A Rare Case of Benign Multicystic Peritoneal Mesothelioma: A Clinical Dilemma

A middle aged housewife presented with an anterior abdominal wall mass which was slowly growing over a period of 1 years over the midline scar of previous caesarean section with cystic degeneration in a part of the tumor. Fine needle aspiration cytology revealed a papillary serous cystadenoma. At exploratory laparotomy tumor was seen arising from the ventral surface of the parietal peritoneum with normal viscera, omentum and ovaries. The pathologist reported the tumor as Benign Multicystic Peritoneal Mesothelioma. It is a rare but clinically favourable neoplasm with wide excision as the definitive treatment. Of the 130 cases reported in the literature, it has the least incidence in the Indian Subcontinent.     

Defining Treatment and Outcomes of Hepaticojejunostomy Failure Following Pancreaticoduodenectomy

Background

The overall complication rate after pancreaticoduodenectomy (PD) approaches 50 %, with anastomotic failure being the most frequent cause of serious postoperative morbidity. Hepaticojejunostomy leaks (also called bile leaks) are the second most common type of leak, behind pancreaticojejunostomy leaks, yet have been the focus of only a single study as reported by Suzuki et al. (Hepatogastroenterology 50:254–257, 12).

Methods

We reviewed the recent experience with bile leaks at a single, high-volume pancreatic surgery center over a six-year time period.

Results

Bile leaks were identified in 16 out of 715 patients (2.2 %). Low preoperative albumin was associated with an increased risk. Bile leaks typically manifested within the first week after surgery as bilious drainage in a surgically placed drain. Associated warning signs included fever and leukocytosis. Patients with a bile leak frequently developed other complications, including a pancreatic fistula, wound infection, delayed gastric emptying, and sepsis. The impact on perioperative outcomes was comparable to patients with a pancreatic leak. A grading system is proposed based on the International Study Group on Pancreatic Fistula model. Grade A bile leaks were classified as those managed with prolonged drainage by operatively placed drains, grade B bile leaks with percutaneous abdominal drainage, and grade C bile leaks with insertion of a percutaneous transhepatic biliary drainage.

Conclusions

Hepaticojejunostomy leaks are rare after PD. The complication severity ranges from trivial to life threatening and is comparable overall to pancreaticojejunostomy leaks. Surgical intervention is rarely, if ever, required. With prompt and aggressive management, a full recovery can be expected.     

Preoperative Imaging for Resectable Periampullary Cancer: Clinicopathologic Implications of Reported Radiographic Findings

Background

High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown.

Methods

We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated.

Results

There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6).

Discussion

While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.     

Current concepts in the treatment of adolescent femoroacetabular impingement

There is growing evidence that symptomatic femoroacetabular impingement leads to intra-articular damage and the development of early-onset osteoarthritis. Symptoms of femoroacetabular impingement often do not manifest until adulthood, but have been increasingly recognised in the paediatric and adolescent population. The surgical treatment of femoroacetabular impingement is aimed at restoring a more normal femoral head–neck offset in order to increase the clearance and prevent femoral abutment against the acetabular edge. Current methods include open and arthroscopic techniques. The latter has been combined with an open approach to gain access to the head–neck junction for osteochondroplasty. Proximal femoral and/or periacetabular osteotomies are used to treat femoroacetabular impingement associated with deformity secondary to childhood hip conditions, such as slipped capital femoral epiphysis and Legg–Calvé–Perthes disease. Some adolescents have severe degenerative joint disease at the time of presentation and may require arthroplasty or arthrodesis. The aim of this review is to identify the major trends and advancements in the management of femoroacetabular impingement in adolescents, including the outcome of studies of the surgical treatment modalities used.     

Mitochondrial function in human brains is affected by pre‐ and post mortem factors

G. Harish, C. Venkateshappa, A. Mahadevan, N. Pruthi, M. M. S. Bharath and S. K. Shankar (2013) Neuropathology and Applied Neurobiology 39, 298–315 Mitochondrial function in human brains is affected by pre‐ and post mortem factors Aim: Mitochondrial function and the ensuing ATP synthesis are central to the functioning of the brain and contribute to neuronal physiology. Most studies on neurodegenerative diseases have highlighted that mitochondrial dysfunction is an important event contributing to pathology. However, studies on the human brain mitochondria in various neurodegenerative disorders heavily rely on post mortem samples. As post mortem tissues are influenced by pre‐ and post mortem factors, we investigated the effect of these variables on mitochondrial function. Methods: We examined whether the mitochondrial function (represented by mitochondrial enzymes and antioxidant activities) in post mortem human brains (n = 45) was affected by increased storage time (11.8–104.1 months), age of the donor (2 days to 80 years), post mortem interval (2.5–26 h), gender difference and agonal state [based on Glasgow Coma Scale: range = 3–15] in the frontal cortex, as a prototype. Results: We observed that the activities of citrate synthase, succinate dehydrogenase and mitochondrial reductase (MTT) were significantly affected only by gender difference (citrate synthase: P = 0.005; succinate dehydrogenase: P = 0.01; mitochondrial reductase: P = 0.006), being higher in females, but not by any other factor. Mitochondrial complex I activity was significantly inhibited by increasing age (r = ?0.40; P = 0.05). On the other hand, the mitochondrial antioxidant enzyme glutathione reductase decreased with severe agonal state (P = 0.003), while the activity of glutathione‐S‐transferase declined with increased storage time (P = 0.005) and severe agonal state (P = 0.02). Conclusion: Our data highlight the influence of pre‐ and post mortem factors on preservation of mitochondrial function with implications for studies on brain pathology employing stored human samples.     

Does Resident Experience Affect Outcomes in Complex Abdominal Surgery? Pancreaticoduodenectomy as an Example

Objectives

Understanding the factors contributing to improved postoperative patient outcomes remains paramount. For complex abdominal operations such as pancreaticoduodenectomy (PD), the influence of provider and hospital volume on surgical outcomes has been described. The impact of resident experience is less well understood.

Methods

We reviewed perioperative outcomes after PD at a single high-volume center between 2006 and 2012. Resident participation and outcomes were collected in a prospectively maintained database. Resident experience was defined as postgraduate year (PGY) and number of PDs performed.

Results

Forty-three residents and four attending surgeons completed 686 PDs. The overall complication rate was 44 %; PD-specific complications (defined as pancreatic fistula, delayed gastric emptying, intraabdominal abscess, wound infection, and bile leak) occurred in 28 % of patients. The overall complication rates were similar when comparing PGY 4 to PGY 5 residents (55.3 vs. 43.0 %; p?>?0.05). On univariate analysis, there was a difference in PD-specific complications seen between a PGY 4 as compared to a PGY 5 resident (44 vs. 27 %, respectively; p?=?0.016). However, this was not statistically significant when adjusted for attending surgeon. Logistic regression demonstrated that as residents perform more cases, PD-specific complications decrease (OR?=?0.97; p?<?0.01). For a resident's first PD case, the predicted probability of a PD-specific complication is 27 %; this rate decreases to 19 % by resident case number 15.

Conclusions

Complex cases, such as PD, provide unparalleled learning opportunities and remain an important component of surgical training. We highlight the impact of resident involvement in complex abdominal operations, demonstrating for the first time that as residents build experience with PD, patient outcomes improve. This is consistent with volume–outcome relationships for attending physicians and high-volume hospitals. Maximizing resident repetitive exposure to complex procedures benefits both the patient and the trainee.