Ahmad M. Sultan

Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study

OBJECTIVES The optimal strategy for the reconstruction of the pancreas following pancreaticoduodenectomy (PD) is still debated. The aim of this study was to compare the outcomes of isolated Roux loop pancreaticojejunostomy (IRPJ) with those of pancreaticogastrostomy (PG) after PD. METHODS Consecutive patients submitted to PD were randomized to either method of reconstruction. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality, and exocrine and endocrine pancreatic functions. RESULTS Ninety patients treated by PD were included in the study. The median total operative time was significantly longer in the IRPJ group (320 min versus 300 min; P = 0.047). Postoperative pancreatic fistula developed in nine of 45 patients in the IRPJ group and 10 of 45 patients in the PG group (P = 0.796). Seven IRPJ patients and four PG patients had POPF of type B or C (P = 0.710). Time to resumption of oral feeding was shorter in the IRPJ group (P = 0.03). Steatorrhea at 1 year was reported in nine of 42 IRPJ patients and 18 of 41 PG patients (P = 0.029). Albumin levels at 1 year were 3.6 g/dl in the IRPJ group and 3.3 g/dl in the PG group (P = 0.001). CONCLUSIONS Isolated Roux loop PJ was not associated with a lower rate of POPF, but was associated with a decrease in the incidence of postoperative steatorrhea. The technique allowed for early oral feeding and the maintenance of oral feeding even if POPF developed.

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy

AIM To elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with liver cirrhosis. METHODS We studied retrospectively all patients who underwent PD in our centre between January 2002 and December 2011. Group A comprised patients with cirrhotic livers, and Group B comprised patients with non-cirrhotic livers. The cirrhotic patients had Child-Pugh classes A and B (patients score less than 8). Preoperative demographic data, intra-operative data and postoperative details were collected. The primary outcome measure was hospital mortality rate. Secondary outcomes analysed included duration of the operation, postoperative hospital stay, postoperative morbidity and survival rate. RESULTS Only 67/442 patients (15.2%) had cirrhotic livers. Intraoperative blood loss and blood transfusion were significantly higher in group A (P = 0.0001). The mean surgical time in group A was significantly longer than that in group B (P = 0.0001). Wound complications (P = 0.02), internal haemorrhage (P = 0.05), pancreatic fistula (P = 0.02) and hospital mortality (P = 0.0001) were significantly higher in the cirrhotic patients. Postoperative stay was significantly longer in group A (P = 0.03). The median survival was 19 mo in group A and 24 mo in group B. Portal hypertension (PHT) was present in 16/67 cases of cirrhosis (23.9%). The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT (P = 0.001). Postoperative morbidity (0.07) and hospital mortality (P = 0.007) were higher in cirrhotic patients with PHT. CONCLUSION Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis. PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is only recommended in patients with Child A cirrhosis without portal hypertension.

Risk Factors for Conversion during Laparoscopic Cholecystectomy: Retrospective Analysis of Ten Years' Experience at a Single Tertiary Referral Centre

Background/Purpose: Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic benign gallbladder disease. The identification of factors that reliably predict the need to convert LC to open cholecystectomy (OC) would help with patient education and counseling. Methods: Between January 2000 and December 2009, 4,698 patients underwent cholecystectomy. LC was attempted in 4,434 patients (94.4%) and OC from the start was performed in 264 patients (5.6%). The causes for conversion were evaluated. The change in conversion rate between 2000 and 2004 and between 2005 and 2009 was analyzed. Factors predictive of conversion were identified by univariate and multivariate analysis. Results: Conversion to OC from an initial LC approach was required in 234 patients (5.3%). The main cause for conversion was dense adhesions (54.7%). Independent risk factors in multivariate analysis were male gender (p < 0.001), increased age (p < 0.001), a history of previous upper abdominal surgery (p < 0.001), a WBC count >9 × 103/μl, and urgently indicated cholecystectomy (p <0.001). The conversion rate decreased significantly from 6.7 to 3.6% over the two time intervals (p < 0.001). Conclusions: Those at highest risk for conversion are elderly male patients with prior abdominal surgery who present emergently with laboratory evidence of biliary inflammation.

Caudate lobe resection with major hepatectomy for central cholangiocarcinoma: is it of value?

BACKGROUND/AIMS The aim of this study was to evaluate the importance of concomitant caudate lobe resection in the course of major hepatectomy for hilar cholangiocarcinoma. METHODOLOGY During the period between January 1995 and December 2010, 159 patients were subjected to major hepatectomy with or without total caudate lobe resection at the Gastroenterology Centre, Mansoura University. These patients were divided in two groups: 1) a caudate lobe preservation (CLP) group (79 patients) and 2) a caudate lobe resection (CLR) group (80 patients). All patient data were retrospectively reviewed. RESULTS This study included 94 men and 65 women with a mean age of 53.5±0 years without operative mortality. No differences were observed between groups regarding operative time, blood loss or the development of any individual postoperative complication. There were 23 (28.8%) margin-positive resections in the CLR group and 49 (62%) margin-positive resections in the CLP group (p≤0.001). Recurrence was confirmed in 53 (67.1%) and in 41(51.3%) patients in the CLP and CLR groups, respectively (p=0.031). The median survival of the CLR group was 36 months with a 5-year survival rate of 28%, while the median survival of the CLP group was 22 months with a 5-year survival rate of 5% (p≤0.001). CONCLUSIONS Caudate lobe resection in combination with major hepatectomy did not affect operative or postoperative morbidity and mortality. However, it led to higher rates of margin-negative resections and significantly improved survival.

