Bilateral double osteotomy in severe torsional malalignment syndrome: 16 years follow-up

Background

Torsional malalignment syndrome (TMS) is a well defined condition consisting of a combination of femoral antetorsion and tibial lateral torsion. The axis of knee motion is medially rotated. This may lead to patellofemoral malalignment with an increased Q angle and chondromalacia, patellar subluxation and dislocation. Conservative management is recommended in all but the most rare and severest cases. In these cases deformity correction requires osteotomies at two levels per limb.

Materials and methods

From 1987 to 2002 in our institution three patients underwent double femoral and tibial osteotomy for TMS bilateral correction (12 osteotomies). All patients were reviewed at mean follow-up of 16 years.

Results

At final follow-up no patients reported persistence of knee or hip pain. At clinical examination both lower limbs showed a normal axis and a normal patella anterior position. Pre-operative femoral version measurement showed an average hip internal rotation of 81.5° (range 80°–85°) and average hip external rotation of 27.2° (10°–40°). Thigh–foot angle measurement showed an average value of 38.6° (32°–45°). At final follow-up femoral version measurement showed an average hip internal rotation of 49° (range 45°–55°) and average hip internal rotation of 44.3° (20°–48°) (Figs. 1, 2, 3, 4, 5, 6). Thigh–foot angles measurement showed an average value of 21.6° (18°–24°) outward.

Conclusion

We recommend a clinical, radiographical and CT scan evaluation of all torsional deformity. In cases of significant deformity, internally rotating the tibia alone is not sufficient. Ipsilateral outward femoral and inward tibial osteotomies are our current recommendation for TMS, both performed at the same surgical setting.     

Primary adenocarcinoma of the urinary bladder: a single site analysis of 21 cases

Purpose

To investigate whether there is a difference between urachal and non-urachal adenocarcinomas in terms of patient survival and to determine the significant prognostic factors.

Methods

Thirty-four patients with histologically proven adenocarcinoma of the urinary bladder were treated at Huashan hospital between 1999 and 2010. 13 cases were excluded, including 12 patients with metastatic involvement from gastrointestinal or reproductive tracts and one without follow-up data after the initial consultation. Life tables, Kaplan–Meier, Cox regression analysis and log-rank test were used.

Results

The difference between patients with urachal adenocarcinoma and patients with non-urachal adenocarcinoma was not statistically significant using the Kaplan–Meier estimates (P = 0.0763). Clinical stage had a significant influence on survival (P = 0.0320, Fig. 2). Patients with surgical resection including partial and radical cystectomy did not have a better prognosis (P = 0.7992, Fig. 3). However, the difference is statistically significant between patients who received partial cystectomy and patients who received radical cystectomy (P = 0.0123, Fig. 4).

Conclusion

Survival of Patients with adenocarcinoma is correlated with clinical stage. Patients with urachal adenocarcinoma and non-urachal adenocarcinoma may have similar survival outcome. Tumor stage was a highly significant predictor of outcome (P = 0.0320). Surgical resection seems to be more important than chemotherapy in the cases of adenocarcinoma of the urinary bladder. We are in favor of radical cystectomy for all patients.     

Pilot Study to Evaluate Feasibility of Image-Guided Breast-Conserving Therapy in the Advanced Multimodal Image-Guided Operating (AMIGO) Suite

Background

The rate of reexcision in breast-conserving surgery remains high, leading to delay in initiation of adjuvant therapy, increased cost, increased complications, and negative psychological impact to the patient.1 ^– 3 We initiated a phase 1 clinical trial to determine the feasibility of the use of intraoperative magnetic resonance imaging (MRI) to assess margins in the advanced multimodal image-guided operating (AMIGO) suite.

