Beata Jabłońska

Hepaticojejunostomy vs. End-to-end Biliary Reconstructions in the Treatment of Iatrogenic Bile Duct Injuries

BackgroundRetrospective comparison of short- and long-term results and quality of life in patients treated for iatrogenic bile duct injuries (IBDI) with Roux-Y hepaticojejunostomy (HJ) or end-to-end ductal anastomosis (EE).MethodsBetween January 1990 and March 2005, 94 patients underwent reconstructive surgery for IBDI: 49, Roux-Y HJ, and 45, EE.ResultsEarly postoperative complications were observed in 12 (24.5%) patients undergoing HJ and three (6.7%) undergoing EE (p = 0.0239). Reoperations in the early postoperative period were performed in four (8%) patients after HJ and in zero patients after EE. Following HJ, one (2%) hospital death occurred due to acute circulatory insufficiency. Long-term results were evaluated in 69 (72%) patients. Postoperative mean weight gain was significantly higher after EE than HJ (p = 0.0191). Recurrent stricture was observed in two (5.3%) patients after HJ and three (9.6%) after EE (p = 0.6509). Terblanche long-term results were comparable in both groups (p = 0.3173). Good Karnofsky quality of life was comparable in both groups (p = 0.8377).ConclusionsMore early complications occurred after HJ than after EE. Long-term results were comparable after both reconstructive methods. After EE, patients achieved a higher weight gain than after HJ. Quality of life in both groups was comparable.

Hepatectomy for bile duct injuries: When is it necessary?

Iatrogenic bile duct injuries (IBDI) are still a challenge for surgeons. The most frequently, they are caused by laparoscopic cholecystectomy which is one of the commonest surgical procedure in the world. Endoscopic techniques are recommended as initial treatment of IBDI. When endoscopic treatment is not effective, surgery is considered. Different surgical biliary reconstructions are performed in most patients in IBDI. Roux-Y hepaticojejunostomy is the commonest biliary reconstruction for IBDI. In some patients with complex IBDI, hepatectomy is required. Recently, Li et al analyzed the factors that had led to hepatectomy for patients with IBDI after laparoscopic cholecystectomy (LC). Authors concluded that hepatectomy might be necessary to manage early or late complications after LC. The study showed that proximal IBDI (involving hepatic confluence) and IBDI associated with vascular injuries were the two independent risk factors of hepatectomy in this series. Authors distinguished two main groups of patients that require liver resection in IBDI: those with an injury-induced liver necrosis necessitating early intervention, and those in whom liver resection is indicated for treatment of liver atrophy following long-term cholangitis. In this commentary, indications for hepatectomy in patients with IBDI are discussed. Complex biliovascular injuries as indications for hepatectomy are presented. Short- and long-term results in patients following liver resection for IBDI are also discussed. Hepatectomy is not a standard procedure in surgical treatment of IBDI, but in some complex injuries it should be considered.

Concentration of gelatinases and their tissue inhibitors in pancreatic inflammatory and neoplastic tumors and their influence on the early postoperative course.

UNLABELLED Pancreatic cancer (PC) is the fourth leading cause of death in the world, due to neoplastic disease. Chronic pancreatitis (CP) is a progressive disease leading towards pancreatic fibrosis. The aim of the study was to assess the impact of matrix metalloproteinases 2 and 9 (MMP2 and 9) and their tissue inhibitor (TIMP 1 and 2) concentrations in case of PC and CP tissue homogenates on early treatment results of patients subject to pancreatic resections. MATERIAL AND METHODS The study group comprised 63 patients, including 25 (39.68%) female and 38 (60.32%) male patients. Group 1 (CP) consisted of 31 patients with CP (F: M = 10/21). Group 2 (PC) consisted of 32 patients with PC (F: M = 15:17). The pancreatic tumor samples were collected from the resected pancreas, being subject to electrophoresis and immunoenzymatic studies. After confirming their activity, MMP2, MMP9, TIMP1, TIMP2 concentrations were determined. Correlation analysis of MMPs and TIMPs concentrations was performed in relation to the following: tumor diameter, age, BMI, hospitalization, duration of symptoms and surgery, blood loss, incidence of perioperative complications. RESULTS Group differences were presented in terms of: age, BMI, ASA, duration of symptoms, jaundice, tumor diameter, time of operation. There were no differences considering weight loss, blood loss, extent of resection, and hospitalization. Significant MMPs and TIMPs concentration differences between groups were demonstrated. CONCLUSIONS Comparison of PC to CP tissue samples showed significantly higher levels of metalloproteinases and TIMPs in the former. Positive correlations of MMP1, TIMP1 and 2 with tumor diameter (CP) were observed, and MMP2 with the duration of surgery and blood loss (PC). There was no MMPs and TIMPs concentration levels influence on the incidence of postoperative complications.

