Retrospective Comparison of Robot-Assisted Minimally Invasive Versus Open Pancreaticoduodenectomy for Periampullary Neoplasms

Background

As with other open procedures now routinely performed using laparoscopy, minimally invasive pancreaticoduodenectomy (MIPD) may result in decreased pain, fewer wound complications, and accelerated recovery. However, when used for periampullary cancers, it is also important to assess if MIPD offers comparable oncologic outcomes.

Methods

Technical and perioperative outcomes were compared between patients with a preoperative diagnosis of periampullary neoplasm offered MIPD or open pancreaticoduodenectomy (OPD) from November 2009 to July 2011.

Results

Fifty-six consecutive MIPD and OPD (28 each) procedures were analyzed. Comparing MIPD to OPD, significant differences included longer median procedure time (431 vs 410 min, p?=?.04) and fewer median lymph nodes harvested (15 vs 20, p?=?.04). R0 resection rate tended to be lower (63 vs 88 %, p?=?.07) as well as surgical site infections (18 vs 43 %, p?=?.08). Clinically significant pancreatic fistula rate was the same between groups (21 %). Other outcomes such as narcotic pain medication use, length of stay, and 30-day readmission rates were also similar.

Conclusions

MIPD is feasible with comparable technical success and outcomes to OPD. However, there is a learning curve to the procedure and further experience and prospective study will be required to better establish the oncologic efficacy of MIPD to open resection.     

Management of Solid-pseudopapillary Neoplasms of the Pancreas: a Comparison with Standard Pancreatic Neoplasms

Background Solid-pseudopapillary neoplasms (SPNs) of the pancreas are increasingly diagnosed, but the exact surgical management in terms of extent of the resection is not well defined. Materials and Methods Patients operated on in our hospital between January 1993 and March 2005 formed the study groups. Results From 659 consecutive resections for pancreatic neoplasms, 12 female patients (1.8%) with a median age of 21 years who underwent resection for (SPN) are compared with the remaining 647 pancreatic resection patients. Jaundice (SPN 0 versus PR 73%, p < 0.001) and weight loss (SPN 0 versus PR 49%, p = 0.001) occurred significantly less often. Neoplasms were distributed equally among the pancreatic head (SPN 5 out of 12 patients versus PR 88%, p < 0.001) and corpus/tail (SPN 6 out of 12 patients versus PR 8%, p < 0.001). The operative time was significantly shorter (SPN 233 min versus PR 280 min, p = 0.012), and there were significantly fewer complications (SPN 1 of 12 patients versus PR 48%, p = 0.007). The mortality was not different (SPN 0 versus PR 1.6%, p = 1.000), and the hospital stay was significantly shorter (SPN 9 days versus PR 15 days, p = 0.012). The median size of the neoplasms was significantly larger (SPN 6.9 cm versus PR 2.5 cm). The median number of lymph nodes harvested was significantly fewer (SPN 1 versus PR 6, p = 0.001), and lymph node metastases occurred significantly less often (SPN 0 versus PR 64%, p < 0.001). The 5-year survival of SPN patients was 100% and is significantly better compared with survival of patients with pancreatic adenocarcinoma (12%, p < 0.001) and ampulla of Vater adenocarcinoma (22%, p = 0.005). Conclusions Patients with solid-pseudopapillary neoplasms of the pancreas present differently and the course of the disease is more benign. These patients can be adequately managed by pylorus-preserving pancreatoduodenectomy or spleen-preserving distal pancreatectomy with excellent early and long-term results.     

Operative Management of Recurrent Choledocholithiasis

Introduction

With the advent of endoscopic and image-directed percutaneous approaches, it is increasingly uncommon to require a surgical approach for recurrent bile duct stones.

Technique

We describe open side-to-side choledochoduodenostomy as one of the surgical options for recurrent bile duct stones. This procedure includes the following elements: exposure of the common bile duct, mobilization of the duodenum (Kocher maneuver), choledochotomy, inspection of the bile duct with a choledochoscopy, and anastomosis of the bile duct with the duodenum. Other options for operative management are discussed.

Conclusion

Surgical drainage procedures for recurrent bile duct stones can be performed for patients who fail to respond to endoscopic and nonoperative interventional treatments with good long-term outcomes.     

Periampullary and Duodenal Neoplasms in Neurofibromatosis Type 1: Two Cases and an Updated 20-Year Review of the Literature Yielding 76 Cases

Background  

Patients with neurofibromatosis type 1 (NF1) are at increased risk to develop tumors throughout the gastrointestinal tract, including neuromas, gastrointestinal stromal tumors (GIST), and periampullary somatostatin-rich carcinoids. Here, we briefly describe two male patients with NF1 and review the recent literature on this topic.     

Emergency Management in Patients with Late Hemorrhage after Pancreatoduodenectomy for a Periampullary Tumor

Background

The mortality rate due to late hemorrhage after surgery for periampullary tumors is high, especially in patients with anastomotic leakage. Patients usually require emergency intervention for late hemorrhage. In this study patients with late hemorrhage and their outcomes were analyzed. Furthermore, independent predictors for late hemorrhage, the need for emergency intervention, and type of intervention are reported.

Methods

From a prospective database that includes 1,035 patients who underwent pancreatoduodenectomy for periampullary tumors between 1992 and 2012, patients with late hemorrhage (>24 h after index operation) were identified. Patient, disease-specific, and operation characteristics, type of intervention, and outcomes were analyzed. Emergency intervention was defined as surgical or radiological intervention in hemodynamically unstable patients.