Methods

All patients received contrast-enhanced three-dimensional MRI while under general anesthesia in the supine position, followed by standard BCT with or without wire guidance and sentinel node biopsy. Additional margin reexcision was performed of suspicious margins and correlated to final pathology (Fig. 1). Feasibility was assessed via two components: demonstration of safety and sterility and acceptable duration of the operation and imaging; and adequacy of intraoperative MRI imaging for interpretation and its comparison to final pathology. Fig. 1

Schema of AMIGO trial     

Giant Fibroadenoma Masquerading as Cystosarcoma Phylloides in an Elderly Lady—A Case Report and Review of Literature

Cavernous haemangioma is a rare disorder of the spleen with fewer than 100 cases reported [1]. Spleen may have an unusual degree of mobility and occupy an atypical location in less than 0.2 % of all the patients [2] Wandering spleen has been associated with incomplete fusion or even absence of gastrosplenic and lienorenal ligaments [3]. A 36-year-old woman presented with a six-month history of pain in the left hypochondrium and a massive splenomegaly. Ultrasonography, Doppler studies, and computed tomography were performed. Ultrasonography showed a large heterogeneous solid cystic mass, measuring 11.2 cm × 10.6 cm, located in the pelvis. Thin soft tissue connecting this mass to spleen noticed. Spleen was malrotated & in left lumbar fossa. Doppler studies shows prominent vessels at the periphery of the mass with high velocity external flow and scanty vascularity at the centre, probably suggesting haemangioma. Contrast-enhanced computed tomography (CECT) of the abdomen showed spleen in left lumbar region with a large heterogeneous, predominantly cystic mass lesion measuring 11.2 x 10.6 cm seen arising from diaphragmatic surface of lower pole of the spleen (Fig. 1), findings were suggestive of wandering spleen with a haemangioma or a hydatid cyst. The patient was explored by a left para-median incision under general anaesthesia. Peroperatively, there was a malrotated enlarged spleen with a large solid lesion confined to the lower half of the spleen (Fig. 2). Gastrosplenic ligament was not visualized. Total splenectomy was done after ligating the splenic artery as the main splenic artery was supplying the mass.     

Non-cirrhotic portal-systemic encephalopathy caused by enlargement of a splenorenal shunt after pancreaticoduodenectomy for locally advanced duodenal cancer: report of a case

We report a case of portal-systemic encephalopathy occurring secondary to a splenorenal shunt, 2 years after a pancreaticoduodenectomy for locally advanced duodenal carcinoma. A 55-year-old woman was brought to our hospital with a decreased level of consciousness. Laboratory testing revealed an elevated serum ammonia level (221 μg/dl) and normal liver function. Retrospective review of a series of contrast-enhanced computed tomography scans of the abdomen identified a splenorenal shunt, which had gradually enlarged over the past 2 years (Fig. 1). The decreased level of consciousness was thought to be due to portal-systemic encephalopathy secondary to the splenorenal shunt. We performed balloon-occluded retrograde transvenous obliteration to occlude the splenorenal shunt, following which her serum ammonia level returned to normal (28 μg/dl) and an alert level of consciousness was maintained.

The presence and distribution of alpha adrenergic receptors in human renal pelvis and calyces

In this study, we aimed to demonstrate the presence of Alpha (α) 1 receptors and subtypes in human pelvis and calyces, because an agent to facilitate kidney stone movement and help decrease pain may be an α 1 adrenergic blocker, as used in ureteral stones. Twenty patients who applied to our clinic for renal cell carcinoma were enrolled to the study. All patients underwent radical nephrectomy. After the specimens were removed, excisional biopsies were performed on healthy pelvises and calyces. Mean α-receptor stain rates in renal pelvis were 2.65 ± 0.74, 1.35 ± 0.81 and 2.9 ± 0.30 for α 1A, 1B and 1D, respectively. For calyces, the rates are 2.40 ± 0.82, 1.50 ± 0.76 and 2.75 ± 0.44 for α 1A, 1B and 1D, respectively (Fig. 1). When the staining patterns were compared, α 1A and 1D were expressed more in both pelvis and calyces than α 1B (p < 0.05). After the demonstration of α-adrenergic receptors in pelvis and calyces of human kidney, it may be helpful in coming up with new alternative treatments for patients suffering from kidney stones.

Suture button suspension following trapeziectomy in a cadaver model

Background

The safety and the effects of different trajectories on thumb motion of suture-button suspensionplasty post-trapeziectomy are not known.

Methods

In a cadaveric model, thumb range of motion, trapeziectomy space height, and distance between the device and nerve to the first dorsal interosseous muscle (first DI) were measured for proximal and distal trajectory groups. Proximal trajectory was defined as a suture button angle directed from the thumb metacarpal to the second metacarpal at a trajectory less than 60° from the horizontal; distal trajectory was defined as a suture button angle directed from the thumb metacarpal to the second metacarpal at a trajectory of greater than 60° from the horizontal (Fig. 1).