Quality-of-life assessment in the treatment of iatrogenic bile duct injuries: hepaticojejunostomy versus end-to-end biliary reconstructions.

Assessment and comparison of quality of life (QOL) in patients treated for iatrogenic bile duct injuries (IBDI) with Roux‐en‐Y hepaticojejunostomy (HJ) or end‐to‐end ductal anastomosis (EE).

Prognostic factors for survival post surgery for patients with gastrointestinal stromal tumors.

Background: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms located in the alimentary tract. Our aim was to assess the influence of prognostic factors on survival in patients surgically treated for GISTs. Study: One hundred and five patients treated between January 1989 and December 2008 were available for study. A retrospective analysis of prognostic factors (age, gender, mitotic index, tumor location, tumor size, risk of malignant behavior, and coexisting other neoplasm) was performed. Univariate and multivariate survival analyses were undertaken. Results: Univariate analyses revealed the importance of patient gender (p = 0.007), disease location (p = 0.055), mitotic index (p = 0.054) and coexistence with other neoplasms (p = 0.004). However, multivariate analysis showed 3 independently statistically significant factors: coexistence with other neoplasm (RR = 3.53, p = 0.004), male gender (RR = 2.60, p = 0.011) and mitotic index ≧10/50 HPF, (RR = 2.60, p = 0.042). Conclusions: Our study has shown that male gender, a high mitotic index ≧10/50 HPF, and coexistence with other malignant neoplasms were independent poor prognostic factors in patients with GIST. The presence of middle or lower gut disease location leads to an increased risk of mortality when compared with the upper gut.

Middle Pancreatectomy - Own Experience

UNLABELLED The aim of the study was to analyse early results after middle pancreatectomy based on our experience. MATERIAL AND METHODS During the period between 2008 and 2009, 154 pancreatic resections were performed at the Department of Gastrointestinal Surgery, Silesian Medical University in Katowice. The following procedures were performed: 109 (70.78%) pancreatoduodenectomies, 32 (20.78%) distal pancreatectomies, 9 (5.84%) middle pancreatectomies, 3 (1.94%) total pancreatic resections, and 1 (0.65%) subtotal pancreatic resection. Early results in case of nine middle pancreatectomies were subject to analysis. RESULTS Average hospitalization period amounted to 24.28 days (ranging between 8 and 57 days). Mean hospitalization period after surgery amounted to 20.71 days (ranging between 6 and 54 days). Average duration of the surgical procedure amounted to 3.6 hours (ranging between 2.25 and 4 hours). Wirsungs duct required drainage in 4 (44.4%) patients. Pancreatoenterostomy was performed in 5 (55.5%) patients. Early postoperative complications were observed in three (33.3%) patients. The most common complications included wound suppuration and intra-abdominal abscess development observed in two (22.2%) patients. Pancreatic fistula development during the postoperative period was observed in case of one (11.1%) patient. Other early postoperative complications included peritoneal cavity hemorrhage (1-11.1%) and pancreatic necrosis (1-11.1%). Two (2.22%) reoperations were required. Early postoperative mortality amounted to 0%. CONCLUSIONS Middle pancreatectomy operations performed in experienced centers are considered as safe procedures with a low rate of complications. The most common indication for middle pancreatectomy is the diagnosis of a benign pancreatic tumor.

Distal Pancreatectomy - OWN Experience

THE AIM OF THE STUDY was the retrospective analysis of early results after distal pancreatectomy (DP). MATERIAL AND METHODS During the period between January, 2000 and December, 2010 distal pancreatectomy was performed in 73 patients, including 32 (43.83%) male, and 41 (56.16%) female patients. Average patient age amounted to 53.92 ± 14.37 years. Surgery was performed by means of laparoscopy or the classical method. RESULTS The mean duration of the procedure amounted to 179.79 ± 59.90 minutes. Fifty-nine (80.82%) patients were subject to splenectomy. After the resection the pancreatic stump was hand-sewn in 69 patients. Pancreatoenterostomy was performed in 4 (5.47%) patients. Early postoperative complications occurred in 11 (15%) patients. Reoperation was required in two (2.7 %) patients. The postoperative mortality rate amounted to 2.7%. The average hospitalization period after surgery amounted to 12.72 ± 9.8 (1- 66) days. CONCLUSIONS Distal pancreatectomy performed in a center experienced in pancreatic surgery is a safe procedure characterized by a low rate of complications and mortality.

Surgical treatment of pancreatic neuroendocrine tumours - clinical experience.

