Magdalena Skórzewska

Frey operation for chronic pancreatitis associated with pancreas divisum: case report and review of the literature

Pancreas divisum (PD) is the most common congenital anomaly of the pancreas, which increases susceptibility to recurrent pancreatitis. Usually, after failure of initial endoscopic therapies, surgical treatment combining pancreatic resection or drainage is used. The Frey procedure is used for chronic pancreatitis, but it has not been reported to be applied in an adult patient with PD-associated pancreatitis. The purpose of the paper was to describe effective treatment of this rare condition by the Frey procedure after failure of interventional endoscopic treatment. A 39-year-old female patient was initially treated for recurrent acute pancreatitis. After endoscopic diagnosis of PD, the minor duodenal papilla was incised and a plastic stent was inserted into the dorsal pancreatic duct. During the following 36 months, the patient was hospitalised several times because of recurrent episodes of pancreatitis. Thereafter, local resection of the pancreatic head combined with lateral pancreaticojejunostomy was performed with no complications. After 54 months of follow-up, the patient demonstrates abnormal glucose metabolism, with a need for enzyme supplementation, and she is free of pain. Local resection of the pancreatic head combined with lateral pancreaticojejunostomy (Frey procedure) offers a favourable outcome after failure of endoscopic papillotomy and duct stenting for pancreatitis associated with PD.

Intraoperative radiotherapy with low energy photons in recurrent colorectal cancer: a single centre retrospective study

Aim of the study Intraoperative radiotherapy (IORT) may improve outcome of surgical treatment of recurrent colorectal cancer (CRC). The aim of this study is to determine the feasibility, safety and long-term results of surgical treatment of recurrent CRC with orthovolt IORT. Material and methods Fifty-nine consecutive CRC patients with local recurrence (LR), undergoing surgery, were included in the retrospective analysis of prospectively collected data. The modified Wanebo classification was used to stage LR (Tr). Twenty-five (43%) patients received IORT using INTRABEAM® PRS 500. The complications were classified according to the Clavien-Dindo classification. Results There were 32 males and 27 females, with a median age of 63 years. Multi-visceral resections were performed in 37 (63%) patients. Median hospitalization time after surgery with IORT was 7 days. One (1.7%) in-hospital postoperative death was reported. Grade 3/4 postoperative complications were found in 11 (19%) patients. Intraoperative radiotherapy had no effect on the postoperative hospitalization time, morbidity and mortality. Median survival after R0 resection was 32 months. Complete resection (R0), no synchronous liver metastases (M0), and no lateral and posterior pelvic wall involvement, were significant predictors of improved survival. Stage of LR was found to be an independent prognostic factor in the multivariate analysis (p = 0.03); Cox regression model). In patients with LR stage < Tr5, a 3-year overall survival (OS) rate was 52%. Conclusions Combination of surgical resection and orthovolt IORT is a safe and feasible procedure that does not increase the risk of postoperative complications or prolongs the hospital stay. Despite aggressive surgery supported by IORT, the advanced stage of LR is a limiting factor of long-term survival.

Duodenal obstruction due to annular pancreas associated with carcinoma of the duodenum

