Matthew Walsh

Pancreatic Lesions in von Hippel–Lindau Disease? A Systematic Review and Meta-synthesis of the Literature

Backgroundvon Hippel–Lindau (vHL) disease is a rare condition that leads to characteristic lesions within many different body systems. Pancreatic manifestations of vHL cover a wide spectrum of pathologies, and thus, accurate characterization and management is critical.MethodsA comprehensive and systematic text word and MeSH search of the medical literature was performed to identify studies where information regarding the prevalence, clinical characteristics, and management recommendations could be extracted.ResultsEleven studies were identified but 2 studies utilized the same data set. Of the 10 remaining studies, a total of 1,442 patients with vHL were available for analysis. Four hundred and twenty patients were examined for any type of pancreatic lesion, 362 for simple cysts or serous cystadenomas (SCAs), and 1,442 for neuroendocrine tumors (NETs). Of the 420 assessed for any pancreatic manifestation of vHL, 252 (60%) had a pancreatic lesion identified. Simple cysts that present as the sole manifestation of pancreatic disease were common and found in 169 of 362 (47%) patients. These are usually asymptomatic and do not normally require intervention. SCAs were reported in 39 of 362 (11%) patients and followed a similar benign course; resection is acceptable in symptomatic patients. NETs were identified in 211 of 1,442 (15%) patients, and 27 of 1,442 (2%) lesions behaved malignantly. Management of NETs depends on size, doubling time, and underlying genetics. Renal cell carcinoma is a characteristic in vHL, but there were no cases of pancreatic metastases identified from the included studies. Adenocarcinomas of the pancreas are not pathogenically linked to vHL.ConclusionsThis review highlights the wide spectrum and high prevalence of pancreatic lesions in vHL. Simple cysts and SCAs are benign, but NETs require careful observation due to their malignant potential.

Intestinal malrotation : a rare but important cause of bowel obstruction in adults

AbstractPURPOSE: Complications of intestinal malrotation are familiar to pediatric surgeons but are rarely encountered by those caring strictly for adults. The aim of this study was to review our experience with disorders of intestinal rotation in adult patients and to emphasize the clinical presentation, radiographic features, and results of surgical treatment. METHODS: Ten adult patients (mean age, 42 (range, 22–73) years) with complications of intestinal malrotation were identified by review of department records. Clinical presentation, operative treatment, and outcome were recorded. RESULTS: Nine patients presented with obstructive symptoms (five chronic and four acute). A diagnosis of malrotation was made preoperatively in all cases by a small-bowel contrast study or CT scan. Patients were treated by laparotomy with adhesiolysis (4 cases including one paraduodenal hernia and two midgut volvuli), Ladd’s procedure (4 cases), or duodenopexy and cecopexy (1 case). One patient presented with an acute abdomen and was found to have appendicitis. There was no mortality. Two patients developed complications (wound infection and ileus). Two patients had recurrent episodes of small-bowel obstruction with a mean follow-up of 30 (range, 2–69) months and one required reoperation. CONCLUSIONS: Complications of intestinal rotation can occur in adult patients and may present with chronic or acute symptoms. Prompt recognition and surgical treatment usually lead to a successful outcome. The diagnosis of intestinal malrotation should be considered in any adult patient with signs and symptoms of small-bowel obstruction.

Decreased Severity in Recurrent Versus Initial Episodes of Acute Pancreatitis.

Objectives The comparative outcomes of initial versus recurrent acute pancreatitis (AP) have not been clearly established. Aim The aim was to compare the clinical outcomes of those with an initial episode of AP to those with recurrent AP stratified by the number of prior episodes. Methods This retrospective cohort study included consecutive patients with AP admitted to the Cleveland Clinic between 2008 and 2011. The odds of severe AP, multisystem organ failure, ICU admission, new local complications, elevated blood urea nitrogen and bedside index for severity in acute pancreatitis score, systemic inflammatory response syndrome, and mortality were compared using univariable and multivariable logistic regression. Results Two hundred and ninety two patients were included, of which 213 (72%) were admitted on their initial AP episode. Mortality in patients experiencing first episode was 4.7%, compared to 0% in patients with recurrent attack of pancreatitis (P = 0.047). Prior episodes of AP were found to be protective against multisystem organ failure (odds ratio, 0.14 for each prior episode; confidence interval, 0.01–0.76) and intensive care unit admission (0.24, confidence interval, 0.06–0.91), adjusting for potential confounding factors such as transfer status and obesity. Conclusions Patients presenting with recurrent AP may be at decreased risk of a clinically severe course and incur decreased mortality.

