Mark Brooke-Smith

Predicting patient survival after pancreaticoduodenectomy for malignancy: histopathological criteria based on perineural infiltration and lymphovascular invasion

BACKGROUND Accurate and simple prognostic criteria based on histopathology following pancreaticoduodenectomy would be helpful in assessing prognosis and considering and evaluating adjuvant therapy. This study analysed the histological parameters influencing outcome following pancreaticoduodenectomy for periampullary malignancy. METHODS A total of 110 pancreaticoduodenectomies were performed from 1998 to 2008. The median age of patients was 69 years (range 20-89 years). The median follow-up was 4.9 years. Of the procedures, 87% (96) were performed for malignancies and the remainder (n= 14) for benign aetiologies. Of the 96 malignancies, 60 were pancreatic adenocarcinoma and the rest were ampullary (14), cholangio (9), duodenal (9) carcinomas and others. Statistical analysis was performed using log-rank and Cox regression multivariate analyses. RESULTS Patients who underwent resection had 1-, 3- and 5-year survival rates of 70%, 46% and 41%, respectively. The 1-, 3- and 5-year survival rates for periampullary cancers other than pancreatic adenocarcinoma were 83%, 69% and 61%, respectively; those for pancreatic adenocarcinoma were 62%, 31% and 27%, respectively (P < 0.003). Poor tumour differentiation (P < 0.02), tumour size >3 cm (P < 0.04), margin <or=2 mm (P < 0.02), nodal involvement (P < 0.003), perineural infiltration (P < 0.0001) and lymphovascular invasion (P < 0.002) were associated with poorer prognosis. In a multivariate analysis, histologically identified perineural infiltration (P < 0.03) and lymphovascular invasion (P= 0.05) were significant factors influencing outcome. Five-year survival was 77% in patients negative for both factors and 15% in patients positive for both (P < 0.0001). In the pancreatic adenocarcinoma subgroup, patients who were negative for both factors had a 5-year survival of 71%, whereas those who were positive for both had a 5-year survival of 16% (P < 0.02). CONCLUSIONS The presence of perineural infiltration and lymphovascular invasion on histopathology is highly significant in predicting 5-year outcomes after pancreaticoduodenectomy for periampullary and pancreatic malignancies.

Prospective evaluation of the International Study Group for Liver Surgery definition of bile leak after a liver resection and the role of routine operative drainage: An international multicentre study

BACKGROUND The International Study Group for Liver Surgery (ISGLS) proposed a definition for bile leak after liver surgery. A multicentre international prospective study was designed to evaluate this definition. METHODS Data collected prospectively from 949 consecutive patients on specific datasheets from 11 international centres were collated centrally. RESULTS Bile leak occurred in 69 (7.3%) of patients, with 31 (3.3%), 32 (3.4%) and 6 (0.6%) classified as grade A, B and C, respectively. The grading system of severity correlated with the Dindo complication classification system (P < 0.001). Hospital length of stay was increased when bile leak occurred, from a median of 7 to 15 days (P < 0.001), as was intensive care stay (P < 0.001), and both correlated with increased severity grading of bile leak (P < 0.001). 96% of bile leaks occurred in patients with intra-operative drains. Drain placement did not prevent subsequent intervention in the bile leak group with a 5-15 times greater risk of intervention required in this group (P < 0.001). CONCLUSION The ISGLS definition of bile leak after liver surgery appears robust and intra-operative drain usage did not prevent the need for subsequent drain placement.

Perianal abscess: A pilot study comparing packing with nonpacking of the abscess cavity

PURPOSE:Perianal sepsis is traditionally treated by incision and drainage, with packing of the residual cavity until healing. This study was designed to show that perianal abscess may be safely treated by incision and drainage alone.METHODS:Healing times, analgesic requirements, pain scores, abscess recurrence, and fistula rates were compared between two randomized groups treated with and without packing of perianal abscess cavities.RESULTS:Fifty patients were recruited (7 lost to follow-up): 20 in the packing and 23 in the nonpacking arm. The groups were comparable in terms of age and gender distribution, type and size of abscess, and the presence of a fistula at operation. Mean healing times were similar (P = 0.214). The rate of abscess recurrence was similar (P = 0.61). Postoperative fistula rates were similar (P = 0.38). Pain scores at the first dressing change were similar (P = 0.296). Although pain scores appeared much reduced in the nonpacking arm, this did not attain statistical significance.CONCLUSIONS:Our pilot study indicates that perianal abscesses can be managed safely without continued packing of the cavity without any obvious complications.

