Filip Čečka

Clinical and economic consequences cf pancreatic fistula after elective pancreatic resection

BACKGROUND Postoperative pancreatic fistula is the main cause of morbidity after pancreatic resection. This study aimed to quantify the clinical and economic consequences of pancreatic fistula in a medium-volume pancreatic surgery center. METHODS Hospital records from patients who had undergone elective pancreatic resection in our department were identified. Pancreatic fistula was defined according to the International Study Group on Pancreatic Fistula (ISGPF). The consequences of pancreatic fistula were determined by treatment cost, hospital stay, and out-patient follow-up until the pancreatic fistula was completely healed. All costs of the treatment are calculated in Euros. The cost increase index was calculated for pancreatic fistula of grades A, B, and C as multiples of the total cost for the no fistula group. RESULTS In 54 months, 102 patients underwent elective pancreatic resections. Forty patients (39.2%) developed pancreatic fistula, and 54 patients (52.9%) had one or more complications. The median length of hospital stay for the no fistula, grades A, B, and C fistula groups was 12.5, 14, 20, and 59 days, respectively. The hospital stay of patients with fistula of grades B and C was significantly longer than that of patients with no fistula (P<0.001). The median total cost of the treatment was 4952, 4679, 8239, and 30 820 Euros in the no fistula, grades A, B, and C fistula groups, respectively. CONCLUSIONS The grading recommended by the ISGPF is useful for comparing the clinical severity of fistula and for analyzing the clinical and economic consequences of pancreatic fistula. Pancreatic fistula prolongs the hospital stay and increases the cost of treatment in proportion to the severity of the fistula.

Long-term survival of a patient after resection of a gastrointestinal stromal tumor arising from the pancreas

BACKGROUND Gastrointestinal stromal tumors (GISTs) may arise in any part of the gastrointestinal tract; extra-gastrointestinal locations are extremely rare. Only a few cases of extragastrointestinal stromal tumor arising from the pancreas were reported. None of the reports described a long-term follow-up of the patients. METHOD This report describes an interesting and unusual case of GIST arising from the pancreas. RESULTS A 74-year-old female presented with a palpable abdominal mass. CT scan showed a large mass 11 x 8 x 4 cm originating from the tail of the pancreas. Percutaneous biopsy revealed a GIST predominantly with spindle cells, but some parts also contained epitheloid cells. The patient was treated by distal pancreatic resection with splenectomy. Immunohistochemistry of the tumor showed a staining pattern characteristic of GIST. The patient has achieved a long-term survival of five years and six months without any sign of recurrence of the disease. CONCLUSION This is the first reported case of an extra-gastrointestinal stromal tumor arising from the pancreas treated surgically, with a long-term survival.

Surgical technique in distal pancreatectomy: a systematic review of randomized trials.

Despite recent improvements in surgical technique, the morbidity of distal pancreatectomy remains high, with pancreatic fistula being the most significant postoperative complication. A systematic review of randomized controlled trials (RCTs) dealing with surgical techniques in distal pancreatectomy was carried out to summarize up-to-date knowledge on this topic. The Cochrane Central Registry of Controlled Trials, Embase, Web of Science, and Pubmed were searched for relevant articles published from 1990 to December 2013. Ten RCTs were identified and included in the systematic review, with a total of 1286 patients being randomized (samples ranging from 41 to 450). The reviewers were in agreement for application of the eligibility criteria for study selection. It was not possible to carry out meta-analysis of these studies because of the heterogeneity of surgical techniques and approaches, such as varying methods of pancreas transection, reinforcement of the stump with seromuscular patch or pancreaticoenteric anastomosis, sealing with fibrin sealants and pancreatic stent placement. Management of the pancreatic remnant after distal pancreatectomy is still a matter of debate. The results of this systematic review are possibly biased by methodological problems in some of the included studies. New well designed and carefully conducted RCTs must be performed to establish the optimal strategy for pancreatic remnant management after distal pancreatectomy.

