by bowel symptoms was often reported by patients but rarely in the control groups. CONCLUSIONS: Beside hemorrhoidal symptoms, many patients with Grade 3-4 hemorrhoids have concomitant functional bowel symptoms, possibly associated with the irritable bowel syndrome. This knowledge might be important while selecting therapy for patients with hemorrhoids.     

The influence of chronic pancreatitis on carcinogenesis: an experimental study in rats

BACKGROUND: The literature contains many controversial or unclearly defined opinions about the risk of development of carcinoma of the exocrine part of the pancreas in patients with chronic pancreatitis. This and our own clinical observations based on analysis of patients with chronic pancreatitis treated surgically (anastomotic and resectional procedures) formed the background to an experimental study to define the risk of carcinogenesis in the course of chronic pancreatitis in rats. EXPERIMENTAL FINDINGS: In Wistar rats with chronic pancreatitis induced by etionine and then exposed to carcinogenic action of azaserine, proliferation, adenomas and acinic cell carcinomas of the exocrine part of the pancreas were diagnosed; the carcinomas were transplantable. In rats treated with azaserine only, benign proliferative lesions and adenomas were found. The presence of the p53 mutation protein was observed in carcinomatous pancreatic cells in malignant lesions of the pancreas in primary and transplantable cancers, but was not detected in benign proliferative lesions and adenomas. Chronic pancreatitis in Wistar rats predisposes the exocrine part of pancreas to malignant transformation. Growth of cancers of the exocrine part of the pancreas in male rats, but not in female rats, suggests hormonal determination of experimental pancreatic cancer. CONCLUSIONS: Results demonstrate that chronic pancreatitis in rats predisposes to malignant proliferative lesions, including acinic cell carcinoma. Expression of the protein product of p53 gene mutations correlated with neoplastic transformation of pancreas preceded by chronic pancreatitis, and was also detected in transplantable tumours.     

Colorectal cancer screening in patients presenting with an inguinal hernia: is it necessary?

BACKGROUND: It has been suggested that patients presenting with an inguinal hernia have an increased risk for colorectal cancer. Therefore, surgeons frequently request screening for colorectal cancer before surgery. The aim of this study was to assess the frequency of premalignant and malignant colonic lesions in a group of patients with an inguinal hernia, and to compare this with a control group of subjects undergoing screening colonoscopy. METHODS: In a case-control study, 243 patients with an inguinal hernia and no history of colonic neoplasia or symptoms suggestive of colorectal cancer underwent perioperative colonoscopy. The patients were stratified into two age groups: less than 50 years old (Group I) and more than 50 years old (Group II). The colonoscopic findings were compared with findings in 534 asymptomatic control patients who underwent screening colonoscopy. RESULTS: The mean age of patients (n=64) and control subjects (n=200) in Group I was similar, at 44 (3) years. The mean age of the patients (n=179) and control subjects (n=334) in Group II was, respectively, 70 (9) years and 64 (7) years (p<0.001). In Group I, no colorectal cancer was found in patients with inguinal hernia, and only one colorectal cancer was found among control subjects (p=0.571). In Group II, a diagnosis of colorectal cancer was made in 7 patients (4%) with inguinal hernia as compared with 10 patients (3%) among the control subjects (p=0.769). In both groups, the size and the histopathologic type of the polyps were not significantly different. CONCLUSIONS: In otherwise asymptomatic patients, the presence of inguinal hernia is not associated with an increased risk for colorectal cancer. Therefore, the presence of an inguinal hernia alone does not justify screening colonoscopy before herniorrhaphy.     

Impact of preoperative endoscopic ultrasound on non-small cell lung cancer staging