Anticoagulation policy after venous resection with a pancreatectomy: a systematic review

BACKGROUND Portal vein (PV) resection is used increasingly in pancreatic resections. There is no agreed policy regarding anticoagulation. METHODS A systematic review was performed to compare studies with an anticoagulation policy (AC+) to no anticoagulation policy (AC-) after venous resection. RESULTS There were eight AC+ studies (n = 266) and five AC- studies (n = 95). The AC+ studies included aspirin, clopidogrel, heparin or warfarin. Only 50% of patients in the AC+ group received anticoagulation. There were more prosthetic grafts in the AC+ group (30 versus 2, Fishers exact P < 0.001). The overall morbidity and mortality was similar in both groups. Early PV thrombosis (EPVT) was similar in the AC+ group and the AC- group (7%, versus 3%, Fishers exact P = 0.270) and was associated with a high mortality (8/20, 40%). When prosthetic grafts were excluded there was no difference in the incidence of EPVT between both groups (1% vs 2%, Fishers exact test P = 0.621). CONCLUSION There is significant heterogeneity in the use of anticoagulation after PV resection. Overall morbidity, mortality and EPVT in both groups were similar. EPVT has a high associated mortality. While we have been unable to demonstrate a benefit for anticoagulation, the incidence of EPVT is low in the absence of prosthetic grafts.

Galanin in the regulation of pancreatic vascular perfusion

Objectives: Acute pancreatitis is associated with compromised pancreatic microcirculation. Galanin is a vasoactive neuropeptide, but its role in the regulation of pancreatic vascular perfusion (PVP) is unclear. Methods: Localization of galanin immunoreactivity was investigated by immunohistochemistry, and the effects of bolus doses of galanin or the antagonist galantide on blood pressure (BP) and PVP (by laser Doppler fluxmetry) were determined in anesthetized possums. Results: Galanin immunoreactivity was abundant in the possum pancreas particularly around blood vessels. Galanin (0.001-10 nmol) produced a dose-dependent increase in BP (to 177% of baseline) and a complex PVP response consisting of a transient increase, then a fall below baseline with recovery to above baseline. Galantide (0.003-30 nmol) caused a dose-dependent biphasic response in BP, with a reduction, recovery, then a further fall, followed by recovery, whereas PVP increased (178%) then fell (to 56%) of baseline. Similar effects were produced by continuous intravenous infusion of galanin (1 and 10 nmol) or galantide (3 and 30 nmol). The second-phase response of these agents is probably a passive response of the pancreatic vasculature to systemic cardiovascular effects. Conclusions: These data suggest that galanin acutely reduces PVP, whereas galantide increases it, implying galanin may be important in the regulation of PVP.

Cirrhosis and microvascular invasion predict outcomes in hepatocellular carcinoma

Liver resection (LR) and liver transplantation (LT) are two modalities offering potential for cure in patients with hepatocellular carcinoma (HCC). The objective of this study was to evaluate the long‐term survival of patients with HCC treated with LT and LR and to analyse variables influencing these outcomes.

Distribution and pathological features of pancreatic, ampullary, biliary and duodenal cancers resected with pancreaticoduodenectomy

BackgroundPancreatic cancer (PC) has the worst survival of all periampullary cancers. This may relate to histopathological differences between pancreatic cancers and other periampullary cancers. Our aim was to examine the distribution and histopathologic features of pancreatic, ampullary, biliary and duodenal cancers resected with a pancreaticoduodenectomy (PD) and to examine local trends of periampullary cancers resected with a PD.MethodsA retrospective review of PD between January 2000 and December 2012 at a public metropolitan database was performed. The institutional ethics committee approved this study.ResultsThere were 142 PDs during the study period, of which 70 cases were pre-2010 and 72 post-2010, corresponding to a recent increase in the number of cases. Of the 142 cases, 116 were for periampullary cancers. There were also proportionately more PD for PC (26/60, 43% pre-2010 vs 39/56, 70% post-2010, P = 0.005). There were 65/116 (56%) pancreatic, 29/116 (25%), ampullary, 17/116 (15%) biliary and 5/116 (4%) duodenal cancers. Nodal involvement occurred more frequently in PC (78%) compared to ampullary (59%), biliary (47%) and duodenal cancers (20%), P = 0.002. Perineural invasion was also more frequent in PC (74%) compared to ampullary (34%), biliary (59%) and duodenal cancers (20%), P = 0.002. Microvascular invasion was seen in 57% pancreatic, 38% ampullary, 41% biliary and 20% duodenal cancers, P = 0.222. Overall, clear margins (R0) were achieved in fewer PC 41/65 (63%) compared to ampullary 27/29 (93%; P = 0.003) and biliary cancers 16/17 (94%; P = 0.014).ConclusionsThis study highlights that almost half of PD was performed for cancers other than PC, mainly ampullary and biliary cancers. The volume of PD has increased in recent years with an increased proportion being for PC. PC had higher rates of nodal and perineural invasion compared to ampullary, biliary and duodenal cancers.

