Gerard V. Aranha

Cholecystectomy in cirrhotic patients: A formidable operation☆

Cholecystectomy and common bile duct exploration in cirrhotic patients is associated with an 83 percent mortality if prothrombin time is prolonged 2.5 seconds over control. The causes of death are related to complications of liver disease such as hepatic encephalopathy, ascites, sepsis and hemorrhage. If the prothrombin time is prolonged, major intraoperative blood loss can be anticipated, and blood and plasma transfusion requirements may be massive. Jaundice in the presence of cirrhosis requires careful preoperative evaluation and is most frequently due to hepatocellular disease rather than extrahepatic biliary obstruction. Cholecystectomy and common duct exploration in cirrhotic patients should be performed only for life-threatening complications of biliary tract disease such as empyema, perforation and ascending cholangitis.

A Comparison of Pancreaticogastrostomy and Pancreaticojejunostomy Following Pancreaticoduodenectomy

This retrospective study compares the results of pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) in our institution, which has extensive experience in both techniques. Between the years of June 1995 and June 2001, 214 patients underwent pancreaticoduodenectomy (PD) at our institution. Of these 177 had PG and 97 had pancreatojejunostomy (PJ). There were 117 (54.6%) males and 97 (45.3%) females with a mean age of 64.2 ± 12.4 years. Indications for surgery were pancreatic adenocarcinoma in 101 (47.2%), ampullary adenocarcinoma in 36 (16.9%), distal bile duct adenocarcinoma in 22 (10.2%), duodenal adenocarcinoma in 9 (4.2%), and miscellaneous causes in 46 (21.4%) of patients. Preoperatively, significant differences in the groups were that the patients undergoing PJ were significantly younger than those undergoing PG. Also noted preoperatively, was that the patients undergoing PG had a significantly lower direct bilirubin than those undergoing PJ. With regard to intraoperative parameters, operative time was significantly shorter in the PJ group when compared to the PG group. When the patients who did not develop fistula (N = 186) were compared to those who developed fistula (N = 28) the significant differences were that the patients who developed fistula were more likely to have hypertension preoperatively and a higher alkaline phosphatase. They also showed a significantly higher drain amylase and were likely to have surgery for ampullary, distal bile duct or duodenal carcinoma rather than pancreatic adenocarinoma. In addition, those patients who developed fistula had a significantly longer postoperative stay, a larger number of intraabdominal abscesses and leaks at the biliary anastomosis. Thirty-day mortality was significantly higher in the PJ group compared to the PG (4 vs. 0, P = 0.041). There was a significantly larger number of bile leaks in the PJ group when compared to the PG (6 vs. 1, P = 0.048). In addition, the PJ group required a significantly larger number of new CT guided drains to control infection (8 vs. 2,P = 0.046) and the PJ group required a larger number of re-explorations to control infection or bleeding (5 vs. 0, P = 0.018). However, the pancreatic fistula rate was not different between the two groups (12% [PG] vs. 14% [PJ]). This retrospective analysis shows that safety of PG can be performed safely and is associated with less complications than PJ and proposes PG as a suitable and safe alternative to PJ for the management of the pancreatic remnant following PD.

Adverse skin lesions after methylene blue injections for sentinel lymph node localization

BACKGROUND Methylene blue dye (MBD) is being used as an alternative to isosulfan blue dye in sentinel lymph node (SLN) biopsies for breast cancer patients. Complications using MBD for SLN localization have not previously been reported. METHODS A retrospective study was conducted of 24 consecutive patients who received MBD. Patients were given 3 to 5 cc of 1% MBD as peritumoral injections within the breast parenchyma and intradermally. Patients who developed local skin lesions at the injection site were queried regarding lesion appearance and when subsequent adjuvant therapy was initiated. RESULTS Five of the 24 patients (21%) developed skin lesions at the injection site. Intradermal injections were discontinued, and only deep parenchymal injections were performed. All 5 patients had improvement of their skin lesions with silver sulfadiazine cream and no patient required debridement. Each patient received adjuvant therapy after surgery without delay. CONCLUSIONS Our institution has experienced patients who developed skin lesions at the MBD injection site when using combined deep parenchymal and intradermal injections. With the increased use of MBD, caution should be used to avoid intradermal injections with SLN localization.