Results

Of the 47 patients (4.5 %) with late hemorrhage, pancreatic fistula was an independent predictor for developing late hemorrhage (OR 10.2). The mortality rate in patients with late hemorrhage was 13 % compared with 1.5 % in all patients without late hemorrhage. Twenty patients required emergency intervention; 80 % underwent primary radiological intervention and 20 % primary surgical intervention. Extraluminal location of the bleeding (OR 5.6) and occurrence of a sentinel bleed (OR 6.6) are indications for emergency intervention.

Conclusion

The type of emergency intervention needed for late hemorrhage is unpredictable. Radiological intervention is preferred, but if it fails, immediate change to surgical treatment is mandatory. This can be difficult to manage but possible when both radiological and surgical interventions are in close proximity such as in a hybrid operating room and should be considered in the emergency management of patients with late hemorrhage.     

Utility of Rush Paraffin-Embedded Tangential Sections in the Management of Cutaneous Neoplasms

BACKGROUND: Mohs micrographic surgery (MMS) modified by the use of tangential, formalin-fixed, paraffin-embedded histologic specimens is advantageous in treating selected skin neoplasms. OBJECTIVE: To review the use of our experience with a modification of MMS to treat lentigo maligna melanoma (LMM), lentigo maligna (LM) and other melanoma in situ (MIS) lesions, dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), and angiosarcoma. METHODS: Our experience utilizing a modification of MMS in the treatment of 77 patients with LM or other MIS, 23 patients with LMM, 11 patients with DFSP, 1 patient with AFX, and 1 patient with angiosarcoma was reviewed. Length of follow-up and rate of recurrence were examined. A literature review of this pertinent modification of the Mohs technique was performed. RESULTS: One hundred fourteen patients underwent MMS for melanocytic (LM, MIS, LMM), spindle cell (DFSP, AFX), and vascular malignant neoplasms. One patient developed locally recurrent LM and one patient with LMM developed satellite metastasis. Regional lymph node metastasis occurred in one patient with LMM and in a patient with angiosarcoma. CONCLUSION: The use of Mohs micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential histologic sections provides the accuracy and tissue conservation of the Mohs procedure while ensuring more confident interpretation of histology in cases of lentigo maligna, lentigo maligna melanoma, dermatofibrosarcoma protuberans, atypical fibroxanthoma, and angiosarcoma.     

Operative Management of Acute Mesenteric Ischemia

Annals of Vascular Surgery -     

Initial and Long-term Results in the Management of Primary Chest Wall Neoplasms

One hundred ten patients with primary chest wall neoplasms were analyzed for long-term results. The diagnosis of 59 malignant and 51 benign tumors was confirmed by the Armed Forces Institute of Pathology. No deaths were associated with primary definitive therapy. Among the five most frequently encountered malignant tumor types, five-year survivals were obtained in 9 of 17 (53%) patients with fibrosarcoma, 8 of 9 (89%) patients with chondrosarcoma, 2 of 8 (25%) patients with solitary chest wall plasmacytoma (multiple myeloma), 1 of 6 (17%) patients with Ewing's sarcoma, and 2 of 4 (50%) of patients with osteogenic sarcoma. Although the five-year survival appears to indicate therapeutic success in patients with Ewing's sarcoma and osteogenic sarcoma, patients with chondrosarcoma or fibrosarcoma may have a more protracted course, and those with solitary plasmacytoma usually develop multiple myeloma. The findings suggest that radical surgical excision is the treatment of choice for chondrosarcoma; radical surgical excision combined with chemotherapy, for fibrosarcoma and osteogenic sarcoma; surgical excision combined with radiation and chemotherapy, for Ewing's sarcoma; and systemic surveillance and therapy, for pathologically confirmed solitary plasmacytoma.     

Operative Management of Anterior Glenohumeral Instability

Abstract Introduction: Management of glenohumeral instability focuses more on operative treatment, while non-operative management, especially in young, active patients, may cause recurrent instability in a high percentage. Aim: Management of anterior glenohumeral instability, their advantages and limitations, the operative techniques and results will be described and discussed. Materials and Methods: A total of 379 patients who were operated between 1985 and 1994 for recurrent shoulder instability were followed up; 110 patients were managed with open Bankart procedure, 165 patients with arthroscopic Bankart and 98 patients were treated with a bone-block procedure. Follow-up evaluation was performed 53 months on average postoperatively. According to Rowe the functional results were classified as excellent and good in 91% with the open Bankart procedure, 80.6% with the arthroscopic Bankart repair and the results using the bone-block were rated as excellent and good in 95.4%. Overall complication rate was 16.3% (arthroscopic), 6.4% (open Bankart) and 4.4% (bone-block group). In patients with long-time results, degenerative signs at the glenoid and/or the humeral head were evaluated on plane radiographs (according to Rosenberg). In 17 long-term results of the bone-block procedure, Stage I osteoarthritis was identified in 25.5%, but no severe osteoarthrosis (stage II or III), while in the open Bankart group an osteoarthrosis rate of 18.6% (stages II and III) was found. Conclusion: Different types and causes of glenohumeral instability recommend different techniques for operative treatment of anterior glenohumeral instability. The bone-block procedure provided the best results regarding stability and function; long-term radiological results indicate that bony repair prevents and does not cause osteoarthrosis.