Long-term follow-up of 120 patients after hepaticojejunostomy for treatment of post-cholecystectomy bile duct injuries: A retrospective cohort study

BACKGROUND Long-term follow-up is essential for assessment of success of the surgical repair of post-cholecystectomy bile duct injuries (BDI). Factors affecting the long-term outcome and satisfactory length of follow-up have been little reported in the literature. The aim of this study is long-term evaluation of hepaticojejunostomy regarding clinical, radiological, laboratory and quality of life assessment. METHOD Between January 1992 to December 2007, 120 patients with postcholecystectomy bile duct injury surgically treated by hepaticojejunostomy Roux-en-Y were followed up for 20 years in Mansoura Gastro-enterology Center. Long-term outcomes and quality of life (QOL) were evaluated for all patients. Univariate and multivariate analyses were done for detection of factors affecting long-term outcome. RESULTS The median follow up period was 149 months, range (70-246 months). Successful long-term outcome was detected in 106 (88.3%) patients. Long-term complications were detected in 35 (29%) patients. Fourteen (11.6%) patients developed anastomotic stricture within different follow up intervals up to 17 years, of which. Seventeen (14.2%) patients developed recurrent episodes of cholangitis at median interval 48 months, range (2-156 months). Post-ERCP pancreatitis, number of anastomosis, operative time, post-operative early complications, and post-operative bile leak were predictors for poor outcome. Physical component was much more affected than mental component in QOL. CONCLUSION Management of BDI in specialized centers is highly recommended. Longer time for follow-up of the patients of surgical repair of bile duct injury up to 20 years should be adopted to ensure successful outcome. Quality of life assessment is essential component of long-term follow-up.

Biliary complications in living donor right hepatectomy are affected by the method of bile duct division

The bile duct division is a crucial step in the donor hepatectomy. Multiple small ducts will make the biliary reconstruction more difficult and may influence the outcome of the recipient. Biliary leakage, bilomas and biliary strictures are well recognized donor complications that may be directly linked to bile duct division. Biliary division still needs more standardization. This work aims to analyze our experience with two different methods of bile duct division in relation to the development of intraoperative and postoperative biliary complications. Between April 2004 and March 2013, 216 liver donors underwent right hepatectomy, in Gastro‐Enterology Surgical Center, Mansoura University, Egypt. According to the method of bile duct division, the study population was divided into 2 groups; 1‐ extrahepatic dissection group (EDG) and 2‐ fluoroscopy guided transection group (FGG), each comprised 108 patients. Data were collected from a prospectively registered database, with special emphasis on the occurrence of biliary complications. Complications were classified according to the latest version of Clavien classification. Intraoperative biliary complications did not differ between both groups, p = 0.313. The commonest postoperative complication was biliary leak/biloma accounting for 32.5% of all donor complications, followed by non‐biliary fluid collections. 24 (11.1%) donors developed 27 biliary complications. The FGG showed significantly less biliary complications (5.6%, 6 donors), when compared to EDG (15.7%, 18 donors), p = 0.015. Grade 3 complications were significantly higher in EDG, p = 0.024. On multivariate analysis, the only significant factor predicting the occurrence of biliary complications was the use of fluoroscopy guided bile duct division, p = 0.009. In conclusion, we believe that the proposed method of biliary division is safe, simple and reproducible. Liver Transpl 20:1393‐1401, 2014.

Caudate lobe resection for hepatocellular carcinoma.

BACKGROUND/AIMS Hepatocellular carcinoma (HCC) originating in the caudate lobe is rare, and the treatment for this type of carcinoma is a complex surgical procedure. We aimed to evaluate the surgical outcomes after isolated caudate lobe resection for HCC. METHODOLOGY We retrospectively analyzed 30 consecutive patients with HCC originating in the caudate lobe who underwent isolated caudate lobe resection. RESULTS Thirty patients underwent caudate lobe resection for HCC. The main sites of the tumors were located in the Spiegel lobe, the paracaval portion and caudate process. The surgical margin was tumor negative in all of the patients. The median tumor size was 4.3cm. The mean operative time was 230 ± 50min and the intraoperative blood loss was 1200 ± 200mL. The hospital morbidity rate was 33%. There was no postoperative mortality. The mean survival rate was 25.3+11.7 months. The overall survival rates were 62%, 34% and 11% at 1, 3 and 5 years, respectively. The disease free survival rate after isolated caudate lobectomy was 31% at 3 years. Recurrence was noted in 12 patients (40%). Eleven patients were identified as having intrahepatic recurrences and 1 patient as having peritoneal dissemination. CONCLUSIONS Isolated caudate lobe resection is a feasible procedure and can be undertaken with low morbidity and nil mortality. Careful technique and detailed anatomic knowledge of the caudate lobe are essential for this procedure.