The Role of Extended Lymphadenectomy for Adenocarcinoma of the Head of the Pancreas: Strength of the Evidence

With improvements in the safety of Whipple resection in recent decades, surgeons have continued to explore the role of more extensive lymphadenectomy in hope of improving long-term survival. A systematic literature search of level I evidence addressing the role of the extent of lymphadenectomy was undertaken. Only reports of prospective, randomized controlled trials comparing pancreaticoduodenectomy with standard lymphadenectomy to pancreaticoduodenectomy with extended lymphadenectomy where information regarding survival, morbidity, mortality, the number of resected lymph nodes in each group and detailed operative technique were included. Four prospective, randomized trials comprising some 424 patients and one meta-analysis were identified. In aggregate, these studies confirmed that the number of resected lymph nodes was significantly higher in the pancreaticoduodenectomy with extended lymphadenectomy group. Morbidity and mortality rates were comparable. Postoperative diarrhea in the early months after operation was problematic in patients undergoing extended lymphadenectomy. In none of the studies was a benefit in long-term survival demonstrated. Standard pancreaticoduodenectomy continues to be the operation of choice for adenocarcinoma of the head of the pancreas.

Defining a role for endoscopic ultrasound in staging periampullary tumors

BACKGROUND The goal of the preoperative workup in patients with suspected periampullary carcinoma is to establish the diagnosis with a high degree of certainty. In this study we compared endoscopic ultrasonography (EUS) and computed tomography (CT) scans for the detection of tumor, lymph node metastasis, and vascular invasion in patients with suspected periampullary carcinoma in order to define a role for EUS in the preoperative staging of these patients. METHODS Thirty-seven consecutive patients received EUS and CT scanning followed by operation for presumed periampullary carcinoma during a 30-month period. Both imaging modalities were reviewed in a blinded fashion and the results compared with pathology and operative reports on all patients. RESULTS Sensitivity, specificity, positive predictive value, and negative predictive value for tumor detection by EUS were 97%, 33%, 94%, and 50%, respectively, compared with 82%, 66%, 97%, and 25% for CT scan. For lymph nodes the values were 21%, 80%, 57%, and 44%, respectively, for EUS compared with 42%, 73%, 67%, and 50% for CT. For vascular invasion, the values were 20%, 100%, 100%, and 89%, respectively, for EUS, compared with 80%, 87%, 44%, and 96% for CT. CONCLUSIONS CT is the initial study of choice in patients with suspected periampullary tumors. EUS is superior for detecting tumor and for predicting vascular invasion. Therefore, EUS should be used for patients in whom CT does not detect a mass and for those with an identifiable mass on CT in whom vascular invasion cannot be ruled out.

The addition of a nurse practitioner to an inpatient surgical team results in improved use of resources

BACKGROUND Resident work hour restrictions and changes in reimbursement may lead to an adverse effect on the continuity of care of a patient after discharge. This study analyzes whether adding a nurse practitioner (NP) to a busy inpatient surgery service would improve patient care after discharge. METHODS In 2007, a NP joined a team of 3 surgery attendings. She coordinated the discharge plan and communicated with patients after discharge. We reviewed the records of patients 1 year before (N = 415) and 1 year after (N = 411) the NP joined the team. The discharge courses of the patients were reviewed, and an unnecessary emergency room (ER) visit was defined as an ER visit that did not result in an inpatient admission. RESULTS The 2 groups were statistically similar with regard to age, race, acuity of the operation, duration of hospital stay, and hospital readmissions. Telephone communication between nurses and discharged patients was 846 calls before the NP and 1,319 calls after the NP, representing an increase of 64% (P < .0001). Visiting nurse, physical therapy, or occupational therapy services were rendered to only 25% of patients before the NP compared to 39% after (P < .0001). There were more unnecessary ER visits before the NP (103/415; 25%) compared to after (54/411; 13%) (P = .001). CONCLUSION Adding a NP to our inpatient surgery service led to an overall improvement in the use of resources and a 50% reduction in unnecessary ER visits. This study shows that the addition of a NP not only improves continuity of care on discharge but also has the potential to yield financial benefits for the hospital.

