Gareth Morris-Stiff

Pancreatic Lesions in von Hippel–Lindau Disease? A Systematic Review and Meta-synthesis of the Literature

Backgroundvon Hippel–Lindau (vHL) disease is a rare condition that leads to characteristic lesions within many different body systems. Pancreatic manifestations of vHL cover a wide spectrum of pathologies, and thus, accurate characterization and management is critical.MethodsA comprehensive and systematic text word and MeSH search of the medical literature was performed to identify studies where information regarding the prevalence, clinical characteristics, and management recommendations could be extracted.ResultsEleven studies were identified but 2 studies utilized the same data set. Of the 10 remaining studies, a total of 1,442 patients with vHL were available for analysis. Four hundred and twenty patients were examined for any type of pancreatic lesion, 362 for simple cysts or serous cystadenomas (SCAs), and 1,442 for neuroendocrine tumors (NETs). Of the 420 assessed for any pancreatic manifestation of vHL, 252 (60%) had a pancreatic lesion identified. Simple cysts that present as the sole manifestation of pancreatic disease were common and found in 169 of 362 (47%) patients. These are usually asymptomatic and do not normally require intervention. SCAs were reported in 39 of 362 (11%) patients and followed a similar benign course; resection is acceptable in symptomatic patients. NETs were identified in 211 of 1,442 (15%) patients, and 27 of 1,442 (2%) lesions behaved malignantly. Management of NETs depends on size, doubling time, and underlying genetics. Renal cell carcinoma is a characteristic in vHL, but there were no cases of pancreatic metastases identified from the included studies. Adenocarcinomas of the pancreas are not pathogenically linked to vHL.ConclusionsThis review highlights the wide spectrum and high prevalence of pancreatic lesions in vHL. Simple cysts and SCAs are benign, but NETs require careful observation due to their malignant potential.

Metabonomics: A Useful Tool for the Future Surgeon

BACKGROUNDnIn the past decade or so, a range of technologies have emerged that have shown promise in increasing our understanding of disease processes and progression. These advances are referred to as the omics technologies; genomics, transcriptomics, and proteomics. More recently, another omics approach has come to the fore: metabonomics, and this technology has the potential for significant clinical impact. Metabonomics refers to the analysis of the metabolome, that is, the metabolic profile of a system. The advantage of studying the metabolome is that the end points of biological events are elucidated.nnnRESULTSnAlthough still in its infancy, the metabonomics approach has shown immense promise in areas as diverse as toxicology studies to the discovery of biomarkers of disease. It has also been applied to studies of both renal and hepatic transplants. Metabolome analysis may be conducted on a variety of biological fluids and tissue types and may utilize a number of different technology platforms, mass spectrometry (MS) and nuclear magnetic resonance (NMR) spectroscopy being the most popular. In this review, we cover the background to the evolution of metabonomics and its applications with particular emphasis on clinical applications.nnnCONCLUSIONSnWe conclude with the suggestion that metabonomics offers a platform for further biomarker development, drug development, and in the field of medicine.

Quantitative Assessment of Hepatic Function and its Relevance to the Liver Surgeon

BackgroundStandard evaluation of patients undergoing hepatic surgery has been through radiological and quantitative determination of liver function. As more complex and extensive surgery is now being performed, often in the presence of cirrhosis/fibrosis or following administration of chemotherapy, it is questioned whether additional assessment may be required prior to embarking on such surgery. The aim of this review was to determine the current knowledge base in relation to the performance of quantitative assessment of hepatic function both pre- and post-operatively in patients undergoing hepatic resectional surgery and liver transplantation.MethodsAn electronic search was performed of the medical literature using the MEDLINE database to identify relevant articles with cross-referencing of all identified papers to ensure full literature capture.Results and ConclusionsThe review has identified a number of different methods of dynamically assessing hepatic function, the most frequently performed being through the use of indocyanine green clearance. With the recent and further anticipated developments in hepatic resectional surgery, it is likely that quantitative assessment will become more widely practiced in order to reduce post-operative hepatic failure and improve outcome.

The Prognostic Value of the Neutrophil–Lymphocyte Ratio (NLR) in Acute Pancreatitis: Identification of an Optimal NLR

IntroductionThe neutrophil–lymphocyte ratio (NLR), calculated from the white cell differential count, provides a rapid indication of the extent of an inflammatory process. The aim of this study was to investigate the prognostic value of the NLR in acute pancreatitis (AP) and determine an optimal ratio for severity prediction.Materials and MethodsNLRs were calculated on days 0, 1, and 2, and correlated with severity. Severity was defined using the Atlanta classification.ResultsOne hundred forty-six consecutive patients managed were included, 22 with severe acute pancreatitis (SAP). NLR in SAP was significantly higher than in the favorable prognosis group on all 3xa0days (day 0, 15.5 vs. 10.5; day 1, 13.3 vs. 9.8; day 2, 10.8 vs. 7.6). The optimal cut-offs from ROC curves were 10.6 (day 0), 8.1 (day 1), and 4.8 (day 2) giving sensitivities of 63–90xa0%, specificities of 50–57xa0%, negative predictive value of 89.5–96.4xa0%, positive predictive values of 21.2–31.1xa0%, and accuracies of 57.7–60xa0%.ConclusionsElevation of the NLR during the first 48xa0h of admission is significantly associated with severe acute pancreatitis and is an independent negative prognostic indicator in AP.