Annular pancreas, the second most common anomaly of the pancreas, is the development of a ring of pancreatic tissue that surrounds and often embraces the duodenum. It was first described by Tiedelmann in 1818 and named “annular pancreas” by Ecker in 1862 [1]. It is usually present in childhood, with symptoms due to duodenal obstruction. In 50% of cases, clinical manifestations become visible after childhood, with abdominal pain, chronic duodenal obstruction, peptic ulceration, obstructive jaundice, pancreatitis, and pancreatic head mass [2, 3]. Therefore, duodeno-jejunostomy is usually applied to relieve strictures caused by such an annulus. Bypass surgery is the treatment of choice [4]. Primary duodenal carcinoma is rare and represents 0.3% of all gastrointestinal malignancies and 25–35% of malignant tumours of the small intestine [5, 6]. Resectability and the presence of distant metastatic disease are the strongest determinants of outcome for patients with duodenal adenocarcinoma. In cases of cancers of the first and second part of the duodenum, the most common procedure is pancreaticoduodenectomy. Despite advancements in techniques of diagnosis and resection and decreased perioperative mortality and morbidity, 5-year survival varies from 37% [7] to 57% [8]. Malignancy in the setting of annular pancreas is an unusual event, and hence only a few cases associated with pancreatic carcinoma, ampullary carcinoma, and cholangiocarcinoma have been reported [9–13]. Only 1 case of annular pancreas associated with duodenal carcinoma has been reported, but without description of the follow-up [14]. We report a case of duodenal carcinoma in a patient with an annular pancreas treated with radical surgery with complete follow-up data. A 53-year-old lady suffered from nausea, post-prandial fullness, and vomiting, and weight loss. She was diagnosed (endoscopy Figure 1, CT scan of the abdomen Figure 2) to have duodenal obstruction with gastric bezoar. The upper intestinal contrast study findings of annular filling defect in the duodenum, prestenotic dilatation, and reverse peristalsis in the proximal segment were suggestive of annular pancreas. A pathology report of the endoscopic biopsy material taken from the stenotic part of the duodenum revealed suspicion of malignancy, i.e. atypic cells. The patient was scheduled for a laparotomy with intraoperative pathological investigation of the suspected lesion, and if malignancy is proven a pancreaticoduodenectomy is anticipated. During the operation a band of fibrous (probably pancreatic) tissue of hard texture encircling the second part of the duodenum was found (Figure 3). Division of the pancreatic ring was done and the abnormal tissue sent for immediate pathology. Once malignant diagnosis was confirmed, and classical Kausch-Whiple pancreaticoduodenectomy with standard lymphadenectomy was done without perioperative complications. The resection specimen had been routinely fixed in buffered 10% formaldehyde and embedded in paraffin wax (Figure 4). Operative time was 300 min, and blood loss was 420 ml. The postoperative course was uneventful; therefore, the patient was discharged from the hospital on the sixteenth postoperative day. A definitive pathological report confirmed tubular carcinoma (G2) of the duodenum associated with the annular pancreas with no lymph node involvement (pT2N0M0) (Figures 5–8). No adjuvant chemotherapy was administered. The patient was followed-up every 3 months thereafter for the first 3 years. In the first (2008) and second year (2009) of the follow-up, abdominal CT-scan was done without signs of recurrence. After 54 months the patient became heavily jaundiced and cachectic, and was therefore hospitalised. Advanced loco-regional recurrence was found on MR cholangiogram, with no liver metastases. The patient died, and no autopsy was performed. Figure 1 Endoscopic view of the duodenum showing ulceration with duodenal stenosis at the second portion Figure 2 Computed tomography scan image revealing a significant dilatation of the stomach with bezoar and the proximal duodenum Figure 3 Intraoperative view of the annular pancreas encircling the second part of the duodenum Figure 4 Cross-sectional view showing the duodenum surrounded by the pancreas tissue (annular pancreas) Figure 5 Tubular adenocarcinoma of the duodenum. Neoplastic tubules border on normal duodenal glands (four-micron sections of representative blocs of the lesion were stained with haematoxylin and eosin (H + E); 100×) Figure 8 Fragment of the pancreas (annular pancreas), which is not involved in cancerous infiltrate (H + E; 100×) Figure 6 Tubular adenocarcinoma of the duodenum. Neoplastic tubules border on normal duodenal glands (four-micron sections of representative blocs of the lesion were stained with haematoxylin and eosin (H + E); 200×) Figure 7 Neoplastic infiltrate of the muscular coat of the duodenum encompasses both an inner circular layer and an outer longitudinal layer (H + E; 100×) Annular pancreas is a rare congenital abnormality, and in adult patients it presents with clinical features that differ from those seen in newborns [15]. Duodenal obstruction is a rare symptom of annular pancreas in adults. It is necessary to remember about the coexistence of the annular pancreas when patients with pancreatic or periampullary malignancies are complicated with unexpected obstruction of the second portion of the duodenum in proportion to the size [9]. Features in the adult patient include peptic ulceration, duodenal obstruction, acute pancreatitis, and obstructive jaundice. Treatment strategies for annular pancreas with obstructive jaundice remain controversial, but usually pancreaticoduodenectomy is necessary [2]. In adult patients pancreatic head malignancy usually produces jaundice, and more rarely duodenal obstruction. Nearly always the main cause of this clinical picture is pancreatic head carcinoma, but pancreas annulare should be taken into consideration. The duodenal ring should always be verified on pathological examination since it may harbour this rare type of adenocarcinoma. In adult patients with duodenal obstruction due to annular pancreas, consideration of associated or coexisting duodenal malignancy is mandatory. Only radical surgery (pancreaticoduodenectomy) may provide long-term survival in such cases.

Treatment of peritoneal metastases from gastric carcinoma

Abstract Patients with advanced gastric cancer and positive peritoneal cytology and/or peritoneal dissemination are deemed to be incurable and to hold dismal prognosis. So far, the only treatment option for these patients has been palliative systemic (chemo)therapy. However, for the last three decades, great progress has been made in attempts to treat (potential) peritoneal dissemination by means of complete cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) after preoperative systemic therapy. This review is focused on the recent achievements of this multimodal strategy. Additionally, the review stands as background for the 4th International Conference “Advances in Surgical Oncology” that was held at the Medical University of Lublin (Poland) in November 2017, and dedicated to cytoreductive surgery and HIPEC for advanced gastric cancer.

Treatment of peritoneal surface neoplasms with intraperitoneal chemotherapy in hyperthermia

Abstract Effective treatment of peritoneal surface neoplasms is possible through the simultaneous use of cytoreductive surgery with intraperitoneal chemotherapy in hyperthermia. It is successfully performed in patients with peritoneal pseudomyxoma, mesothelioma, as well as a limited and resectable peritoneal carcinomatosis in the course of colorectal cancer. It can also be used in patients with gastric or ovarian cancer but also metastatic colorectal cancer or metastases to the ovaries from gastric cancer. Aggressive surgical management of patients with primary or secondary neoplasms of the peritoneal surface was initiated by Sugarbaker’s research group.