Role of interventional radiology in the management of complications after pancreaticoduodenectomy.

BACKGROUND This study evaluated the role of interventional radiology (IR) procedures to manage complications after pancreaticoduodenectomy. METHODS A retrospective review was made of the records of patients with postsurgical complications managed with IR. RESULTS Among the 440 patients reviewed, the mortality, morbidity and reoperation rates were 1.6%, 36%, and 2%, respectively. Complications occurred in 159 patients, of which 39 (25%) required > or = 1 IR procedures. Of those 39 patients, 72% underwent percutaneous drainage of an intra-abdominal abscess, 18% underwent percutaneous biliary drainage, and 10% underwent angiography for gastrointestinal bleeding or pseudoaneurysm. The reoperation rate among the 159 patients with complications was 6% (n = 9). Reoperation was avoided in 90% of patients receiving IR. Four patients underwent reoperation despite IR for persistent abscess, pancreatic fistula, anastomotic disruption, or mesenteric venous bleeding. CONCLUSIONS The majority of complications occurring after pancreaticoduodenectomy can be managed effectively using IR, thus minimizing morbidity and the need for reoperation.

Hepatoid carcinoma of the stomach

A patient with primary gastric carcinoma exhibiting he‐patoid differentiation is described. The tumor itself was not associated with a high serum alpha‐fetoprotein, but the cells stained positive for alpha‐fetoprotein and alpha‐1 antitrypsin. The patient underwent a total gastrectomy and wedge excision of the liver metastasis. The presence of metastatic hepatoid adenocarcinoma of the stomach should be considered in a patient who, during surgery for a primary gastric carcinoma, is found to have a liver metastasis that is diagnosed by frozen‐section biopsy as a hepatoma. Because of lymph node and liver metastasis, prognosis appears to be poor for such patients.

Lateral pancreaticojejunostomy for chronic pancreatitis.

Chronic pancreatitis is a progressive fibrosis of the pancreas that leads to loss of endocrine and exocrine function. The most common symptom in this disease is intractable pain. The etiology of pain in chronic pancreatitis is not clearly understood. However, many of these patients have dilated ducts consisting of saccular dilations and intervening constructions referred to as the “chain of lakes” phenomenon. These patients can be diagnosed with either endoscopic retrograde cholangiopancreatography (ERCP) or computed tomography (CT). These patients are best treated by the Partington Rochelle modification of the Puestow Procedure otherwise known as lateral pancreaticojejunostomy. Overall pain relief in published studies occurs in 50-90% of patients. Another proposed advantage of the lateral pancreaticojejunostomy is preservation of endocrine and exocrine pancreatic function as long as the pancreas is not further damaged by alcohol.

Redrainage of the pancreatic duct in chronic pancreatitis

Recurrent pain after a drainage procedure for chronic pancreatitis is considered an indication for pancreatectomy. To evaluate whether redrainage might be a better alternative, 14 patients who underwent redrainage after a failed pancreaticojejunostomy were reviewed. Patients with previous pseudocyst drainage were excluded. Initial operations included five caudal, three longitudinal, and six side-to-side pancreaticojejunostomies. Nine patients treated since 1974 had ERCP, which showed obstructed segments of pancreatic duct in the head of the gland. Two caudal pancreaticojejunostomies and one longitudinal pancreaticojejunostomy were revised to longitudinal pancreaticojejunostomies. The other 11 were revised to side-to-side pancreaticojejunostomies. Operative findings confirmed undrained segments of the pancreatic duct in the pancreatic head. Postoperatively, one patient died from hemorrhage and four patients had complications. At most recent follow-up from 6 months to 20 years postoperatively, three patients were pain free and six had substantial relief from pain (71 percent). Of eight patients who were not diabetic before redrainage, diabetes developed in only two. Only one of seven patients without pancreatic exocrine insufficiency required pancreatic enzymes after redrainage. Patients with recurrent pain after pancreaticojejunostomy should undergo ERCP. If segments of the pancreatic duct are obstructed, redrainage can provide satisfactory pain relief with a minimal loss of endocrine and exocrine function. This problem is best avoided by initial complete drainage of the major and minor pancreatic ducts.