Brandon C. Chapman

Fecal microbiota transplant in patients with Clostridium difficile infection: A systematic review.

BACKGROUND Fecal microbiota transplantation (FMT) restores a diverse bacterial profile to the gastrointestinal tract and may effectively treat patients with Clostridium difficile infection (CDI). The objective of this systematic review was to evaluate the effectiveness of FMT in the treatment of CDI. METHODS Ovid MEDLINE, EMBASE, Web of Science, and Cochrane database were used. The authors searched studies with 10 or more patients examining the resolution of symptoms after FMT in patients with CDI. Reviews, letters to the editors, and abstracts were excluded. Participants were patients with CDI. Intervention used was FMT. Quality assessment was performed using the Cochrane risk of bias assessment tool. Results were synthesized using a narrative approach. RESULTS Retrospective and uncontrolled prospective cohort studies suggest that FMT is a highly effective therapy for recurrent/refractory CDI, with clinical success rates ranging from 83% to 100%, which is similar to rates published by two randomized controlled trials. Fecal microbiota transplantation may be effectively administered via antegrade (upper gastrointestinal) or retrograde (lower gastrointestinal) routes of delivery. Fecal microbiota transplantation rarely results in major adverse events. However, diarrhea, cramping, and bloating commonly occur and are typically self-limited. Most studies were uncontrolled retrospective studies. CONCLUSION Fecal microbiota transplantation should be considered in patients with recurrent episodes of mild to moderate CDI who have failed conventional antimicrobial therapy. There is insufficient evidence to recommend FMT for the treatment of severe CDI. LEVEL OF EVIDENCE Systematic review, level III.

Postoperative pneumoperitoneum: is it normal or pathologic?

BACKGROUND Pneumoperitoneum on computed tomography (CT) after abdominal surgery is common, but its incidence, duration, and clinical significance is widely debated. MATERIALS AND METHODS A retrospective, cohort study of patients who underwent abdominal CT within 30 days of abdominal surgery. RESULTS Among 344 patients, pneumoperitoneum was found in 39% (135/344) of patients on postoperative days 0-6 in 53%, 7-13 in 41%, 14-20 in 23%, 21-27 in 13%, and 28-30 in 0%. Pneumoperitoneum was associated with the presence of a drain (P = 0.014) but not with age, gender, body mass index, smoking history, lung disease, or open versus laparoscopic surgery (P > 0.05 for all variables). Eight patients required intervention (6%), most commonly for anastomotic leak (4 patients, 50%). CONCLUSIONS Postoperative pneumoperitoneum on abdominal CT can be seen in up to 23% of patients 3-weeks postoperatively; however, only 6% of the patients required intervention emphasizing the typically benign consequences of postoperative free air.

Metastatic Papillary Gallbladder Carcinoma with a Unique Presentation and Clinical Course

CONTEXT Papillary gallbladder adenocarcinoma (PGA) represents 5% of malignant gallbladder tumors. Metastatic disease frequently involves lymph nodes or other structures in the hepatoduodenal ligament. CASE REPORT A Fifty-nine-year-old female with right upper quadrant pain and a giant gallbladder on ultrasound was found to have a segment 6 liver lesion during an attempted laparoscopic cholecystectomy. After appropriate staging, she underwent an open cholecystectomy and extended right hepatic lobectomy with portal lymph node dissection. Pathology demonstrated well-to-moderately differentiated PGA with identical morphology and immunohistochemistry in the liver resection specimen with negative margins. Despite adjuvant chemotherapy, she developed increased uptake in the head of the pancreas on PET scan. Endoscopic ultrasound with fine needle aspiration demonstrated metastatic PGA. She underwent an attempted Whipple operation but due to repeatedly positive pancreatic duct margins, she ended up with a total pancreatectomy and splenectomy. Final pathology showed metastatic PGA along the entire length of the pancreatic duct with only a single focus of tumor invasion into the pancreatic parenchyma. She developed a new liver metastases six months later that was unresponsive to FOLFOX therapy and she died of metastatic disease 33 months from her initial diagnosis. CONCLUSION To our knowledge, this is the first report of metastatic PGA recurring along the entire pancreatic duct with disease confined to the pancreas only. We hypothesize that papillary tumor cells spread to pancreatic duct via the common bile duct and remained dormant for several years. An aggressive surgical approach may prolong survival in well-selected patients with PGAs.