Results

There were no significant differences in range of motion and trapeziectomy space height between both groups. The device was significantly further away from the nerve to the first DI in the proximal trajectory group compared to the distal trajectory group, but was still safely away from the nerve in both groups (greater than 1 cm).

Conclusions

These results suggest that the device placement in either a proximal or distal location on the second metacarpal will yield similar results regarding safety and thumb range of motion.     

Robotic Left Pancreatectomy for Pancreatic Solid Pseudopapillary Tumor

Background

Solid pseudopapillary pancreatic tumors of pancreas are a rare entity, seen most often in females in their second or third decades. Although previously believed to be benign, this tumor is currently considered a low-grade malignant epithelial neoplasm with low metastatic rate and high overall survival.1,2 Its resection could be performed by robotic technique with respect to oncological principles to avoid tumor cell dissemination.3

Methods

In this multimedia article, we present a 28-year-old female with a history of hyperthyroidism who underwent a computed tomography (CT) scan because of a persistent high C-reactive protein level following caesarean section. This CT scan revealed a 7-cm cystic lesion of the pancreatic tail. The serum tumor marker CA 19-9 was normal. Further investigation with an magnetic resonance imaging (MRI) scan showed that the lesion was macrocystic with internal septas compatible with a solid pseudopapillary neoplasm.4 The patient was treated with robotic distal splenopanceatectomy (video).

Results

The operative time was 5 h with an estimated blood loss of 250 mL. No blood transfusion was necessary. The postoperative period was uneventful, and she was discharged on postoperative day 8. The histological finding revealed a solid pseudopapillary tumor of the pancreas pT2pN0 (0/14 lymph nodes removed). There was no evidence of clinical, biological, and radiological pancreatic fistula, and a control CT scan on postoperative day 8 did not show any abdominal fluid collection. The patient’s 1 month follow-up was normal.

Discussion

The robotic distal splenopancreatectomy is a procedure that offers some technical and oncological advantages over the already described minimally invasive techniques for distal pancreatic tumors.5,6 These advantages are mainly due to the stability of the operative field, to the 3D and magnified vision, and to the articulated robotic arms.7–9 The 3D representation and the stability of the operative field facilitate the performance of operative steps, as the creation of the retropancreatic tunnel and vascular identification. Moreover, the robotic articulated arms permit a superior handling of vascular structures, allowing a fine dissection that is extremely useful during lymphadenectomy. Articulated instruments easily achieve the correct rotation axis, thus minimizing peri-pancreatic tissue retraction and manipulation of the pancreatic gland. This smooth and no-touch technique in theory minimizes the risk of pancreatic capsule rupture as well as tumor cell dissemination, respecting oncological surgical standards. However, robotic surgery needs an adequate learning curve, especially concerning the installation and the lack of force feedback.

Conclusion

The robotic distal pancreatectomy is a possible minimally invasive technique for patients with solid pseudopapillary pancreatic tumors. It presents some advantages over the laparoscopic approach. Nevertheless its oncological indications are yet to be defined.10     

Mechanical failure of a lightweight polypropylene mesh

We report the case of a 41-year-old male who underwent repair of a recurrent midline abdominal incisional hernia with components separation. The hernia defect was repaired with a 30 cm × 30 cm underlay biological (Strattice) mesh used to partially bridge a small residual gap between the rectus muscles and reinforced with a 30 cm × 30 cm lightweight polypropylene onlay mesh (BARD? soft mesh). The patient later developed a large persistent seroma that was excised 18 weeks later. On exploration of the previous hernia repair, it was noted that the onlay polypropylene mesh had fractured leaving a 3 cm by 2 cm defect, but the underlying biological mesh was intact preventing a recurrence of the hernia (see Fig. 1). The fractured mesh was repaired with an additional onlay 10 cm × 10 cm polypropylene mesh, the seroma was de-roofed, and the patient was later discharged. This case highlights the early mechanical failure of a lightweight polypropylene mesh; the precise mechanism of failure in this case is unclear and, however, may be related to high intra-abdominal pressures postoperatively.

