Distal Pancreatectomy with En Bloc Celiac Axis Resection for Locally Advanced Pancreatic Adenocarcinoma Following Neoadjuvant Therapy

Background

Celiac trunk encasement by adenocarcinoma of the pancreatic body is generally regarded as a contraindication for surgical resection. Recent studies have suggested that a subset of stage III patients will succumb to their disease in the absence of distant metastases. We hypothesized that patients with stage III tumors invading the celiac trunk, who are free of distant disease following neoadjuvant therapy, may derive prolonged survival benefit from aggressive surgical resection.

Methods

We performed a retrospective review of distal pancreatectomies with en bloc celiac axis resection for pancreatic adenocarcinoma.

Results

Eleven patients underwent a distal pancreatectomy with en bloc celiac axis resection after completing neoadjuvant chemoradiation therapy. Median operative time was 8?h, 14?min, and median estimated blood loss was 700?ml. Median length of stay was 9?days. Five patients (45%) had postoperative complications; three were Clavien grade I. Four patients (35%) had pancreatic leaks; two were ISGPF grade B, and two were grade A. There were two 90-day perioperative deaths. Ten patients had R0 resections (91%). After a median follow-up of 41?weeks, six patients recurred. Four of the five patients with SMAD4 loss recurred, and two of the five patients with intact SMAD4 recurred. Median disease-free and overall survival were 21?weeks and 26?months, respectively.

Conclusions

Resection of pancreatic body adenocarcinoma with celiac axis resection is technically feasible with acceptable perioperative morbidity and mortality.     

Prognosis of patients with acute renal failure requiring dialysis: results of a multicenter study

Despite several decades of clinical experience, the mortality rate for patients with acute renal failure (ARF) requiring dialysis remains high, and the evaluation of the patients prognosis has been difficult. To date, the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system has been used more frequently for prediction in studies of ARF than any other scoring system, but has not been prospectively validated in controlled multicenter studies of this entity. In a multicenter, prospective, controlled trial evaluating the use of biocompatible hemodialysis membranes (BCMs) in patients with ARF, we evaluated the extent to which the APACHE II scoring system, based on the physiological variables in the 24 hours before the onset of dialysis and the presence or absence of oliguria, is predictive of outcome. Analysis of survival and recovery of renal function for the 153 patients treated in this study show that APACHE II scores are predictive both of survival and recovery of renal function, whether analyzed separately by type of dialysis membrane used (BCM or bioincompatible [BICM]) or for both groups combined (all P < 0.01). There was no evidence of a significant center effect or interaction of APACHE II score with dialysis membrane in our study. After adjusting for the APACHE II score, there was a positive effect of the BCM on both probability of survival (P < 0.05) and recovery of renal function (P < 0.01). In patients dialyzed with BCMs, oliguria at onset of dialysis had an adverse effect on both survival and recovery of renal function (both P < 0.01). Receiver operator curves (ROCs) using APACHE II score and the use of BCMs in nonoliguric patients yielded a statistically significant improvement versus the use of APACHE II score alone in the area under the curve (AUC) for survival (0.747 to 0.801; P < 0.05) and recovery of renal function (0.712 to 0.775; P < 0.05). We conclude that the use of the APACHE II score determined at the time of initiation of dialysis for patients with ARF is a statistically significant predictor of patient survival and recovery of renal function. The use of the APACHE II score measured at the time of dialysis initiation, especially when modified by the presence or absence of oliguria, should help in predicting outcome when evaluating interventions for patients with ARF.     

Simultane Behandlung von obliterativen Karotispathologien und koronarer Herzkrankheit

Introduction

Combined carotid artery endarterectomy and coronary artery bypass grafting (C-CABG) has been identified as having a high perioperative risk. Therefore, carotid artery stenting has been recommended. Missing level I evidence on C-CABG as well as carotid stenting has motivated us to review our experience over the past 5 years.

Methods and patients

We report a single centre retrospective study of 113 C-CABG performed between January 2000 and December 2004. The median age of the patients was 65 years (22 patients were 80 years old or older). Carotid endarterectomy was performed first followed by the aortocoronary bypass in the same operation.

Results

The 30-day mortality was 4.4% (5/113), with no neurological death. The overall neurological complication rate was 3.5% (4/113) due to one stroke that resolved within 30 days, and three TIAs.

Conclusion

C-CABG with preliminary carotid endarterectomy is a safe technique with a low stroke rate. The risky part of the C-CABG is not the carotid intervention itself but the CABG procedure. Therefore, as long as single carotid artery stenting has not clearly shown early and/or long-term advantages over carotid endarterectomy, it does not seem to be justified in combined carotid and aorto-coronary bypass procedures.     

Transcranial color-coded duplex sonography in unilateral flow-restrictive extracranial carotid artery disease.