Pancreatic Castleman disease treated with laparoscopic distal pancreatectomy

BACKGROUND Castleman disease is an uncommon lymphoproliferative disorder most frequently occurring in the mediastinum. Abdominal forms are less frequent, with pancreatic localization of the disease in particular being extremely rare. Only seventeen cases have been described in the world literature. METHOD This report describes an interesting and unusual case of pancreatic Castleman disease treated with laparoscopic resection. RESULTS A 48-year-old woman presented with epigastric pain. CT scan showed a well-encapsulated mass on the ventral border of the pancreas. Endosonography with fine needle aspiration biopsy was performed. Biopsy showed lymphoid elements and structures of a normal lymph node. The patient was treated with laparoscopic distal pancreatectomy. The pancreas was transected with a Ligasure device and the pancreatic stump was secured with a manual suture. One year after surgery the patient was complaint-free and showed no signs of recurrence of the disease. CONCLUSIONS Laparoscopic distal pancreatectomy is a feasible and safe method for the treatment of lesions in the body and tail of the pancreas. Transection of the pancreas with a Ligasure device offers the advantages of low bleeding and low risk of pancreatic fistula.

Impact of postoperative complications on clinical and economic consequences in pancreatic surgery

Purpose Patients who develop complications consume a disproportionately large share of available resources in surgery; therefore the attention of healthcare funders focuses on the economic impact of complications. The main objective of this work was to assess the clinical and economic impact of postoperative complications in pancreatic surgery, and furthermore to assess risk factors for increased costs. Methods In all, 161 consecutive patients underwent pancreatic resection. The costs of the treatment were determined and analyzed. Results The overall morbidity rate was 53.4%, and the in-hospital mortality rate was 3.7%. The median of costs for all patients without complication was 3,963 Euro, whereas the median of costs for patients with at least one complication was significantly increased at 10,670 Euro (P < 0.001). In multivariate analysis American Society of Anesthesiologists ≥ 3 (P = 0.006), multivisceral resection (P < 0.001) and any complication (P < 0.001) were independently associated with increased costs. Conclusion Postoperative complications are associated with an increase in mortality, length of hospital stay, and hospital costs. The treatment costs increase with the severity of the postoperative complications. Those factors that are known to increase the treatment costs in pancreatic resection should be considered when planning patients for surgery.

DRAPA trial – closed-suction drains versus closed gravity drains in pancreatic surgery: study protocol for a randomized controlled trial

BackgroundThe morbidity of pancreatic resection remains high, with pancreatic fistula being the most common cause. The important question is whether any postoperative treatment adjustment may prevent the development of clinically significant postoperative pancreatic fistulae. Recent studies have shown that intraabdominal drains and manipulation using them are of great importance. Although authors of a few retrospective reports have described good results of pancreatic resection without the use of intraabdominal drains, a recent prospective randomized trial showed that routine elimination of drains in pancreaticoduodenectomy is associated with poor outcome. An important issue arises as to which type of drain is most suitable for pancreatic resection. Two types of surgical drains exist: open drains and closed drains. Open drains are considered obsolete nowadays because of frequent retrograde infection. Closed drains include two types: passive gravity drains and closed-suction drains. Closed-suction drains are more effective, as they remove fluid from the abdominal cavity under light pressure. However, some surgeons believe that closed-suction drains represent a potential hazard to patients and that negative pressure might increase the risk of pancreatic fistulae. Nobody has yet specifically dealt with the question of which kind of drainage is most appropriate in pancreatic surgery.Methods/DesignThe aim of the DRAins in PAncreatic surgery (DRAPA) trial is to compare the closed-suction drain versus the closed passive gravity drain in pancreatic resection. DRAPA is a dual-centre, prospective, randomized controlled trial. The primary endpoint is the rate of postoperative pancreatic fistula; the secondary endpoint is postoperative morbidity with follow-up of 3 months.DiscussionNo study to date has compared different types of drains in pancreatic surgery. This study is designed to answer the question whether any particular type of drain might lower the rate of postoperative pancreatic fistula or other complications.Trial registrationClinicalTrials.gov Identifier: NCT01988519. Registered 13 November 2013.

Expression of Bcl-2 in Breast Cancer: Correlation with Clinicopathological Characteristics and Survival

Breast cancer is the most common malignancy in women. It is an immensely heterogeneous disease, characterised by a broad variety of clinical development. The research in recent years has focused on finding new markers of prognosis. This study investigates the role of expression of the bcl-2 protein in breast cancer. We analysed bcl-2 expression in 57 women with primary breast carcinoma who were treated with neoadjuvant (primary) chemotherapy, followed by a surgical procedure. The bcl-2 expression was correlated with other clinicopathological characteristics of the tumour - histological grade, stage, expression of hormonal receptors, proliferation rate, and with the survival of the patients. No significant association of bcl-2 expression with either overall survival or disease free survival was found.