Evidence behind use of orthovolt intraoperative radiotherapy and other techniques of IORT in recurrent colorectal cancer treatment

There are only scarce literature data on the use of with orthovolt intraoperative radiation therapy in treatment of colorectal cancer recurrence. Previous experience with intraoperative radiotherapy using low-energy photons highlights the need for better strategies of combined therapy in referral centres where multidisciplinary treatment options are widely available. There is an absolute need for large randomized studies that will clearly assess the value of different treatment options in colorectal cancer (CRC) recurrences, and thus create uniform rules to be observed in this disease.

Wyniki leczenia chorych na nowotwory złośliwe z przerzutami do wątroby: 8-letnie doświadczenie jednego ośrodka

Wstep. Leczenie chirurgiczne przerzutow nowotworow litych do wątroby powinno odbywac sie w ramach zespolu wielodyscyplinarnego. Cel pracy. Celem pracy jest ocena wynikow leczenia skojarzonego chorych na rozne nowotwory lite z przerzutami do wątroby przez zespol wielodyscyplinarny jednego ośrodka onkologicznego w ciągu ostatnich 8 lat. Material i metody. Retrospektywną analizą objeto 166 chorych (84 kobiety i 82 mezczyzn) w wieku od 19 do 78 lat (średnia 58 ± 11,2), leczonych z powodu przerzutow do wątroby pierwotnych nowotworow litych o roznej lokalizacji, z wyjątkiem guzow neuroendokrynnych. Kazdorazowo rozwazano okolooperacyjne leczenie systemowe zgodnie z aktualnymi zaleceniami Polskiej Unii Onkologii. Wyniki. W czasie obserwacji (mediana 35 miesiecy) zmarlo 46% chorych. Resekcje wątroby wykonano u 107 (65%)chorych, w tym u 19 chorych polączono je z (RF-)termoablacją zmian przerzutowych, ktorą wykonano jako samodzielny zabieg u dalszych 59 (36%) chorych. Śmiertelnośc pooperacyjna wyniosla 1,2%. Powiklania II° wg klasyfikacji Clavien-Dindo wystąpily u 33 (19,8%) chorych, natomiast III° i IV° — u 8 (4,8%) chorych. Przezycia 1-roczne, 3-letniei 5-letnie wyniosly odpowiednio 78%, 41% i 37%. Piecioletnie przezycia calkowite u chorych na raka jelita grubego po resekcjach przerzutow metachronicznych wyniosly 48%. Wnioski. Skojarzone leczenie chorych na nieendokrynne nowotwory lite z przerzutami do wątroby przez zespol wielodyscyplinarny jest bezpieczne i skuteczne. W starannie dobranej grupie chorych mozna osiągnąc blisko 50% calkowitych przezyc 5-letnich. Resekcja wątroby jest optymalną metodą leczenia chirurgicznego przerzutow do wątroby.

Intraoperative Radiotherapy with Low-Energy Photons in Rectal Cancer Recurrence

Despite the significant progress in treatment of patients with colorectal cancer (CRC) over recent decades, local recurrence (LR) continues to pose a significant therapeutic challenge. LR is one of the most common forms of relapse after conventional treatment of CRC. LR significantly worsens the prognosis and constitutes one of the major causes of CRC treatment failure. Long-term local control and survival rates vary from 41 to 77 % and from 1 to 50 %, respectively, with the most favourable results in patients with positive prognostic factors (Pezner et al. 2002). Reported median survival in patients with LR is 11–15 months and the 5-year survival rate is less than 5 % (Haddock et al. 2011). Loco-regional relapse is associated with high mortality, and a positive circumferential margin in primary tumour resection is proven to be directly associated with a high LR rate (Kang et al. 2010). Advanced relapse, often infiltrating adjacent bony structures and pelvic organs, prevents the execution of salvage radical surgery (Lopez-Kostner et al. 2001). In rectal cancer the LR risk among patients who have undergone surgical treatment only is reported to be from 19 to 30 % (Lopez-Kostner et al. 2001; Dubois et al. 2011). This risk is significantly reduced to 2.5–16 % if surgery is supplemented with radiotherapy (preoperative or postoperative) (Dubois et al. 2011; Moriya 2006). When total mesorectal excision is performed after preoperative radiotherapy, LR risk can be decreased to 4.6 % (Dubois et al. 2011). Prevention of LR depends primarily on meticulous surgical technique with achievement of clear (>2 mm) circumferential resection margins. Treatment with curative intent depends on radical resection with microscopically uninvolved margins (R0), as a negative resection margin is the strongest prognostic factor. Obtaining R0 resection is extremely important and has a direct impact on long-term survival and local control of disease with acceptable quality of life (Lopez-Kostner et al. 2001; Wiggers et al. 2003).