Pancreatic duct stenting for the duration of ERCP only does not prevent pancreatitis after accidental pancreatic duct cannulation: a prospective randomized trial

Background

Pancreatic duct stent placement during endoscopic retrograde cholangiopancreatography (ERCP) has been recommended in patients at risk for post-ERCP pancreatitis. However, the optimal duration of stent placement remains an open question. Our aim was to compare the efficacy of pancreatic stenting for the duration of ERCP only with spontaneous dislodgment/deferred endoscopic removal in preventing post-ERCP pancreatitis after accidental wire-guided pancreatic duct cannulation.

Methods

All patients in whom accidental wire-guided pancreatic duct cannulation had occurred during ERCP underwent immediate 5-Fr unflanged pigtail pancreatic duct stenting before attempting any other endoscopic maneuver. At the end of the ERCP, patients were randomly assigned to immediate stent removal (group A) or to leaving the stent in place (group B). Assessment of post-ERCP pancreatitis was blind.

Results

Post-ERCP pancreatitis occurred in 6/21 (29 %) patients in group A and in 0/19 patients in group B (P = 0.021); the two groups were well matched for their baseline characteristics. Post-ERCP pancreatitis was mild in two patients, moderate in two patients, and severe in two patients. Stents dislodged spontaneously in 14/19 (74 %) patients within 24–96 h; uneventful endoscopic removal was carried out after 96 h in 5 cases. Proximal stent migration did not occur in any case.

Conclusions

Pancreatic duct stent placement for the duration of ERCP only does not prevent post-ERCP pancreatitis. Pancreatic stents should be left in place until spontaneous dislodgment occurs or endoscopic removal is deemed timely. 5-Fr unflanged pigtail stents remain in place for a period sufficient to prevent post-ERCP pancreatitis and do not migrate proximally.     

Extent of Pancreatic Fibrosis as a Determinant of Symptom Resolution After the Frey Procedure: A Clinico-pathologic Analysis

Objective

The aim of this study was to evaluate the association of histopathologic features of chronic pancreatitis and pain relief after the Frey procedure.

Design

We retrospectively analyzed 35 patients who underwent the Frey procedure for chronic pancreatitis over a 5-year period (November 2005 to February 2011).

Setting

Thirty-five patients with varied etiologies of chronic pancreatitis and persistent symptoms were referred to a multi-disciplinary pancreatitis clinic where a consensus decision to recommend surgery was established. The Frey procedure was then performed.

Main outcome measures

We compared symptomatic outcomes with the degree of pancreatic fibrosis, duct dilatation, and presence of pancreatic duct stones based on a blinded evaluation of resected pancreatic tissue.

Results

Symptom resolution was associated with severe or extensive (>75 %) fibrosis and absence of symptom resolution was associated with mild or minimal (<25 %) fibrosis (chi-squared, p value?<?0.05). Symptom resolution was associated with pancreatic duct >4 mm and absence of symptom resolution was associated with pancreatic duct ≤4 mm (chi-squared, p value?<?0.05). There was no difference in outcomes for patients with and without pancreatic duct stones.

Conclusion

Symptom resolution after the Frey procedure is more likely in the setting of severe or extensive fibrosis due to chronic pancreatitis.     

The Impact of Internal or External Transanastomotic Pancreatic Duct Stents Following Pancreaticojejunostomy. Which One Is Better? A Meta-analysis

Background

The use of pancreatic duct stent to improve postoperative outcomes of pancreatic anastomosis remains a matter of debate, and the value of stenting when performing anastomosis for normal pancreas (soft and duct less than 3 mm) needs further study. The aim of the present meta-analysis was to evaluate the perioperative outcomes of patients with stenting during pancreatic anastomosis and compare the effect of external stent with that of internal stent indirectly.

Methods

A systematic literature search (EMBASE, MEDLINE, PubMed, The Cochrane Library, and Web of Science) was performed to identify studies evaluating external stent or internal stent. Included literature was assessed and extracted by two independent reviewers. A meta-analysis including comparative studies providing data on patients with and without external stenting or internal stenting during pancreaticojejunostomy anastomosis was performed.

