James Stephenson

Laparoscopic pancreatic surgery: a review of present results and future prospects

Pancreatic surgery is still associated with a relatively high morbidity and mortality compared with other specialties. This is a result of the complex nature of the organ, the difficult access as a result of the retroperitoneal position and the number of technically challenging anastomoses required. Nevertheless, the past two decades have witnessed a steady improvement in morbidity and a decrease in mortality achieved through alterations of technique (particularly relating to the pancreatic anastomoses) together with hormonal manipulation to decrease pancreatic secretions. Recently minimally invasive pancreatic surgery has been attempted by several centres around the world which has stimulated considerable interest in this approach. The majority of the cases attempted have been distal pancreatectomies, because of the more straightforward nature of the resection and the lack of a pancreatic ductal anastomosis, but more recently reports of laparoscopic pancreaticoduodenectomy have started to appear. The reports of the series to date have been difficult to interpret and although the results are claimed to be equivalent or better than those associated with a traditional approach a careful examination of the literature and comparison with the best results previously reported does not presently support this. In the present review we examined all the reports of pancreatic procedures performed laparoscopically and compared the results with those previously achieved at open surgery.

Potential applications of fish oils rich in n -3 fatty acids in the palliative treatment of advanced pancreatic cancer

The palliative treatment of patients with advanced pancreatic cancer (APC) has undergone little advancement in the last 15 years. Novel therapies that have been investigated to extend survival have shown little benefit over existing chemotherapy regimens. Patients with APC often experience significant weight loss, which is one of the primary factors involved in declining quality of life. Recently, the ability of n-3 fatty acid rich oral preparations to attenuate or reverse tumour-related weight loss has been investigated in this patient group with encouraging results. Laboratory investigation has also yielded promising results suggesting a potential direct tumouricidal effect of n-3 fatty acids as well as the putative potentiation of existing chemotherapy regimes. The present review aims to examine the potential applications of fish oils rich in n-3 fatty acids in patients with APC, present a selection of the studies carried out to date and outline avenues of possible further clinical investigation.

Assessment of the IMV diameter as a surrogate marker to evaluate response to neoadjuvant chemoradiotherapy for locally advanced rectal adenocarcinoma

Neoadjuvant chemoradiotherapy for locally advanced rectal cancer aims to downstage prior to definitive management. Repeat imaging assessment of the tumour post‐therapy has implications for treatment. Our aim was to assess if the inferior mesenteric vein (IMV) diameter measured on CT can be used as a surrogate marker for evaluation of tumour response to neoadjuvant treatment.

Imaging findings post colorectal endoscopic mucosal resection

Endoscopic mucosal resection is commonly the treatment regime of choice for large sessile colonic polyps. We describe the computed tomography findings of a 51 year old female who presented with transient severe abdominal pain without systemic upset post endoscopic mucosal polyp resection, which resolved with conservative management. This is the second case in the literature that demonstrates normal appearances post endoscopic mucosal resection. The clinical team and radiologist need to be aware of these findings when making management decisions in patients who present with acute pain post endoscopic mucosal resection.

Reply to Akingboye et al

We thank Akingboye etxa0al for their interest and critique (1) of our paper assessing the inferior mesenteric vein (IMV) diameter as a surrogate marker to evaluate response to neoadjuvent chemoradiotherapy (CRT) for locally advanced rectal adenocarcinoma (2). They raise an interesting point reguarding correlation of IMV diameter of whole mount specimens with and without tumours to validate the hypothosis (1). Imaging correlation to histopathological specimens is a tried and tested method to correlate rectal cancer staging and subsequent tumour regression grade post neoadjuvent radiotherapy (3, 4), however we have some apprehensions with the suggestion in this case, 1) the measurement of the IMV ex-vivo may not correlate with the measurement on computed tomography due to lack of circulation, flow and venous pressure and potential changes in vessel elasticity ex-vivo. As we state in the paper, and Akingboye etxa0al state the hypothesis is that change in vessel diameter is likely to be in part due to changes in splanchnic circulation and venous return secondary to tumourgenesis (5). n nThis article is protected by copyright. All rights reserved.

