Michael Wayne

Alternative reconstruction after pancreaticoduodenectomy.

BackgroundPancreaticoduodenectomy is the procedure of choice for tumors of the head of the pancreas and periampulla. Despite advances in surgical technique and postoperative care, the procedure continues to carry a high morbidity rate. One of the most common morbidities is delayed gastric emptying with rates of 15%–40%. Following two prolonged cases of delayed gastric emptying, we altered our reconstruction to avoid this complication altogether. Subsequently, our patients underwent a classic pancreaticoduodenectomy with an undivided Roux-en-Y technique for reconstruction.MethodsWe reviewed the charts of our last 13 Whipple procedures evaluating them for complications, specifically delayed gastric emptying. We compared the outcomes of those patients to a control group of 15 patients who underwent the Whipple procedure with standard reconstruction.ResultsNo instances of delayed gastric emptying occurred in patients who underwent an undivided Roux-en-Y technique for reconstruction. There was 1 wound infection (8%), 1 instance of pneumonia (8%), and 1 instance of bleeding from the gastrojejunal staple line (8%). There was no operative mortality.ConclusionUse of the undivided Roux-en-Y technique for reconstruction following the Whipple procedure may decrease the incidence of delayed gastric emptying. In addition, it has the added benefit of eliminating bile reflux gastritis. Future randomized control trials are recommended to further evaluate the efficacy of the procedure.

Central pancreatectomy without anastomosis

BackgroundCentral pancreatectomy has a unique application for lesions in the neck of the pancreas. It preserves the distal pancreas and its endocrine functions. It also preserves the spleen.MethodsThis is a retrospective review of 10 patients who underwent central pancreatectomy without pancreatico-enteric anastomosis between October 2005 and May 2009. The surgical indications, operative outcomes, and pathologic findings were analyzed.ResultsAll 10 lesions were in the neck of the pancreas and included: 2 branch intraductal papillary mucinous neoplasms (IPMNs), a mucinous cyst, a lymphoid cyst, 5 neuroendocrine tumors, and a clear cell adenoma.ConclusionCentral pancreatectomy without pancreatico-enteric anastomosis for lesions in the neck and proximal pancreas is a safe and effective procedure. Morbidity is low because there is no anastomosis. Long term endocrine and exocrine function has been maintained.

Renal cell cancer without a renal primary

Renal cell carcinoma has been increasing in incidence over the past two decades. Men are affected more than women and metastatic disease at presentation occurs in up to one third of patients. Metastasis can occur to virtually any organ, and involvement of multiple organs is not uncommon. To date, no reports have been found of metastatic disease without a renal primary. We present a case of renal cell cancer initially presenting as a subcutaneous mass with subsequent pancreatic and parotid gland metastases in absence of a primary renal source.

Endoscopic subfascial perforator vein surgery for patients with severe, chronic venous insufficiency.

Before 1985, surgery on incompetent perforator veins in patients with severe, chronic, venous insufficiency and venous ulcerations was generally performed utilizing long skin incisions through diseased skin and subcutaneous tissues. Known as “the Linton operation,” wound infections and poor healing complicated this procedure. In 1985 G. Hauer demonstrated a new surgical technique for identifying and ligating incompetent perforator veins using an endoscopic approach in the limbs’ subfascial space. This seminal contribution marked the advent of subfascial endoscopic perforator surgery (SEPS). From 1996 to 2003 our group prospectively collected data on 86 patients with chronic venous insufficiency (CVI) who underwent a SEPS procedure. Preoperative assessment consisted of color-flow duplex ultrasound scanning and ascending and descending phlebography. The patient’s ages ranged from 42 to 82 years (mean 60). A total of 98 limbs underwent the SEPS procedure from the cohort group of 86 patients. The CHEAP classification of the limb disease was used: 45 limbs were classified as group C5, 53 limbs group C6. Ninety-eight SEPS procedures were performed without significant morbidity on 86 patients. Of the 53 limbs in class C6, 41 had ulcer healing within 12 weeks. The remaining 12 limbs in class C6 had ulcer healing within 6 months. In this latter group, 9 had ulcers greater than 4 cm in widest diameter. These patients underwent a split-thickness skin graft at the time the SEPS procedure was performed. The grafts have remained intact after 2 years in this cohort group. The results of this study demonstrate that the SEPS procedure incorporated into the overall treatment plan for patients with CVI produces excellent healing with minimal postoperative complications. The study also underscores the important role incompetent perforator veins have in the formation of venous ulcers.

Three synchronous, sporadic and separate periampullary and pancreatic tumors: more than a coincidence?

Three sporadic, synchronous, and separate lesions in the ampulla of Vater and the head of the pancreas presented in an 81-year-old male. One was symptomatic and two were incidental. One was detected preoperatively (the ampullary lesion) and two by examination of the resected specimen (the neuroendocrine and pancreatic carcinomas). The case is summarized and the literature and the issue of commonality are reviewed.