A Case of Pancreatic Cancer in the Setting of Autoimmune Pancreatitis with Nondiagnostic Serum Markers

Background. Autoimmune pancreatitis (AIP) often mimics pancreatic cancer. The diagnosis of both conditions is difficult preoperatively let alone when they coexist. Several reports have been published describing pancreatic cancer in the setting of AIP. Case Report. The case of a 53-year-old man who presented with abdominal pain, jaundice, and radiological features of autoimmune pancreatitis, with a “sausage-shaped” pancreas and bulky pancreatic head with portal vein impingement, is presented. He had a normal serum IgG4 and only mildly elevated Ca-19.9. Initial endoscopic ultrasound-(EUS-) guided fine-needle aspiration (FNA) of the pancreas revealed an inflammatory sclerosing process only. A repeat EUS guided biopsy following biliary decompression demonstrated both malignancy and features of autoimmune pancreatitis. At laparotomy, a uniformly hard, bulky pancreas was found with no sonographically definable mass. A total pancreatectomy with portal vein resection and reconstruction was performed. Histology revealed adenosquamous carcinoma of the pancreatic head and autoimmune pancreatitis and squamous metaplasia in the remaining pancreas. Conclusion. This case highlights the diagnostic and management difficulties in a patient with pancreatic cancer in the setting of serum IgG4-negative, Type 2 AIP.

Avoiding bile duct injury in cholecystectomy through anatomical appreciation.

Laparoscopic cholecystectomy is a common operation performed on thousands of patients across Australia, New Zealand and the world every year. In the literature, great focus is placed on new and improving techniques in relatively uncommon complex procedures. However, it is in common procedures for common conditions where small improvements have the greatest potential benefits to the health of our community. It is reassuring to find groups such as Rajkomar et al. continuing to examine how improvement can be made with existing techniques in a common procedure like cholecystectomy and keep it in the forefront of our minds. It is relatively recently that the concept of obtaining the critical view has been popularized to avoid bile duct injuries in laparoscopic cholecystectomy. It was however 20 years ago, in 1995, that Strasberg et al. used the term ‘critical view of safety’ to describe the window that is developed by careful dissection of Calot’s triangle (which forms part of the hepatobiliary triangle bounded inferiorly by the cystic duct, medially by the common hepatic duct and superiorly by the undersurface of the liver), exposing the base of the liver bed, cystic duct and cystic artery. In this article, the importance of pulling the fundus of the gallbladder laterally to prevent the cystic duct and bile duct lying in the same plane, thereby reducing the risk the bile duct is mistaken for the cystic duct, is highlighted. Connor et al. elegantly describe five key initial steps in performing safe laparoscopic cholecystectomy: (i) retract the gallbladder laterally to a 10 o’clock position relative to the principle plane of the liver (Cantlie’s line); (ii) confirm Hartmann’s pouch is retracted up and towards segment IV; (iii) identify Rouviere’s sulcus; (iv) dissect the posterior peritoneum of the hepatobiliary or hepatocystic triangle; and (v) confirm the critical view is obtained. In the article by Strasberg et al. while routine cholangiography was performed, it was acknowledged that alone it was not sufficient to prevent bile duct injury. Since that time several population-based studies have shown that the intention of performing routine cholangiography is protective for bile duct injuries particularly for in-experienced surgeons or in cases with a history of acute cholecystitis. The article by Rajkomar et al. aims to further define a safe starting point for anterior dissection of Calot’s triangle to obtain the critical view of safety by examining the anatomy of the inferior surface of the quadrate lobe/segment IV. It is demonstrated that a pyramidal shape of the inferior quadrate lobe indicates that the cystic duct and bile duct are closer to parallel and the anterior dissection of the hepatobiliary triangle should begin more laterally. It is pointed out that there is a degree of overlap and other shapes to the quadrate lobe can also be associated with a narrow cystic/bile duct angle and careful dissection is always warranted. While experienced surgeons may appreciate these subtleties in anatomy subconsciously after performing many procedures, and adjust their techniques accordingly, description of these variations brings it into the consciousness and aids in the teaching of trainees so that learning curves are reduced and safe independence is achieved earlier. Videos, such as the one referenced in Connor et al. aid in depicting this anatomy and facilitating training.