Straight-to-test faecal tagging CT colonography for exclusion of colon cancer in symptomatic patients under the English 2-week-wait cancer investigation pathway: a service review

AIMnTo present the initial 12 months of data of a straight-to-test (STT) computed tomography colonography (CTC) protocol as the first-line investigation for change in bowel habit (CIBH) and iron deficiency anaemia (IDA) in patients over 60 referred directly from primary care.nnnMATERIALS AND METHODSnIn 12 months, 1,792 STT CTC for IDA and CIBH were performed. No colonoscopies were performed as the primary investigation in this cohort. Data from this cohort were gathered prospectively.nnnRESULTSnThe colorectal cancer (CRC) detection rate was 4.9% and polyp detection rate was 13.5%. The CRC rate increased related to age (p=0.001), the CRC detection rate was 2.6% in patients aged 60-69 years, compared to 4.9%, 7.4%, and 11.4% in the 70-79, 80-89, and >90 years age groups. The CRC rate was higher in patients with IDA compared to CIBH (6.8% versus 3.9%, p=0.017). There were significantly more left-sided cancers (p=0.0165). Non-colonic cancers were found in 4.3% of patients and 6.8% had incidental findings that required further investigation and 11.9% had a new, potentially significant, incidental finding.nnnCONCLUSIONnThese results are comparable to colonoscopy in terms of diagnostic accuracy and similar to those of CTC in published multicentre trials. This exciting model of care within radiology enables earlier testing, reduces waiting times, with fewer outpatient appointments, and results in good clinician and patient satisfaction.

Peripheral vision: abdominal pathology missed outside the centre of gaze

Radiology misses have been the subject of much debate on both sides of the Atlantic in recent years. There is now greater focus in trying to reduce radiology errors by continuous education and changing the working environment to try and protect the radiologist, and ultimately the patient from potential harm. Duty of candour is a relevant and sensitive area. Developing robust validated reporting pathways within the healthcare structure is very important so as to encourage a learning from discrepancies culture and to put the patient and their families at the center of reporting and acknowledging errors in radiology. Having reflected in our daily practice and while writing this pictorial review, we have concluded that during reporting MRI scans, routine assessment of the localizer images, focusing outside the area of interest and having a more structured approach to image interrogation are key actions which may help reduce the number of omissions. We present a myriad of cases where pathology was missed outside the center of gaze in relation to the abdomen or outside the abdomen on abdominal MRI, and suggest key high yield sequence related review areas to minimize the chance of missing potentially significant pathology.

Multidisciplinary team and clinical meeting data: JRF national survey of trainees 2015

OBJECTIVEnTo collect radiology trainees views on training for clinic-multidisciplinary team meetings (MDTMs), identify aspects requiring improvement and develop a guide to aid training. This is central to quality assurance and is within the core RCR curriculum.nnnMETHODSnThe Junior Radiology Forum National Training Survey 2015 was emailed to 1222 UK trainees. Questions related to role in MDTMs, training, use of the MDTM eportfolio tool and experience of leading meetings.nnnRESULTSn611 radiology trainees responded. 22% received teaching in MDTM preparation. 29% of trainees use the eportfolio MDT assessment tool. 76% of trainees who run MDTMs have adequate preparation time. 18% always review cases with a consultant prior to a meeting. 7% of trainees always debrief with a consultant. 9.7% have been asked to lead an MDTM which they did not feel comfortable with. Most trainees think trainees should be running MDTMs post FRCR2B.nnnCONCLUSIONnThere are currently deficits in teaching and consultant supervision when trainees are learning to participate in MDTMs. Formal teaching sessions and timetabled preparation/debrief time with a consultant should be available. Trainees should not be asked to lead meetings without adequate support. This also ensures a safe MDTM environment for the patient. The eportfolio assessment tool can be used to sign off competence levels before independently leading an MDTM. Advances in knowledge: These results suggest shortfalls in the current model for preparing radiology trainees for their central role in clinico-MDT meetings. Using this data, a guide for trainees has been written to address these deficits.