Prevention and Early Detection of Pancreatic Cancer

Preventing cancer has much to offer. Aside from plummeting health care costs, we might enjoy a healthier life free of cancer and chronic disease. Prevention requires the adoption of healthier choices and a moderate amount of exercise. The supporting evidence is observational, clinical, and partly common sense. Further investigations reveal several substances in a whole-food plant-based diet that have protective effects and an inhibitory effect on tumor development. For pancreatic cancer, the basis of cure remains a century old operation that rarely cures. With little to lose, prevention deserves center stage and additional studies.

A Tale of 2 Techniques:Preoperative Biliary Drainage and Routine Surgical Drainage with Pancreaticoduodenectomy

Preoperative drainage of an obstructed biliary tree before pancreaticoduodenal resection (PDR) and placement of intraabdominal drains following pancreatic resection have been suggested to be both unnecessary and associated with a higher complication rate. The evidence for and against that practice is presented and analyzed to highlight its risks and benefits. A selective approach on an individual basis for preoperative biliary decompression is advocated, based on multiple factors. Additionally, the evidence for routine use of surgical drains after PDR is critically reviewed and the rationale for routine drainage is made.

Cancer of the Pancreas—Actual 5, 10, and 20+Year Survival: The Lucky and Fortunate Few

Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malignancy. This article updates an earlier experience of actual long-term survival of CaP in patients treated between 1991 to 2000, and reviews the literature. Survival is expressed as actual, not projected, survival.

Familial Pancreatic Cancer: The Case for Prophylactic Pancreatectomy in Lieu of Serial Screening and Shared Decision Making

At-risk family members with familial pancreatic cancer (FCaP) face uncertainty regarding the individual risk of developing pancreatic cancer (CaP) and whether to choose serial screening or prophylactic pancreatectomy to avoid CaP. We treated 2 at-risk siblings with a history of FCaP, congenital hepatic fibrosis (CHF), and jaundice secondary to a bile duct stricture. In one, a pancreaticoduodenal resection was done and in the second a total pancreatectomy. Malignancy was not present, but extensive pancreatic intraepithelial neoplasia (PanIn) 2 was present throughout both pancreata. The clinical course and literature review are presented along with the previously unreported association of CHF and CaP.

Toxicology of the pancreas: a review

Toxicology of the Pancreas is a complete summary of the pancreas. It covers every aspect of the pancreas relevant to the clinician and the researcher. Areas such as embryology, anatomy, immunology and toxicology are covered in great detail. It also provides a brief insight into pancreatic cancer. This brevity was disappointing because, as a clinician, pancreatic cancer is a very important subject and questions about it are raised frequently by patients with chronic diseases of the pancreas.The book is too detailed for the lay person, and even contains too much for the general practitioner. The information given is outstanding but very detailed. It is best suited for specialists in pancreatic disease and researchers.I especially enjoyed the reviews of anatomy and physiology. These chapters were very well written and very insightful. They will be a good source for my continued review. The book, in its entirety, will be an excellent source of reference for anyone whose research or clinical practice examines patients with pancreatic disease. The only exception to the level of coverage is patients with pancreatic cancer, but sufficient information about pancreatic cancer is provided to help the general practitioner give an explanation to their patients before referring them to a specialist.I also enjoyed the toxicology chapters. I was impressed with the level of detail and with the fact that the details were current. These chapters bring insight to different toxicological agents and their effects on the pancreas. It allows one to understand more completely how the various toxic agents that people bring into their bodies affect the pancreas. The detailed descriptions of the pancreatic duct and relation to the common bile duct also helps clinicians to understand more about the disease entity gallstone pancreatitis, which remains an unsolved mystery. The book also highlights the toxic effect of smoking on the pancreas. This area is not emphasized sufficiently in the medical community. Everyone knows of the toxic effects of smoking on the lungs but not many know of its toxic effect on the pancreas.The chapters on the endocrine and exocrine pancreas were too detailed for the general practitioner, as well as for the general public. They will be an excellent resource for the medical student learning about the pancreas and for researchers and pancreatic specialists. I enjoyed them very much and found information that I had not read before. These chapters have helped me better understand the genesis of pancreatic diseases, which will help me in my clinical practice.I was very pleased to see a chapter on autoimmune pancreatitis. This condition, formerly known as idiopathic pancreatitis, is finally starting to receive attention. This is an area of interest for me and my practice. My partner and I receive many referrals of patients with this condition. Unfortunately, we receive them when their only treatment option is surgery. We need early markers for autoimmune pancreatitis so that we can treat these patients with steroids. We need to be able to diagnose this by needle biopsy specimen, not by surgical pathology. In the coming years this disease will become more prevalent in our society simply because more people are becoming aware of it. We need to improve our diagnostic skills pertaining to this disease so that patients can avoid surgery and be treated medically.In summary, I would like to commend the authors for their fine work. Toxicology of the Pancreas was pleasurable reading and has helped my practice. Thank you for enhancing my knowledge, which will help me to be a better hepatobiliary-pancreatic surgeon.