Results

Thirteen articles including 1,867 patients were identified for inclusion: five randomized controlled trials study and eight observational clinical studies. Meta-analyses revealed that use of external stent was associated with a significantly decreased risk for pancreatic fistula in total (odds ratio (OR) 0.47; 95 % confidence interval (CI) 0.31–0.71; P?=?0.0004; I ²?=?3 %), pancreatic fistula in normal pancreas(OR 0.5; 95 % CI 0.30–0.82; P?=?0.007; I ²?=?5 %), and overall morbidity(OR 0.64; 95 % CI 0.45–0.90; P?=?0.01; I ²?=?0 %); however, the meta-analysis showed that there were no significant differences between internal stenting and non-stenting groups as regards perioperative outcomes and that in fact it may increase pancreatic fistula rate in normal pancreas(OR 1.97; 95 % CI 1.05–3.69; P?=?0.03; I ²?=?0 %).

Conclusions

The results of this analysis demonstrate a trend toward reduced pancreatic fistula with the use of external pancreatic stents in pancreaticojejunostomy. An internal stent does not impact development of fistula and that in fact it was not useful in a soft pancreas. Our conclusion may be limited to stenting during the duct-to-mucosa pancreaticojejunostomy anastomosis, and the value of stenting during invagination anastomosis needs further study.     

Effect of pulsed radiofrequency in treatment of facet-joint origin back pain in patients with degenerative spondylolisthesis

Background

Degenerative spondylolisthesis is a well-recognized source of low back pain mainly induced by facet joint pain. Pulsed radiofrequency (PRF) allows heat dissipation, thus producing a temporary injury that affects only type C fibers responsible for pain conduction.

Objectives

We attempted to test whether PRF is a better choice for facet pain due to spondylolisthesis compared to routine steroid injection.

Methods

Patients were randomly assigned to one of two groups: group one received pulsed RF, and group 2 received injection by steroids (triamcinolone) and bupivacaine.

Outcomes assessment

Multiple outcome measures were utilized which included the numeric rating scale (NRS), the Oswestry Disability Index (ODI), satisfaction status, and analgesic intake with assessment at 3, 6, and 12 months post-treatment. Significant pain relief was defined as 50 % or more, whereas significant improvement in disability score was defined as reduction of 40 % or more.

Results

Eighty patients were enrolled in the study and were divided into the two groups of study. PRF significantly reduced NRS at 6-month follow-up compared to steroid + bupivacaine. 75.6 ± 14.3 % at pre-treatment and 19.3 ± 9.5 % at 6 months (p = 0.001) in PRF group. The mean ODI is depicted in two groups of study (Fig. 1). Interestingly, ODI% was significantly lower in PRF group at 12 weeks and 6 months compare to steroid + bupivacaine group (p = 0.022 and 0.03, respectively), but it was not significantly different at 6 weeks (p = 0.31). Proportion of patients who did not require analgesics were significantly higher in PRF group compared to other group (p = 0.001) in Log-rank (Mantel–Cox) test.

Conclusion

Our results demonstrated that the application of PRF might be more effective than steroid and bupivacaine injection in decreasing back pain due to degenerative facet pain and improvement in function of patients.     

Aggressive Treatment for Hepatic Metastases from Breast Cancer: Results from a Single Center

Background

Breast cancer (BC) is the most common cancer among women worldwide. It has been estimated that approximately 12–20 % of patients will develop liver metastases from breast cancer (BCLM) and that in approximately 5 % of cases the liver is the only metastatic site. Patients with isolated BCLM have the poorest prognosis with a median survival ranging from 19 to 26 months.

Methods

A total of 26 women with isolated BCLM and without any sign of disease progression after a cycle of chemotherapy were retrospectively reviewed. Women were treated with hepatic resection (HR) for unilobar disease or surgical “open” RFA for bilobar disease. Data were collected on either original BC or BCLM and from patients follow-up.