UNLABELLED The aim of the work was the clinical characteristics and analysis of preliminary results for surgical treatment of pancreatic neuroendocrine tumors (PNETs), based on own material. MATERIAL AND METHODS. In the period from 2005 to 2009, in the Department of Gastrointestinal Surgery, Silesian Medical University in Katowice, there were 27 patients (15 males and 12 females) treated surgically for pancreatic neuroendocrine tumours, constituting 65.86% (27/41) of all gastroenteropancreatic neuroendocrine tumours. Prior to the surgery, the following diagnostic examinationswere performed: laboratory tests and imaging examinations (abdominal ultrasound and CT scan). The following tumour localisation was established: head of the pancreas - 14, body of the pancreas - 4, tail of the pancreas - 5, body and tail of the pancreas - 1, retroperitoneal space - 4. There were found 24 (88.89%) primary tumours and 3 (11.11%) recurrences. The following methods of surgical treatment were applied: pancreatoduodenectomy - 11, distal pancreatic resection with splenectomy - 6, middle segment resection with anastomosis between the pancreatic tail and jejunal loop: Roux-Y procedure - 1, pancreatic resection by Beger procedure - 1, pancreatic head and body resection with splenectomy - 1, tumour enucleation or local excision - 4, exploratory laparotomy with specimen collection - 3. RESULTS The mean hospitalisation period was 25 days (4-78 days). The mean procedure duration was 4.2 hours (1.15-9.15 hours). Early post-operative complications were observed in 10 patients (37.04%). The following early complications were observed: intra-abdominal abscess - 2, wound suppuration - 2, pancreatic fistula - 1, acute pancreatitis - 1, pancreaticojejunal anastomosis leak - 1, peritoneal cavity haemorrhage - 1, acute cholangitis - 1, adhesion obstruction - 1, subobstruction - 1, portal vein thrombosis - 1, sepsis - 1, fluid in pleural cavity - 1, acute heart failure - 1. There were performed 2 (7.41%) repeat surgeries: one due to adhesion obstruction and one due to peritoneal cavity haemorrhage. Death of 1 patient (3.71%) was recorded in the post-operative period due to acute heart failure. CONCLUSIONS Pancreatic neuroendocrine tumours constituted the majority of gastroenteropancreatic neuroendocrine tumours in the analysed patient group. Most commonly, PNETs were localised in the head of the pancreas. In the presented material, the mortality rate does not exceed 4%, similarly as in other renowned centres.

Is endoscopic therapy the treatment of choice in all patients with chronic pancreatitis

Chronic pancreatitis (CP) is a progressive inflammatory disease of the pancreas characterized by destruction of the pancreatic parenchyma with subsequent fibrosis that leads to pancreatic exocrine and endocrine insufficiency. Abdominal pain and local complications (bile duct or duodenal stenosis and pancreatic tumor) secondary to CP are indications for therapy. At the beginning, medical therapy is used. More invasive treatment is recommended for patients with pancreatic duct stones (PDS) and pancreatic obstruction in whom standard medical therapy is not sufficient. Recently, Clarke et al assessed the long-term effectiveness of endoscopic therapy (ET) in CP patients. The authors compared ET with medical treatment. They reported that ET was clinically successful in 50% of patients with symptomatic CP. In this commentary, current CP treatment, including indications for ET and surgery in CP patients, is discussed. Recommendations for endoscopic treatment of CP according to the European Society of Gastrointestinal Endoscopy Clinical Guidelines are reviewed. Different surgical methods used in the treatment of CP patients are also discussed. ET is the most useful in patients with large PDS, pancreatic duct obstruction and dilation. It should be the first-line option because it is less invasive than surgery. Surgery should be the first-line option in patients in whom ET has failed or in those with a pancreatic mass with suspicion of malignancy. ET is a very effective and less invasive procedure, but it cannot be recommended as the treatment of choice in all CP patients.

Hemorrhage from the inferior epigastric artery malformation into the external intestinal fistula as an atypical complication of Crohn's disease

Dear Sir, Severe lower gastrointestinal bleeding is a rare complication of Crohns disease, occurring in 0.9% to 6% of cases. Most bleeding episodes originate from colonic ulcers or ulcerated areas within the mucosa.1 In most cases, hemorrhage from the inferior epigastric artery is into the abdominal wall or retroperitoneal space.2,3 Only two cases of bleeding into the intestine and life-threatening hemorrhage due to injury to the inferior epigastric artery following ileostomy construction appearing as massive bloody diarrhea have been reported in the literature.4,5 One case of intraperitoneal hemorrhage from IEA has been reported.5 We present the unique case of life-threatening spontaneous hemorrhage into the external intestinal fistula from the …