Implications of Sentinel Lymph Node Drainage to Multiple Basins in Head and Neck Melanoma

BackgroundSentinel lymph node biopsy (SLNB) for head and neck melanoma is challenging due to unpredictable drainage. We sought to determine the frequency of drainage to multiple lymphatic basins and asked if this was associated with prognosis in a large, single-center cohort.MethodsWe queried patients diagnosed with head and neck melanomas who had a SLNB performed from January 1998 to April 2016. Demographic and clinical characteristics were compared using Student’s t test, Pearson chi-square analysis, log-rank test, Wilcoxon-Mann–Whitney test, and Kaplan–Meier curves.ResultsWe identified 269 patients with head and neck melanoma that had SLNBs performed in the following locations: 223 neck, 92 parotid/preauricular, 29 occipital/posterior auricular, 1 axilla. There were 68 (25%) patients who had drainage to multiple basins. These patients were similar to those with single basin drainage in age, gender distribution, Breslow depth, and percent with a positive SLNB (all p > 0.05). Fewer patients with drainage to multiple basins had a completion lymph node dissection (CLND, p = 0.03). A trend toward increased 3-year locoregional recurrence was seen for patients with drainage to multiple basins in univariate analysis (27% vs. 18%, p = 0.10) but was lost in multivariate analysis (p = 0.49), possibly because of higher recurrence rates in patients with positive nodes but no CLND (p = 0.02). No difference was detected for distant recurrence or overall survival based on SLN drainage.ConclusionsHead and neck melanoma SLNB drainage to multiple basins is common. Drainage to multiple basins does not seem to be associated with increased sentinel lymph node positivity, locoregional recurrence, distant recurrence, or survival.

Open and minimally invasive pancreatic surgery—a review of the literature

Background: There is increasing evidence demonstrating the safety, feasibility and improved postoperative recovery of laparoscopic pancreas resections. The purpose of this study is to review recent advances in laparoscopic distal pancreatectomy (LDP) and minimally invasive pancreaticoduodenectomy (MIPD) with an emphasis on laparoscopic technique, intraoperative outcomes, perioperative outcomes, and oncologic outcomes. Methods: A systematic literature search was performed using MEDLINE, Web of Science, and Embase. Studies were included if they were an original series in adult patients comparing laparoscopic and open pancreatectomies between 2005 and 2015 with ten or more patients in the laparoscopic group. Patient demographics and intraoperative, postoperative, and oncologic variables were recorded. Odds ratios (ORs) were calculated from dichotomous data and the mean difference (MD) from the continuous data, both with 95% confidence intervals (CIs). Results: A total of 495 articles were reviewed, 42 of which were selected and included in the distal pancreatectomy group and 19 studies in the pancreaticoduodenectomy group. LDP was performed in 20.2% (n=3,759/18,587) of patients. MIPD was performed in 14.8% (n=3,692/24,923) of patients. Patients in the LDP group had longer operating times (P<0.001), lower estimated blood loss (P<0.001), reduced number of red blood cell transfusions (P<0.001), higher rate of spleen preservation (P<0.001), lower positive margin (P<0.001), lower overall complication rates (P<0.001), reduced 30-day mortality or in-hospital mortality (P=0.012), less post-operative bleeding (P=0.003), decreased wound infections (P<0.001), shorter length of hospital stay (P<0.001), earlier return of bowel function (P<0.001), quicker time to PO intake (P<0.001), and fewer days of IV narcotics (P=0.016). The LDP group had similar lymph node (LN) retrieval (P=0.325), number of patients with positive LN (P=0.734), pancreatic fistula rates (P=0.539), need for re-operation (P=0.354), readmission rates (P=0.898), and time to ambulation (P=0.081) as the open group. The MIPD group had longer operating room times (P<0.001), fewer intra-operative red blood cell transfusions (P=0.009), lower positive margin rate (P=0.022), increased post-operative bleeding (P=0.024), shorter length of hospital stay (P<0.001), lower readmission rate (P=0.048), earlier return of bowel function (P<0.001), and shorter time to PO intake (P<0.001) in comparison to the open group. However, both groups had similar LN retrieval (P=0.142), number of patients with positive LNs (P=0.099), overall morbidity (P=0.145), 30-day or in-hospital mortality (P=0.853), pancreatic fistula (P=0.685), delayed gastric emptying (DGE) (P=0.092), bile leak (P=0.617), wound infections (P=0.061), and similar reoperation rates (P=0.863). Conclusions: Analysis of the available literature suggests that laparoscopic pancreatectomies are feasible, safe, and potentially have improved perioperative recovery; while achieving equivalent oncologic outcomes when compared to open resection. Further investigation with randomized controlled trials is needed to avoid selection bias and control for confounding factors inherently found in the studies reviewed. However, this analysis does suggest a growing acceptance of laparoscopic pancreas surgery.

Perioperative outcomes and survival following neoadjuvant stereotactic body radiation therapy (SBRT) versus intensity-modulated radiation therapy (IMRT) in pancreatic adenocarcinoma

To compare outcomes in patients receiving neoadjuvant stereotactic body radiation therapy (SBRT) with those receiving intensity‐modulated radiation therapy (IMRT) for pancreatic adenocarcinoma.

Impact of neoadjuvant chemoradiation on perioperative outcomes in patients with rectal cancer

Neoadjuvant chemoradiation for rectal cancer is associated with lower local recurrence rates. The objective of this study is to assess the impact of neoadjuvant therapy on perioperative complications in patients with rectal cancer.