Markus Trochsler

Extracorporeal machine perfusion of the pancreas: technical aspects and its clinical implications – a systematic review of experimental models

Pancreas or pancreatic islet transplantation is an important treatment option for insulin-dependent diabetes and its complications. However, as the pancreas is particularly susceptible to ischaemic-reperfusion injury, the criteria for pancreas and islet donation are especially strict. With a chronic shortage of donors, one critical challenge is to maximise organ availability and expand the donor pool. To achieve that, continuous improvement in organ preservation is required, with the aims of reducing ischaemia-reperfusion injury, prolong preservation time and improve graft function. Static cold storage, the only method used in clinical pancreas and islet cell transplant currently, has likely reached its plateau. Machine perfusion, hypothermic or normothermic, could hold the key to improving donor pancreas quality as well as quantity available for transplant. This article reviews the literature on experimental models of pancreas machine perfusion, examines the benefits of machine perfusion, the technical aspects and their clinical implications.

Adhesion barriers for abdominal surgery: a sticky problem

Understanding of adhesion formation after abdominal surgery and its unwanted eff ects can be traced back to the advent of intra-abdominal surgery. Weibel and Majno described the eff ect of abdominal surgical interventions in post-mortem studies, noting abdominal adhesions in 67% of patients who had previous abdominal surgery. Many subsequent studies have supported this fi nding and indicated even higher rates of adhesion formation after abdominal surgery. In an attempt to explain the pathogenesis of peritoneal adhesions, Schade and Williamson undertook ultra structural analysis of adhesions in rodents and concluded that desquamation of mesothelial cells, leaving a denuded surface, seemed to be the critical event in adhesion formation. Subsequently, Buckman and colleagues thought that fi brin was deposited on an exposed basement membrane, and failure to clear this deposited fi brin due to local depression of plasminogen activator activity was the unifying mechanism of ab dominal adhesion formation. Present understanding is that adhesion formation is a normal part of wound healing, with various factors determining either resolution or pathological adhesion formation. Schade and Williamson’s work formed the scientifi c basis for changes in surgical techniques, which aim to reduce tissue handling and limit tissue damage and adhesion formation. To prevent intraperitoneal adhe sions after repeat laparotomies, intraperitoneal application of paraffi n, camphor, air insuffl ation, and amnion was recom mended by Kubanyl, who also pointed out that no reliable method to prevent abdominal adhesions existed. This pessimistic view resonates to the present day, and often leads to fatalistic acceptance of postoperative abdominal adhesion formation rather than use of an active approach to reduce or prevent adhesions in routine surgical practice. Many drugs have been administered both topically and systemically in an attempt to reduce adhesion formation, but only a few candidates have progressed to clinical trials. The drugs available up to now to reduce adhesions at the time of surgery can be divided into two groups: liquids, which are instilled to the abdominal cavity at the end of an operation, and topical gels or fi lms. Adhesion-reducing liquids such as icodextrin solution or polyethylene glycol rely on the principle of fl otation. The bowel moves freely with the fl uid instilled into the abdominal cavity and allows injured peritoneal surfaces to heal undisturbed. Gels or fi lms such as oxidised regenerated cellulose or hyaluronate carboxymethylcellulose act as a mechanical barrier, separating the operative surfaces within the abdomen. They must be retained long enough for suffi cient healing, but also reabsorb without inducing a foreign body reaction. In The Lancet, Richard ten Broek and colleagues present a systematic review and meta-analysis on the benefi ts and harms of adhesion barriers for abdominal surgery. The authors limit the evaluation to literature on adhesion barriers approved so far—hyaluronate carboxy methylcellulose, oxidised regenerated cellulose, icodextrin 4% solution, and polyethylene glycol—for abdominal surgery. Other systematic reviews fail to show compelling evidence that these products are able to prevent or minimise intraperitoneal adhesion formation or can alleviate morbidity of intrabdominal adhesion formation such as infertility, small bowel obstruction, or repeated laparotomies. The authors chose reoperation due to small bowel obstruction as their primary outcome, which is highly relevant in surgical practice and has been well documented since the SCAR-3 study. Through a comprehensive literature search, 28 trials including data of 5191 patients were pooled and analysed. Trials published by diff erent surgical subspecialties were included. The authors paid careful attention to assessing Published Online September 27, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)62002-4

Systematic review of congenital and acquired portal-systemic shunts in otherwise normal livers.

Portal‐systemic shunts (PSSs) are rarely seen in healthy individuals or patients with non‐cirrhotic liver disease. They may play an important role in hepatic metabolism as well as in the spread of gastrointestinal metastatic tumours to specific organs. Small spontaneous PSSs may be more common than generally thought. However, epidemiological data are scarce and inconclusive. This systematic review examined the prevalence of reported PSSs and the associated detection methods.

Liver resection for non-colorectal non-neuroendocrine metastases.

Liver resections for non‐colorectal non‐neuroendocrine liver metastases (NCNELM) are gaining popularity. This study examines the outcomes of liver resections in patients with NCNELM in an Australian hospital.