Results

Overall survival from BC diagnosis was 47.69 ± 22.25 months (range 33–84, median 45.5 months); it was 52.25 ± 14.57 months (range 33–84, median 48.5 months) for the HR patients and 43.79 ± 27.14 months (range 9–101, median 39 months) for the RFA patients. Overall survival from BCLM treatment was 21.12 ± 12.78 months (range 9–64, median 15.5 months); in detail it was 29.42 ± 14.53 months (range 12–64, median 29.5 months) for the resected patients and 14 ± 4.45 months (range 9–24, median 13.5 months) for patients treated by RFA with a strongly significant survival difference for operated patients (p = 0.001). Overall disease-free survival from BCLM was 15.96 ± 13.16 months (range 3–64, median 12 months), disease-free survival for resected patients was 23.22 ± 16.2 months (range 8–64, median 18.5 months), and for patients treated by RFA was 9.64 ± 4.22 months (range 3–18, median 9 months; Fig. 1). Overall 1, 2, and 5 years (actuarial) survival was respectively 80.7, 57, and 31 %. Given in details for the two groups, they were respectively 100, 66.6 and 34 % (actuarial) for the resected group patients and 64.2, 21.4, and 11.5 % (actuarial) for the RFA patients.

Development of a dynamic model for ventral hernia mesh repair

Introduction

The adequate way of mesh fixation in laparoscopic ventral hernia repair is still subject to debate. So far, simulation has only been carried out in a static way, thereby omitting dynamic effects of coughing or vomiting. We developed a dynamic model of the anterior abdominal wall.

Materials and methods

An aluminium cylinder was equipped with a pressure controlled, fluid-filled plastic bag, simulating the abdominal viscera. A computer-controlled system allowed the control of influx and efflux, thus creating pressure peaks of up to 200 mmHg to simulate coughing and 290 mmHg to simulate vomiting. We tested fixation with tacks (Absorbatack, Covidien Deutschland, Neustadt a. D., Germany). The model was controlled for the friction coefficient of the tissue against the mesh and the physiologic elasticity of the abdominal wall surrogate.

Results

The model was able to create pressure peaks equivalent to physiologic coughs or vomiting. Physiologic elasticity was thereby maintained. We could show that the friction coefficient is crucial to achieve a physiologic situation. The meshes showed a tendency to dislocate with an increasing number of coughs (Fig. 4). Nevertheless, when applied in a plain manner, the meshes withstood more cough cycles than when applied with a bulge as in laparoscopic surgery.

Conclusions

The dynamic movement of the abdominal wall, the friction between tissue and mesh and the way of mesh application are crucial factors that have to be controlled for in simulation of ventral abdominal hernia closure. We could demonstrate that patient specific factors such as the frequency of coughing as well as the application technique influence the long term stability of the mesh.     

Pancreatic Atrophy Relative to External Versus Internal Drainage of the Pancreatic Duct After Pylorus-Preserving Pancreaticoduodenectomy

Background

Atrophy of the pancreatic parenchyma, which occurs frequently after pylorus-preserving pancreaticoduodenectomy (PPPD), is often associated with pancreatic exocrine insufficiency. Many surgeons prefer to insert a drainage tube into the remnant pancreatic duct primarily to prevent pancreatic leakage at the pancreaticojejunostomy (PJ) after PPPD. Drainage methods vary widely but can be roughly classified as internal or external drainage. This study intended to evaluate their effects on pancreatic parenchymal atrophy following PPPD.

Methods

Fifty-seven patients who underwent PPPD were retrospectively divided into two groups, 28 who underwent external and 29 who underwent internal pancreatic drainage. External drainage tubes were removed 4 weeks after PPPD. The volume of the pancreatic parenchyma was serially measured on abdominal computed tomography (CT) scans before PPPD, as well as 7 days and 3, 6, and 12 months after surgery. Degree of pancreatic parenchymal atrophy was determined by calculating pancreatic volume relative to that on day 7.

Results

Univariate analysis showed that patient sex, age, body mass index, concurrent pancreatitis, pathology, and types of PJ did not significantly affect changes in pancreatic volume following PPPD. The degree of pancreatic volume atrophy did not differ significantly in the external and internal drainage groups. No patient in the external drainage group experienced drainage-related surgical complications. The incidence of PJ leak was comparable in the two groups. Postoperative pancreatic atrophy did not induce new-onset diabetes mellitus at 1 year.

Conclusions

Both external and internal pancreatic drainage methods showed similar atrophy rate of the pancreatic parenchyma following PPPD.     

External Stent Versus No Stent for Pancreaticojejunostomy: A Meta-analysis of Randomized Controlled Trials

Background

The effectiveness of an external pancreatic duct stent for reduction of the pancreatic fistula after pancreaticoduodenectomy remains controversial.