Pelvic floor dyssynergia: efficacy of biofeedback training.

BACKGROUND AND STUDY AIMS Paradoxical contraction of the pelvic floor during attempts to defaecate is described as pelvic floor dyssynergia (anismus). It is a behavioural disorder (no associated morphological or neurological abnormalities); consequently, biofeedback training has been recommended as a behavioural therapy for such a disorder. The aim of the present study was to evaluate long-term satisfaction of patients diagnosed with pelvic floor dyssynergia after biofeedback. PATIENTS AND METHODS Sixty patients (35 females and 25 males) with a mean age of 30±12years and a 4year duration of constipation were included. Forty-five patients had normal colonic transit and 15 patients had slow colonic transit. History, physical examination and barium enema were done to exclude constipation secondary to organic causes. Colonic and pelvic floor functions (colon-transit time, anorectal manometry, EMG and defaecography) were performed before and after biofeedback treatments. Patients were treated on a weekly basis with an average of (6±2) sessions. RESULTS At the end of sessions, 55 out of 60 patients (91.6%) reported a subjectively overall improvement. Symptoms of dyschezia were reported less frequently after biofeedback. Age and gender were not predictive factors of outcome. No symptoms at initial assessment were predictive for patients satisfaction but the only factor of predictive value was the diagnosis of anismus and the motivated patient who wanted to continue the sessions. CONCLUSION Biofeedback remains a morbidity free, low-cost and effective outpatient therapy for well-motivated patients complaining of functional constipation and diagnosed as pelvic floor dyssynergia.

Predictors of long term survival after hepatic resection for hilar cholangiocarcinoma: A retrospective study of 5-year survivors

AIM To determine predictors of long term survival after resection of hilar cholangiocarcinoma (HC) by comparing patients surviving > 5 years with those who survived < 5 years. METHODS This is a retrospective study of patients with pathologically proven HC who underwent surgical resection at the Gastroenterology Surgical Center, Mansoura University, Egypt between January 2002 and April 2013. All data of the patients were collected from the medical records. Patients were divided into two groups according to their survival: Patients surviving less than 5 years and those who survived > 5 years. RESULTS There were 34 (14%) long term survivors (5 year survivors) among the 243 patients. Five-year survivors were younger at diagnosis than those surviving less than 5 years (mean age, 50.47 ± 4.45 vs 54.59 ± 4.98, P = 0.001). Gender, clinical presentation, preoperative drainage, preoperative serum bilirubin, albumin and serum glutamic-pyruvic transaminase were similar between the two groups. The level of CA 19-9 was significantly higher in patients surviving < 5 years (395.71 ± 31.43 vs 254.06 ± 42.19, P = 0.0001). Univariate analysis demonstrated nine variables to be significantly associated with survival > 5 year, including young age (P = 0.001), serum CA19-9 (P = 0.0001), non-cirrhotic liver (P = 0.02), major hepatic resection (P = 0.001), caudate lobe resection (P = 0.006), well differentiated tumour (P = 0.03), lymph node status (0.008), R0 resection margin (P = 0.0001) and early postoperative liver cell failure (P = 0.02). CONCLUSION Liver status, resection of caudate lobe, lymph node status, R0 resection and CA19-9 were demonstrated to be independent risk factors for long term survival.

Intraoperative endoscopic retrograde cholangio-pancreatography: A useful tool in the hands of the hepatobiliary surgeon.

AIM To evaluate the efficacy of intraoperative endoscopic retrograde cholangio-pancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) for patients with gall bladder stones (GS) and common bile duct stones (CBDS). METHODS Patients treated for GS with CBDS were included. LC and intraoperative transcystic cholangiogram (TCC) were performed in most of the cases. Intraoperative ERCP was done for cases with proven CBDS. RESULTS Eighty patients who had GS with CBDS were included. LC was successful in all cases. Intraoperative TCC revealed passed CBD stones in 4 cases so intraoperative ERCP was performed only in 76 patients. Intraoperative ERCP showed dilated CBD with stones in 64 cases (84.2%) where removal of stones were successful; passed stones in 6 cases (7.9%); short lower end stricture with small stones present in two cases (2.6%) which were treated by removal of stones with stent insertion; long stricture lower 1/3 CBD in one case (1.3%) which was treated by open hepaticojejunostomy; and one case (1.3%) was proved to be ampullary carcinoma and whipples operation was scheduled. CONCLUSION The hepatobiliary surgeon should be trained on ERCP as the third hand to expand his field of therapeutic options.