Intra-abdominal drainage following pancreatic resection: A systematic review.

AIM To study all the aspects of drain management in pancreatic surgery. METHODS We conducted a systematic review according to the PRISMA guidelines. We searched the Cochrane Central Registry of Controlled Trials, EMBASE, Web of Science, and PubMed (MEDLINE) for relevant articles on drain management in pancreatic surgery. The reference lists of relevant studies were screened to retrieve any further studies. We included all articles that reported clinical studies on human subjects with elective pancreatic resection and that compared various strategies of intra-abdominal drain management, such as drain vs no drain, selective drain use, early vs late drain extraction, and the use of different types of drains. RESULTS A total of 19 studies concerned with drain management in pancreatic surgery involving 4194 patients were selected for this systematic review. We included studies analyzing the outcomes of pancreatic resection with and without intra-abdominal drains, studies comparing early vs late drain removal and studies analyzing different types of drains. The majority of the studies reporting equal or superior results for pancreatic resection without drains were retrospective and observational with significant selection bias. One recent randomized trial reported higher postoperative morbidity and mortality with routine omission of intra-abdominal drains. With respect to the timing of drain removal, all of the included studies reported superior results with early drain removal. Regarding the various types of drains, there is insufficient evidence to determine which type of drain is more suitable following pancreatic resection. CONCLUSION The prophylactic use of drains remains controversial. When drains are used, early removal is recommended. Further trials comparing types of drains are ongoing.

The effect of somatostatin and its analogs in the prevention of pancreatic fistula after elective pancreatic surgery

SummaryBACKGROUND: The prophylactic use of somatostatin and its analogs has been suggested to lower the rate of pancreatic fistula. The aim of this review is to discuss the results of published randomized trials and meta-analyses studying the effect of somatostatin and its analogs. METHODS: We performed a Medline search for prospective randomized trials, systematic reviews and meta-analyses with regard to the prophylactic use of somatostatin and its analogs. RESULTS: Eleven randomized trials and six meta-analyses were identified. The randomized trials differ in terms of study designs, diagnosis, operative procedures, drug dosage, time of administration, and the pancreatic fistula definition; therefore, it is advisable to carefully interpret the results of the individual randomized trials. CONCLUSIONS: The routine administration of somatostatin and its analogs in elective pancreatic surgery cannot be recommended. However, selective administration is advisable in cases which carry significantly higher risk of developing pancreatic fistula.

Gangliocytic Paraganglioma of the Duodenum

A 54-year-old woman was examined following a positive fecal occult blood test performed within the screening program for colorectal cancer. The patient had no symptoms, no previous surgeries and her history was unremarkable. Physical examination and basic laboratory tests, including a blood count, were normal. A coloscopy was performed with a finding of a single polyp 5 mm in size in the sigmoid colon. The polyp was removed endoscopically and the histological examination revealed an adenoma. Subsequently, gastroduodenoscopy was performed and revealed a duodenal lesion very near the ampulla (Figure 1). The lesion was 18 mm in diameter with ulceration at the apex. No bleeding was visible. A biopsy sample was taken from the ulceration. No malignant structures were found. Endosonography was then performed and showed the homogeneous structure of the lesion originating from the submucous layer of duodenum. No lymphadenopathy was found (Figure 2). Magnetic resonance imaging revealed a mass in the second portion of the duodenum with no significant lymphadenopathy and no distant metastases. Figure 1) Gastroduodenoscopy showing a mass in the duodenum Figure 2) Endosonography showing homogenous lesion 15 mm in diameter, it does not infiltrate muscularis propria. There is no lymphadenopathy The diagnosis was not known before the treatment, but the lesions had the hallmark characteristics of a gastrointestinal stromal tumour. Endoscopic treatment of the lesion was considered but was not possible due to its location; thus, surgical resection was pursued. The abdominal cavity was approached through a right subcostal incision. A duodenotomy in the D2 was performed along with extirpation of the lesion. No complications occurred. The postoperative course was uneventful and the patient was discharged on postoperative day 11. A final histological examination showed findings typical of gangliocytic paraganglioma of the duodenum (Figure 3); the resection line was free of the tumour. Figure 3) Histological examination of the surgical specimen showing an irregular composition of spindle cells typical of gangliocytic paraganglioma. Hematoxylin-eosin stain, original magnification ×40 The patient is currently being followed-up at our department and is complaint free, showing no signs of recurrence of the disease two-and-a-half years after the surgery.