Atypical mycobacterial infection mimicking metastatic cholangiocarcinoma

Mycobacterial infections are rare in developed countries. Isolated involvement of the liver and biliary tree by mycobacterial infection is extremely rare. We report a case of a 45-year-old Caucasian female presenting with obstructive jaundice with a common bile duct stricture and multiple hypodense liver lesions raising suspicion of a metastatic cholangiocarcinoma. Percutaneous core biopsies of the liver lesions however suggested granulomatous process and histology at surgical excision confirmed this finding. Atypical mycobacteria (M. abcessus) sensitive to Amikacin were cultured from the surgical specimen proving the diagnosis. With the resurgence of tubercular and atypical mycobacterial infections in the developed world, it is important not to overlook these in differential diagnosis of various malignancies.

Electrosurgery: what do young surgeons need to know?

The term ‘electrosurgery’ is often used as an umbrella term to describe the different forms of energy used in surgery. Usage of energy occurs in virtually all operations, even more so in laparoscopic surgery, which has become the gold standard for many procedures. Its use, mainly to dissect tissue and control bleeding, has become so common in modern-day surgery that it is an indispensable tool for surgeons. Basic knowledge of the principles of energy usage in surgery is the key to its safe usage. Understanding of electrophysics allows the operator to select the optimal electrosurgical device for a particular set of circumstances and be vigilant to the potential complications associated with the respective instrument. Although popularized since the 1960s, formal teaching of electrosurgical principles was only introduced in Australia in 2002 via the Basic Surgical Skills course and currently in the Australian and New Zealand Surgical Skills Education and Training course. Despite its routine use, operators are found to have obvious deficits in electrosurgery knowledge. This holds true from experienced consultant surgeons to junior surgical registrars. We were keen to identify the level of general knowledge of electrosurgery in our division of surgery and thus a survey was conducted among the general surgery consultants, fellows and registrars. Besides asking for basic information (e.g. position, gender, years of surgical experience, personal complications using electrosurgery, etc.), the questionnaire included 11 multiple choice questions on basic knowledge of electrosurgery, its complications and their prevention. Surprisingly, results were less than satisfactory in all three groups (Table 1). While consultants answered only every second question correctly (53.9%), fellows and registrars did even worse and answered only 41% and 37% of our basic knowledge questions correctly respectively. Asking for electrosurgery-related complications, 69% of the participants (n = 11) have personally caused an injury via an electrosurgical instrument, majority of them in open procedures (54%), and 81% (n = 13) of them know of a colleague who has done so. Given the relevance of this topic to every surgeon and the obvious gaps in knowledge, we wrote this article which intends to provide a quick introduction or a refreshment of fundamental electrosurgical knowledge for the time-strapped junior registrar and consultant alike.

Troubleshooting in laparoscopy: how to treat 'poor image quality'.

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Mycobacterial Infection of the Gallbladder Masquerading as Gallbladder Cancer with a False Positive Pet Scan

Isolated mycobacterial infection of gall bladder is an extremely rare entity. Only anecdotal reports are evident in the literature. A preoperative diagnosis of mycobacterial infection of gallbladder is therefore very difficult. The case of a 72-year-old male who underwent surgery for suspected gallbladder cancer is presented. The diagnosis of cancer was based on radiological findings and an abnormal uptake of fluorine-18-fluoro-2-deoxy-D-glucose (FDG) on positron emission tomography (PET) scan whilst being followed up for colorectal cancer. He underwent cholecystectomy and gallbladder bed resection. Histopathology was consistent with mycobacterial infection of the gallbladder.

Pancreatic, periampullary and biliary cancer with liver metastases: Should we consider resection in selected cases?

AIM To analyse the safety and efficacy of curative intent surgery in biliary and pancreatic cancer. METHODS An extensive literature review was performed using MEDLINE, Google Scholar and EMBASE to identify articles regarding hepato-pancreatoduodenectomy or resection of liver metastasis in patients with pancreatic, biliary tract, periampullary and gallbladder cancers. RESULTS A total of 19 studies were identified and reviewed. Major hepatectomy was undertaken in 391 patients. The median overall survival for pancreatic cancer ranged from 5-36 mo and for biliary tract/gallbladder cancer, it was 8-38 mo. The 30 d mortality rate was only 1%-9%. Overall Survival was significantly better for patients, who had good response to neoadjuvant chemotherapy, underwent metachronous liver resection and who had intestinal type tumours. CONCLUSION Resection of liver metastases in pancreatic and biliary cancers may provide survival benefit without compromising safety and quality of life in a very select group of patients. These data may be utilised to formulate selection criteria that may allow future investigation of resection in the era of more effective systemic therapy.

Intermittent superior mesenteric artery syndrome in a patient with multiple sclerosis

A 42-year-old man with multiple sclerosis presented with recurrent vomiting, in the context of recent weight loss. Computed tomography scan of the abdomen and pelvis revealed duodenal compression by the superior mesenteric artery (SMA), consistent with intermittent SMA syndrome. Subsequent gastroscopy and barium meal follow-through showed resolution of the obstruction. SMA syndrome is rare and has not previously been reported in a patient with multiple sclerosis. We hypothesize that loss of the aortomesenteric fat pad on the background of contorted body habitus from multiple sclerosis placed the patient at risk for intermittent positional compression of his duodenum.