Bryce R. Taylor

Quality of life, nutritional status, and gastrointestinal hormone profile following the Whipple procedure.

Pancreatic cancer is the second commonest gastrointestinal cancer, after colorectal cancer, in Canada, and most other European and North American countries. Unfortunately, most patients present with advanced locoregional or metastatic disease. For the 10-20% of patients who have localized disease, pancreatic resection is generally the preferred treatment option. Because pancreaticoduodenectomy can be performed safely in expert hands, it has become a more accepted procedure for patients with pancreatic cancer. Furthermore, it has also meant that there is increasing scrutiny of the longterm outcome of patients, especially their nutritional status and quality of life. In a study of 25 unselected patients who had a Whipple procedure at least 6 months previously and were not known to have residual or recurrent disease, patients appeared to have few gastrointestinal symptoms compared to control patients. However, none of the subjects appeared to be clinically malnourished. Dietary intake and lean body mass were comparable to that of the control group. Quality of life was excellent in these patients. The mean utilities were 0.98 and 1.0 suggesting near normal wellbeing. Similarly, results using the SIP and GIQLI suggested no/minimal impairment in general wellbeing and gastrointestinal function. Two other studies suggest that median survival and performance status are improved in patients having a resection, but it may be due to their disease being more favorable rather than the treatment being beneficial. Further studies objectively assessing the quality of life of all patients undergoing treatment for pancreatic cancer at the various disease stages are required.

Periampullary tumors: Which ones should be resected?*

Resection was carried out in 118 patients for periampullary lesions. Ninety-eight of these were adenocarcinomas and were treated by the Whipple operation, total pancreatectomy, or local resection (87 patients, 7 patients, and 4 patients, respectively). Diagnosis of pancreatic head carcinoma before resection was falsely positive in 27 percent of the patients. Mortality for radical resection was 4 percent. Five year survival for ampullary carcinoma was 32 percent, and for pancreatic head carcinoma it was 7 percent. Resection of all periampullary tumors is recommended, with the Whipple operation being the standard in most cases.

Recurrent pyogenic cholangitis with hepatolithiasis--the role of surgical therapy in North America.

PurposeTo determine role of surgical intervention for Recurrent Pyogenic Cholangitis with hepatolithiasis at a North American hepatobiliary center.MethodsRetrospective analysis of 42 patients presenting between 1986 and 2005.ResultsMean age is 54.3xa0years (24–87). Twenty-seven patients (64%) underwent surgery, after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous intervention in 19/27 patients. Surgical procedures were: 10 common bile duct explorations with choledochojejunostomy and a Hutson loop and 17 hepatectomies (10 with, 7 without Hutson loop). Liver resection was indicated for lobar atrophy or stones confined to single lobe. Operative mortality was zero; complication rates for hepatectomy and common bile duct exploration were comparable (35% vs. 30%). Median follow-up was 24xa0months (3–228). Of 21 patients with Hutson loops, only seven (33%) needed subsequent loop utilization, with three failures. At last follow-up, 4/27 (15%) surgical patients had stone-related symptoms requiring percutaneous intervention, compared to 4/11 (36%) surviving nonoperative patients. Cholangiocarcinoma was identified in 5/42 (12%) patients; four were unresectable and one was an incidental in-situ carcinoma in a resected specimen.ConclusionSurgery is a valuable part of multidisciplinary management of recurrent pyogenic cholangitis with hepatolithiasis. Hepatectomy is a useful option for selected cases. Hutson loops are useful in some cases for managing stone recurrence. Cholangiocarcinoma risk is elevated in this disease.

Effects of Peritoneovenous Shunting on Body Composition

The effect of peritoneovenous shunting on body composition has been studied in 7 cirrhotic patients undergoing a successful shunt and 3 patients in whom the shunt was unsuccessful. In the 7 patients with functioning shunts, their weight had decreased by a mean of 9 kg (p less than 0.001) by 6 wk after initial diuresis, natriuresis, and kaliuresis, and was associated with a decrease in total body potassium (TBK) but not total body nitrogen (TBN). This resulted in a significant decrease in the TBK/TBN ratio from 2.12 +/- 0.74 to 1.66 +/- 0.20 (p less than 0.01). By a mean of 14 mo, in these 7 patients there was a significant increase in mean TBN (from 1.54 +/- 0.10 to 1.84 +/- 0.10, p less than 0.005) associated with an improvement in the mean nitrogen index (from 0.74 +/- 0.04 to 0.88 +/- 0.04, p less than 0.005). These changes were associated with a significant increase in nonalcoholic calories, a nonsignificant increase in protein consumption, and a positive nitrogen balance. After the initial kaliuresis, mean potassium balance remained constantly positive (+22.7 +/- 3.4 mmol/day), serum aldosterone levels normalized, and TBK increased. In contrast, 3 patients with failed peritoneovenous shunting continued to lose weight significantly despite the presence of ascites; TBN and nitrogen index also decreased. In conclusion, body composition studies appear to have confirmed the clinical observation that cirrhotic patients with massive ascites have depleted body protein which is gradually repleted only after successful shunting. In this situation TBK, long used as a measure of lean body mass, is less satisfactory than TBN and nitrogen index. This improvement in body protein appears to be explained by an increased dietary intake associated with improved nitrogen balance, but these changes are not found in patients in whom the shunt failed.

Transduodenal Resection of Peri-Ampullary Lesions

Transduodenal resection (TDR) of lesions near the ampulla of Vater is an alternative to the Whipple pancreaticoduodenectomy. A retrospective analysis was performed to determine the long-term outcome and the utility of intraoperative frozen section examinations in aiding operative decision making in patients undergoing TDR. From 1992 to 2002, 19 patients with an average age of 64.2 years (range: 33–84 years) underwent a transduodenal resection of a peri-ampullary lesion; median follow-up was 47 months (range: 2–100 months). Pathology of the lesions was as follows: 11 with benign ampullary adenomas, including 4 with familial adenomatous polyposis (FAP); 7 with peri-ampullary adenocarcinomas; and 1 with a benign stricture. Survival for the entire cohort is 100%. In 12 cases an intraoperative frozen section was performed. The specificity and positive predictive value of the intraoperative histology were both 100%, and the sensitivity and negative predictive value were 57% and 38%, respectively. Three of the 4 patients with FAP have recurrent adenomatous change; 2 of the 7 with carcinoma have metastatic adenocarcinoma. Transduodenal resection of peri-ampullary lesions appears to be a safe alternative to radical resection for benign adenomas and selected carcinoma. Intraoperative frozen section assessment is recommended in cases of potential adenocarcinoma.

Percutaneous transhepatic sphincterotomy in the management of biliary tract disease

This report describes a novel modification of existing transhepatic techniques and illustrates successful relief of mechanical obstructive jaundice in 2 patients in whom surgical or endoscopic intervention was contraindicated or impossible.In each, percutaneous transhepatic cholangiogram (PTC) was performed in the usual manner. A standard endoscopic papillotome was then advanced across the stricture into the duodenum. Sphincterotomy was performed at the 11 to 1 oclock position using blended current for 3–4 seconds. Repeat cholangiography showed successful decompression of the biliary tree in both patients. No morbidity or mortality was directly attributable to percutaneous transhepatic sphincterotomy in these patients. This technique offers a safe and therapeutic alternative to biliary tract obstruction, and should be considered in selected patients who are not candidates for surgery or endoscopy.