Methods

MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials were searched for eligible randomized controlled trials (RCTs). Reviews of each trial were conducted and data were extracted. The primary outcome was pancreatic fistula. Statistical pooling used the fixed or random effects model and reported as risk ratio (RR) or mean difference (MD) with the corresponding 95 % confidence intervals (CI).

Results

Four RCTs including a total of 416 patients were detected. Methodological quality assessment revealed a better quality of all analyzed trials. Placing an external stent across pancreaticojejunal anastomosis could significantly reduce the incidence of pancreatic fistula (RR?=?0.57, 95 % CI?=?0.41–0.80, P?=?0.001, I ²?=?0 %), overall morbidity (RR?=?0.79, 95 % CI?=?0.64–0.98, P?=?0.03), and the length of hospital stay (MD?=??3.98 days, 95 % CI?=??6.42 to ?1.54, P?=?0.001, I ²?=?13 %). No significant difference was found in terms of hospital mortality, delayed gastric emptying, operation time, operative blood loss, blood replacement, and reoperation rate.

Conclusions

This meta-analysis provides compelling evidence that the application of an external pancreatic duct stent after pancreaticoduodenectomy can decrease the incidence of pancreatic leakage when compared with no stent. Moreover, the external drainage of pancreatic juice is associated with lower postoperative overall morbidity and shorter hospital stay.     

Pancreatic Secondary Lesions from Renal Cell Carcinoma

Background

Metastatic lesions to the pancreas are uncommon. The most frequent metastases are from renal cell carcinoma (RCC). We analyzed the clinical features and survival of patients with pancreatic metastasis from renal cell carcinoma.

Methods

We retrospectively reviewed the clinical records of patients with pancreatic metastases from RCC, observed in our department from January 2004 to March 2010. Follow-up continued to September 2013.

Results

In the study period 13 patients with a diagnosis of metastasis from RCC were observed in our clinic, and among them 9 pancreatic resections were performed (2 pancreaticoduodenectomy, 1 duodenum-preserving pancreatic head resection, 1 central pancreatectomy, and 5 distal pancreatectomy). Four patients did not undergo a pancreatic resection: two refused surgery, one had an endoscopic biliary stent for jaundice placed and then underwent a surgical biliary bypass, and the fourth patient was too advanced and had only an endoscopic biliary stent. The mean follow-up was 56 months (range  5–115, median  53), with one nonresected patient lost in follow-up after 38 months. Among the other 12 patients, 4 died: two for progression of disease 5 and 20 months respectively after our observation. The mean (±SEM) disease-free survival of seven resected patients with curative intent was 40 ± 11 months (median  34).

Conclusions

Pancreatic metastases from RCC are often asymptomatic. They generally present slow growth and an indolent behavior. Surgery is the treatment of choice in those patients with only pancreatic involvement, achieving long-term survival and disease-free survival.     

The Hybrid Intrathoracic Oesophago-gastric Anastomosis in Oesophageal Cancer—Morbidity and Mortality

Background

The technique of the side-to-side, hybrid stapled/hand-sewn, intrathoracic, oesophago-gastric anastomosis was first described in 1996 (Bird et al. Aust N.Z J Surg 66:77–763, 1996). However despite some clinical and theoretical advantages, it has never been as popular as either hand-sewn or circular-stapled anastomosis. The aim of this study was to review the experience of a single surgeon (RC) who has used this type of anastomosis since 1993 as the routine means of reconstruction following oesophagectomy.

Methods

A retrospective review of prospectively collected data was performed. The study included 195 consecutive oesophageal resections performed by a single surgeon (RC) from 1993 to 2011.

Results

Of 195 patients undergoing oesophagectomy, 180 patients had an intrathoracic anastomosis for oesophageal cancer. Of the 180 patients, 177 had an anastomosis formed using the hybrid technique. The clinical anastomotic leak rate in this group was found to the 2.7 % with an in hospital mortality of 0.5 %. The total number of patients requiring post-operative dilatation was 17/180 or approximately 9 % of patients.

Conclusions

The hybrid oesophageal anastomosis is associated with a low mortality and anastomotic leak rate and a modest incidence of stricturing.