A Structured Educational Curriculum Including Online Training Positively Impacts American Board of Surgery In-Training Examination Scores

OBJECTIVE To assess the effect of a structured postgraduate year 1 educational curriculum, including online surgical training, on American Board of Surgery In-Training Examination (ABSITE) scores. DESIGN This was a retrospective cohort study. SETTING The study was performed in an academic surgical residency program in a tertiary care hospital, Cleveland Clinic Foundation, Cleveland, Ohio. PARTICIPANTS The participants were 140 surgical postgraduate year 1 residents from 2000 to 2009. Interns from 2000 to 2004 were grouped together and completed a self-directed learning curriculum. Interns from 2005 to 2009 participated in a structured educational curriculum that included lectures and the use of an online program. Lectures were based on the American College of Surgeons curriculum. The online program consisted of 8 to 12 hours of assigned tutorials and quizzes that corresponded to the lectures and 3 multiple-choice (MC) examinations. RESULTS Use of a structured educational curriculum led to improved ABSITE scores (66 ± 9%) compared with that of those who had no curriculum (55 ± 10%, p < 0.001). Several variables positively correlated with the ABSITE score: United States Medical Licensing Examination step 1 score (p < 0.001), monthly quiz scores (p = 0.003), average MC examination scores (p = 0.005), lecture attendance (p = 0.02), and time spent online (p = 0.04). Multivariable analysis demonstrated that the step 1 United States Medical Licensing Examination score, time spent online, and MC examination score are predictive of total the ABSITE score. When ABSITE subscores (basic science and clinical science) were compared, the online curriculum had a greater effect on basic science subscores, whereas lectures had a greater effect on clinical science subscores. CONCLUSIONS Providing surgery residents a structured curriculum with lectures and an online component positively impacts ABSITE scores.

Su1851 Long-Term Outcomes of Combined Endoscopic/Laparoscopic Intragastric Enucleation of Gastric Stromal Tumors

S A T A b st ra ct s endophytic or in anatomically difficult locations. This technique allowed patients to avoid an extensive resection. Endoscopic resection alone was associated with a positive deep margin, which the push-pull technique managed with a laparoscopic, full-thickness, R0 resection site resection. In highly selected populations, this hybrid push pull technique may represent an improvement over standard endoscopic or laparoscopic management for gastric GISTs.

Tu1627 Maturation of Robot-Assisted Pancreaticoduodenectomy Program Within an Established Pancreatic Surgery Unit

Introduction: When tumors are found to be adherent to the superior mesenteric or portal vein during pancreatoduodenectomy, en bloc portal venous resection (PVR) is an option to achieve complete tumor resection. It has also been reported that PVR without confirmed histopathologic portal venous infiltration (PVI) is associated with significantly better survival. The aim of this study was to evaluate oncologic outcome and prognostic factors in patients receiving PVR for pancreatic cancer. Methods: A unicenter retrospective study was performed on the basis of a prospectively maintained database. IBM SPSS Version 21 was used for all calculations with the significance level set to p=0.05. Results: From 2001 to 2013, 103 patients received pancreatoduodenectomy with PVR for pancreatic head cancer. Median survival in patients with PVR without PVI was 25 months, whereas confirmed PVI was associated with poor median survival of 14 months (p<0.05). In patients with PVR, only PVI and lymph node ratio, but notmargin status, T orN stage, grading, lymphatic, microvessel or perineural infiltration, age or gender were independent prognostic factors in a multivariate Cox proportional hazards model. Conclusion: Portal venous resection for tumor adherence in pancreatic cancer is associated with equal median survival as in patients without PVR when there is no histopathologic infiltation of the large veins. Additional prognostic information is only provided by lymph node ratio, whereas margin status and other standard histopathologic parameters have no additional predictive value in this situation.

634 Robotic Assisted Laparoscopic Central Pancreatectomy With Roux-en-Y Pancreaticojejunostomy for Pancreatic Neuroendocrine Tumor

In the submitted video we present robotic gastrectomy for gastric cancer, in order to demonstrate the role of the robot in the management thereof. The robotic surgery platform offers technical advantages over the laparoscopic approach for gastrectomy with lymphadenectomy for cancer. The excellent visualization and wristed instrumentation allow for more precise dissection than can be done with laparoscopic or open surgery. Though long-term oncologic outcomes remain to be determined, robotic gastrectomy is safe and feasible in selected patients.

Hepatic artery pseudoaneurysm presenting as right upper quadrant pain and massive upper gastrointestinal hemorrhage

Hepatic artery pseudoaneurysm presenting as right upper quadrant pain and massive upper gastrointestinal hemorrhage