AIM: To determine if the addition of preoperative endoscopic ultrasound (EUS) to non-small cell lung cancer staging can reduce the proportion of patients in whom malignant mediastinal lymph nodes (inoperable disease) are discovered at surgery. METHODS: All patients with lung cancer who underwent mediastinoscopy or thoracotomy for cancer diagnosis, staging, or treatment from 1999 to 2005 were identified. Patients who had undergone preoperative EUS were designated as the EUS group. The control group was composed of similar patients who had not undergone preoperative EUS, and were frequency matched to those in the EUS group in a 3:1 ratio by preoperative cancer stage. The proportion of patients in whom malignant mediastinal lymph nodes were diagnosed at surgery was the primary outcome. RESULTS: Forty-four patients (average age, 67.8 years) met criteria for the EUS group, and 132 patients (average age, 67.4 years) were selected as control subjects. Overall, in the EUS group, 3 of 44 patients (6.8%) were found to have malignant mediastinal lymph nodes at surgery, compared with 41 of 132 patients (31.1%) in the control group (p = 0.003). In patients undergoing thoracotomy for cancer resection, 3% in the EUS group, compared with 20% in the control group, were found to have malignant mediastinal lymph nodes at surgery (p = 0.01). There was also a trend toward lower yield of mediastinoscopy done for cancer diagnosis or staging in the EUS group (p = 0.08). CONCLUSIONS: Preoperative EUS in lung cancer patients may reduce unnecessary surgery at which advanced inoperable disease is discovered.     

Safety of portal vein resection using centrifugal pump-assisted venous bypass between the superior mesenteric vein and the umbilical vein

BACKGROUND/AIMS: To achieve complete resection of pancreatic cancer, portal vein resection has been performed with increasing frequency at the time of pancreaticoduodenal resection (pancreaticoduodenectomy or total pancreatectomy). In the meantime, visceral congestion and liver ischemia are of great concern during the procedure. We investigated safety of portal vein resection using a centrifugal pump-assisted bypass between the superior mesenteric vein and the umbilical vein. METHODOLOGY: A retrospective comparison was performed in 49 consecutive patients who underwent pancreatoduodenal resection with or without portal vein resection using the bypass for pancreatic cancer. Twenty-two patients underwent portal vein resection using the bypass (group 1). The other 27 patients undergoing pancreatoduodenal resection without portal vein resection comprise the control group (group 2). RESULTS: Total operative time was 756 +/- 159 min and 526 +/- 109 min (p<0.001) and median blood loss was 2090 mL and 1200 mL in groups 1 and 2, respectively. However, the centrifugal pump-assisted bypass allowed stable bypass flow, and neither intestinal edema nor ischemic change of the liver was observed during portal vein resection and the subsequent reconstruction. Postoperatively, the peak postoperative AST, ALT and total bilirubin levels showed no significant difference and postoperative day of starting a liquid diet was similar between the groups (9.0 +/- 5.4 vs. 9.8 +/- 3.8 days, p=0.48). In addition, the rates of morbidity (55% vs. 48%) including biliary and pancreatic leak as well as mortality (9% vs. 4%) did not significantly differ between the 2 groups. CONCLUSIONS: The centrifugal pump-assisted bypass may be useful to prevent hepatic ischemia and visceral congestion during portal vein resection procedures, resulting in similar postoperative outcomes to the control after pancreaticoduodenal resection for pancreatic cancer.     

Effect of preoperative biliary drainage on surgical results after pancreaticoduodenectomy in patients with distal common bile duct cancer：Focused on the rate of decrease in serum bilirubin

AIM： To examine if the rate of decrease in serum bilirubin after preoperative biliary drainagecan be used as a predicting factor for surgical complications and postoperative recovery after pancreaticoduodenectomy in patients with distal common bile duct cancer.METHODS： A retrospective study was performed in 49 consecutive patients who underwent pancrea-ticoduodenectomy for distal common bile duct cancer. Potential risk factors were compared between the complicated and uncomplicated groups. Also, the rates of decrease in serum bilirubin were compared pre- and postoperatively. RESULTS： Preoperative biliary drainage （PBD） was performed in 40 patients （81.6%）. Postoperative morbidity and mortality rates were 46.9% （23/49） and 6.1% （3/49）, respectively. The presence or absence of PBD was not different between the complicated and uncomplicated groups. In patients with PBD, neither the absolute level nor the rate of decrease in serum bilirubin was significantly different. Patients with rapid decrease preoperatively showed faster decrease during the first postoperative week （5.5 ± 4.4 μmol/L vs -1.7 ± 9.9 μmol/L, P = 0.004）.CONCLUSION： PBD does not affect the surgical outcome of pancreaticoduodenectomy in patients with distal common bile duct cancer. There is a certain group of patients with a compromised hepatic excretory function, which is represented by the slow rate of decrease in serum bilirubin after PBD.