Patient views through the keyhole: new perspectives on single-incision vs. multiport laparoscopic cholecystectomy

OBJECTIVESnSingle-incision laparoscopic cholecystectomy (SILC) may be associated with less pain, shorter hospital stay and better cosmetic results than multiport laparoscopic cholecystectomy (MLC). Advocates suggest that patients prefer SILC, although research directly addressing the question of patient preferences is limited. This study aimed to assess patient preferences using currently available evidence.nnnMETHODSnPatients awaiting elective cholecystectomy were shown a series of postoperative images taken after SILC or MLC and asked which procedure this led them to prefer. This was repeated after patients had completed a questionnaire constructed using published objective data comparing patient-reported outcomes of SILC and MLC.nnnRESULTSnThe study was completed by 113 consecutive patients. After their initial viewing of the images, 16% of subjects preferred MLC. Younger age, lower body mass index and female sex were associated with choosing SILC. After completing the questionnaire, 88% of patients preferred MLC (P < 0.001). Patients ranked the level of risk for complications and postoperative pain above cosmetic results in determining their choice of procedure.nnnCONCLUSIONSnPatients initial preference when presented with cosmetic appearance was for SILC. When contemporary outcome data were included, the majority chose MLC. This underlines the need to fully inform patients during the consent process and indicates that patient views of SILC may differ from the views of those introducing the technology.

Thrombotic complications following liver resection for colorectal metastases are preventable

BACKGROUNDnSurgery for colorectal liver metastases (CRLM) can be expected to be associated with a significant rate of thromboembolic complications due to the performance of long-duration oncologic resections in patients aged 60 years.nnnAIMSnTo determine the prevalence of clinically significant thrombotic complications, including deep venous thrombosis (DVT) and pulmonary embolus (PE), in a contemporary series of patients undergoing resection of CRLM with standard prophylaxis.nnnMATERIAL AND METHODSnA prospectively maintained database identified patients undergoing resection of CRLM from January 2000 to March 2007 and highlighted those developing thromboembolic complications. In addition, the radiology department database was reviewed to ensure that clinically suspicious thromboses had been confirmed radiologically by ultrasound in the case of DVT or computed tomography for PEs.nnnRESULTSnDuring the period of the study, 523 patients (336 M and 187 F) with a mean age of 65 years underwent resection. A major hepatectomy was performed in 59.9%. One or more complications were seen in 45.1% (n=236) of patients. Thrombotic complications were seen in 11 (2.1%) patients: DVT alone (n=4) and PE (n=7). Eight of 11 thrombotic complications occurred in patients undergoing major hepatectomy, 4 of which were trisectionectomies. Patients were anti-coagulated and there were no mortalities.nnnCONCLUSIONSnThe symptomatic thromboembolic complication rate was lower in this cohort than may be expected in patients undergoing non-hepatic abdominal surgery. It is uncertain whether this is due entirely to effective prophylaxis or to a combination of treatment and a natural anti-coagulant state following hepatic resection.

Pre-liver transplant biopsy in hepatocellular carcinoma: a potential criterion for exclusion from transplantation?

BACKGROUNDnIn cirrhotic patients with hepatocellular carcinoma (HCC), poor differentiation in pre-liver transplantation (LT) biopsy of the largest tumour is used as a criterion for exclusion from LT in some centres. The potential role of pre-LT biopsy at one centre was explored.nnnMETHODSnA prospective database of patients undergoing orthotopic LT for radiologically diagnosed HCC at St Jamess University Hospital, Leeds during 2006-2011 was analysed.nnnRESULTSnA total of 60 predominantly male (85.0%) patients with viral hepatitis were identified. There were discrepancies between radiological and histopathological findings with respect to the number of tumours identified (in 27 patients, 45.0%) and their size (in 63 tumours, 64.3%). In four (6.7%) patients, the largest lesion, which would theoretically have been targeted for biopsy, was not the largest in the explant. Nine (31.0%) patients with multifocal HCC had tumours of differing grades. In two (6.9%) patients, the largest tumour was well differentiated, but smaller tumours in the explant were poorly differentiated. In one patient, the largest lesion was benign and smaller invasive tumours were confirmed histologically.nnnCONCLUSIONSnThe need to optimize selection for LT in HCC remains. In the present series, the largest tumour was not always representative of overall tumour burden or biological aggression and its potential use to exclude patients from LT is questionable.