PURPOSETo provide transcranial color-coded duplex flow-velocity data for the basal cerebral arteries in patients with unilateral flow-restrictive extracranial carotid artery disease, and to compare these data with the flow velocities obtained in healthy control subjects.METHODSTranscranial color-coded duplex sonography was performed in 78 patients with different patterns of cross flow through the anterior and posterior communicating arteries associated with unilateral obstruction (70% to 100%; 46 stenoses and 32 occlusions) of the internal carotid arteries. Peak systolic, mean, and end diastolic velocities were measured in the anterior, middle, and precommunicating and postcommunicating posterior cerebral arteries. These measurements were compared with the values obtained in 125 age- and sex-matched health control subjects.RESULTSPatients with anterior communicating artery cross flow to the middle cerebral artery (63%) had increased peak velocity in the anterior cerebral artery and decrease peak velocity in the middle cerebral artery on the obstructed (ipsilateral) side, and increased peak velocity in the anterior cerebral artery on unobstructed (contralateral) side. Patients with anterior communicating artery cross flow to the pericallosal artery (19%) had increased contralateral peak systolic velocity and mean anterior cerebral artery velocities. Patients without anterior communicating artery cross flow (18%) had normal peak velocities in the anterior and middle cerebral arteries. Patients with posterior communicating artery cross flow (42%) had ipsilaterally decreased peak systolic and mean middle cerebral artery velocities and increased peak velocities in the precommunicating posterior cerebral artery. Patients without posterior communicating artery cross flow (58%) had ipsilaterally decreased peak systolic and mean middle cerebral artery velocities.CONCLUSIONOur findings suggest that typical abnormalities of basal cerebral artery flow velocities occur in patients with unilateral 70% to 100% obstruction of the internal carotid arteries resulting in different patterns of cross flow through the circle of Willis.     

Repetitive short-term bile duct obstruction and relief causes reproducible and reversible bile acid regurgitation

BACKGROUND: Long-term bile duct obstruction causes sinusoidal regurgitation of bile acids, a shift in bile acid metabolism, and alterations of liver histology. In this study we investigated the regurgitation of bile acids during short-term bile duct obstruction and its reversibility and reproducibility. In addition, the biotransformation of taurodeoxycholate and its appearance in bile and perfusate effluent were studied as well as liver histology. METHODS: Rat livers (n = 5) were perfused in vitro with 32 nmol/min/g liver taurodeoxycholate over 85 min with the bile duct being intermittently closed for 30 and 20 min, respectively. RESULTS: Within the first 5 min after bile duct obstruction bile acids started to regurgitate to the perfusate effluent amounting to approximately 15% of hepatic uptake until the end of the perfusion period. After relief of obstruction, bile flow and biliary bile acid excretion showed an overshoot phenomenon and were almost doubled compared to preobstruction. In contrast, sinusoidal bile acid regurgitation declined. The same phenomenon was observed during the second closure/opening cycle of the bile duct. Regurgitated bile acids consisted of significantly more taurodeoxycholate metabolites (approximately 70%) than did biliary bile acids (approximately 30%). Histology of liver parenchyma was preserved. CONCLUSIONS: During repetitive short-term bile duct obstruction bile acid regurgitation is reversible and reproducible. The absence of altered mechanical barriers suggests that specific pathways are involved in the regurgitation process of bile acids.     

Surgical approaches and techniques in the management of severe hyperhidrosis

Thoracoscopy has afforded a huge advance for upper thoracic sympathetic procedures compared with prior open procedures. Different clinical syndromes of hyperhidrosis exist and require different forms of treatment. The classic severe palmoplantar pattern of hyperhidrosis will not respond effectively in the long term to any nonoperative treatment and requires sympathectomy for cure. Thoracoscopic sympathectomy is the first-line treatment in these patients. The author's preference is sympathotomy at the second or third rib level, because this method spares the ganglion. It is possible that ganglionectomy or wide extent of sympathectomy will increase the chance of CH, but, conversely, limited "ramicotomy" procedures are often ineffective. T2 sympathectomy has been suggested as possibly being involved with increased CH, but avoiding T2 sympathectomy has been implicated in failure to treat some instances of palmoplantar hyperhidrosis effectively. Axillary and facial hyperhidrosis and facial blushing syndromes are not as universally and overwhelmingly benefited by sympathectomy and these need evaluation on a case-by-case basis. Axillary hyperhidrosis failures with aluminum chloride can be treated with local axillary procedures. Although botulinum type A injection and axillary curettage appear effective in axillary hyperhidrosis, botulinum toxin type A injection has a short duration of efficacy measured in months, whereas the efficacy of curettage appears to be long lasting. Thoracoscopic sympathectomy for axillary hyperhidrosis at levels T3, T4, or T5 is usually, but not always, effective for axillary hyperhidrosis and may result in severe CH.