Prognostic value of the lymph node ratio after resection of periampullary carcinomas

BACKGROUNDnData have indicated that the lymph node ratio (LNR) may be a better prognostic indicator than lymph node status in pancreatic cancer.nnnOBJECTIVESnTo analyse the value of the LNR in patients undergoing resection for periampullary carcinomas.nnnMETHODSnA cut off value of 0.2 was assigned to the LNR in accordance with published studies. The impact of histopathological factors including a LNR was analysed using Kaplan-Meier and Cox regression methods.nnnRESULTSnIn total, 551 patients undergoing a resection (January 2000 to December 2010) were analysed. The median lymph node yield was 15, and 198 (34%) patients had a LNR > 0.2. In patients with a LNR of > 0.2, the median overall survival (OS) was 18 versus 33 months in patients with an LNR < 0.2 (P < 0.001). Univariate analysis demonstrated a LNR > 0.2, T and N stage, vascular or perineural invasion, grade and resection margin status to be significantly associated with OS. On multivariate analysis, only a LNR > 0.2, vascular or perineural invasion and margin positivity remained significant. In N1 disease, a LNR was able to distinguish survival in patients with a similar lymph node burden, and correlated with more aggressive tumour pathological variables.nnnCONCLUSIONnA LNR > 0.2, and not lymph note status, is an independent prognostic factor for OS indicating the LNR should be utilized in outcome stratification.

Lymphoepithelial cysts of the pancreas:a management dilemma.

Pancreatic lymphoepithelial cysts (LECs) are rare, benign lesions that are typically unexpected post-operative pathological findings. We aimed to review clinical, radiological and pathological features of LECs that may allow their pre-operative diagnosis. Histopathology databases of two large pancreatic units were searched to identify LECs and notes reviewed to determine patient demographic details, mode of presentation, investigations, treatment and outcome. Five male and one female patients were identified. Their median age was 60 years. Lesions were identified on computed tomography performed for abdominal pain in two patients, and were incidentally observed in four patients. Five LECs were located in the tail and one in the body of the pancreas, with a median cyst size of 5 cm. Obtaining cyst fluid was difficult and a largely acellular aspirate was yielded. The pre-operative diagnosis was mucinous cystic neoplasm in all patients. This series of patients were treated distal pancreatectomy and splenectomy. A retrospective review of radiological examinations suggested that LECs have a relatively low signal on T2 imaging and a high signal intensity on T1 weighted images. LECs appear more common in elderly males, and are typically incidental, large, unilocular cysts. Close attention to signal intensity on MRI may allow pre-operative diagnosis of these lesions.

The Modified Early Warning Score (MEWS): An Instant Physiological Prognostic Indicator of Poor Outcome in Acute Pancreatitis

CONTEXTnThe Modified Early Warning Score (MEWS) is a bedside scoring system that is non-invasive, simple and repeatable to reflect dynamic changes in physiological state.nnnOBJECTIVEnThis study aims to assess accuracy of MEWS and determine an optimal MEWS value in predicting severity in acute pancreatitis (AP).nnnMETHODSnA prospective database of consecutive admissions with AP to a single institution was analysed to determine value of MEWS in identifying severe acute pancreatitis (SAP) and predicting poor outcome. Receiver operator curves (ROC) were used to determine optimal accuracy. Sensitivity, specificity, negative predictive value (NPV), and positive predictive values (PPV) were calculated for the optimal MEWS values obtained.nnnRESULTSnOne-hundred and 42 patients with AP were included. The optimal highest MEWS per 24 hours period (hMEWS) and mean MEWS per 24 hour period (mMEWS) in predicting SAP as determined by ROC were 2.5 and 1.625 respectively; with hMEWS ≥3 and mMEWS >1 utilised in this cohort as MEWS scores are whole numbers. On admission, sensitivity, specificity, NPV, PPV, and accuracy of hMEWS ≥3 was 95.5%, 90.8%, 99.0%, 65.6% and 92.0%; and for mMWES >1 was 95.5%, 87.5%, 99.0%, 58.3% and 88.7%, both superior than the Imrie score: 31.5%, 92.1%, 88.9%, 40.0% and 83.5%. The accuracy of hMEWS ≥3 and mMEWS >1 increased over the subsequent 72 hours (days 0-2) from 92 to 96%, and 89% to 94%, respectively.nnnCONCLUSIONSnMEWS provides a novel, easy, instant, repeatable, reliable prognostic score that may be superior to existing scoring systems. A larger cohort is required to validate these findings.