Nicholas Alexakis

Meta-analysis of the value of somatostatin and its analogues in reducing complications associated with pancreatic surgery

The role of somatostatin and its analogues in reducing complications after pancreatic resection is controversial. This is a meta‐analysis of the evidence of benefit.

Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ.

There is no clear consensus on the better therapeutic approach (endoscopic versus surgical) to choledocholithiasis. This study is a meta‐analysis of the available evidence.

Pancreatic Pseudocyst in Chronic Pancreatitis: Endoscopic and Surgical Treatment

SurgeryIntroductionThe incidence and prevalence of chronic pancreatitisappear to be increasing [1–4]. Pancreatic pseudocyst is acommon complication of chronic as well as acute pancre-atitis that is unrelated to the underlying aetiology. Ad-vances in radiological techniques have in part led to anincrease in the diagnosis of pseudocyst and better charac-terization of associated complications. There is now a bet-ter understanding of the natural history of pseudocysts inrelation to the underlying disease. The introduction ofnew treatment modalities has also increased the optionsfor surgical management. Thus with better knowledge ofthe disease and with technical advances the indications,timing and methods to treat pancreatic pseudocysts haveundergone a marked evolutionary change.DefinitionA pancreatic pseudocyst is a localised collection ofpancreatic-enzyme-rich fluid, originating in or adjacent tothe pancreas and enclosed in a wall of granulation and/orfibrous tissue lacking an epithelial lining [5]. The princi-ple mechanism leading to pseudocyst formation is be-lieved to involve disruption of the main pancreatic ductand/or peripheral ductules causing leakage and activationof pancreatic enzymes, which in turn leads to localisedautodigestion and necrosis of pancreatic parenchyma.This evokes an inflammatory response with the formationof a distinct pseudocyst wall composed of granulation tis-sue and blood vessels that organizes with more connectivetissue and fibrosis [6–11].On-table pancreatography [12] and endoscopic retro-grade cholangiopancreatography (ERCP) have demon-strated a communication between the pseudocyst and thepancreatic ductal system in up to 80% of the patients [13,14], and peripheral or main pancreatic duct disruption isknown to be an early event in acute pancreatitis [15].Rarely disruption of a retention cyst [16] or trauma thatdisrupts the pancreatic ductal system may also lead to apseudocyst [17–19].

Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones

BACKGROUND The present study is a meta-analysis of English articles comparing one-stage [laparoscopic common bile duct exploration or intra-operative endoscopic retrograde cholangiopancreatography (ERCP)] vs. two-stage (laparoscopic cholecystectomy preceded or followed by ERCP) management of common bile duct stones. METHODS MEDLINE/PubMed and Science Citation Index databases (1990-2011) were searched for randomized, controlled trials that met the inclusion criteria for data extraction. Outcomes were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) using RevMan 5.1. RESULTS Nine trials with 933 patients were studied. No significant differences was observed between the two groups with regard to bile duct clearance (OR, 0.89; 95% CI, 0.65-1.21), mortality (OR, 1.2; 95% CI, 0.32-4.52), total morbidity (OR, 0.75; 95% CI, 0.53-1.06), major morbidity (OR, 0.95; 95% CI, 0.60-1.52) and the need for additional procedures (OR, 1.58; 95% CI, 0.76-3.30). CONCLUSIONS Outcomes after one-stage laparoscopic/endoscopic management of bile duct stones are no different to the outcomes after two-stage management.

Transparent cap-assisted colonoscopy versus standard adult colonoscopy: a systematic review and meta-analysis

BACKGROUND: Cap-assisted colonoscopy uses a transparent plastic hood attached to the tip of the colonoscope to flatten the semilunar folds and improve mucosal exposure. Several studies have examined the effect of cap-assisted colonoscopy on polyp detection, but the data are inconsistent. OBJECTIVE: This study aimed to evaluate whether cap-assisted colonoscopy improves the yield of colorectal neoplasia detected compared with standard colonoscopy. DATA SOURCES: A systematic search of the PubMed, MEDLINE, Embase, and Cochrane databases identified 12 studies that met the inclusion criteria for data extraction. STUDY SELECTION: Publications that compared cap-assisted colonoscopy vs standard colonoscopy in adults in a prospective randomized controlled study were selected for review. MAIN OUTCOME MEASURES: The primary outcomes used for meta-analysis were cecal intubation rate, cecal intubation time, and polyp detection rate. The analysis was performed using a fixed-effect model. Outcomes were calculated as odds ratios or standardized mean differences with 95% confidence intervals. The average polyp miss rate determined by tandem colonoscopy was also calculated. RESULTS: The outcomes of 6185 patients were studied. Cap-assisted colonoscopy detected significantly more patients with polyps (OR 1.13; p = 0.030) and had a lower average polyp miss rate (12.2% vs 28.6%) than standard colonoscopy. Cap-assisted colonoscopy had a significantly higher cecal intubation rate than standard colonoscopy (OR 1.36; p = 0.020), whereas the time to cecal intubation (standard mean difference, 0.04 min; p = 0.280) was similar for the 2 colonoscope types. CONCLUSIONS: Cap-assisted colonoscopy is associated with improved detection of colorectal neoplasia and higher cecal intubation rates than standard adult colonoscopy.

Survival of patients with periampullary carcinoma is predicted by lymph node 8a but not by lymph node 16b1 status.

The aim of this study was to assess the impact of metastatic disease in lymph nodes 8a and 16b1 (as defined by the Japanese Pancreas Society) on survival in patients with periampullary malignancy.

Fungal Infection but Not Type of Bacterial Infection Is Associated with a High Mortality in Primary and Secondary Infected Pancreatic Necrosis

Introduction: Knowledge of microbiology in the prognosis of patients with necrotizing pancreatitis is incomplete. Aim: This study compared outcomes based on primary and secondary infection after surgery for pancreatic necrosis. Method: From a limited prospective database of pancreatic necrosectomy, a retrospective case note review was performed (October 1996 to April 2003). Results: 55 of 73 patients had infected pancreatic necrosis at the first necrosectomy. 25 of 47 patients had resistant bacteria to prophylactic antibiotics (n = 21) or did not receive prophylactic antibiotics (n = 4), but this was not associated with a higher mortality (9 of 25) compared to those with sensitive organisms (4 of 22). Patients with fungal infection (n = 6) had a higher initial median (95% CI) APACHE II score compared to those without (11 (9–13) verus 8.5 (7–10), p = 0.027). Five of six patients with fungal infection died compared to 13 of 47 who did not (p = 0.014). With the inclusion of secondary infections 21 (32%) of 66 patients had fungal infection with 10 (48%) deaths compared to 11 (24%) of 45 patients without fungal infection (p = 0.047). Conclusion: Whether associated with primary or secondary infected pancreatic necrosis, fungal but not bacterial infection was associated with a high mortality.

Use of sealants in pancreatic surgery: critical appraisal of the literature.

Background/Aims: Fibrin sealants containing both fibrin and thrombin have been used to control bleeding, reinforce suture lines and enhance tissue healing. However, the literature provides contradictory results. Methods: A systematic literature search was performed to determine the use of fibrin sealants in pancreatic surgery. These articles were then critically appraised according to their methodologies, outcomes and conclusions. Results: Twenty-four studies were found, including 6 controlled randomized trials. Of these, 16 studies were analyzed. Many methodological flaws and lack of consistency in definitions were found, making comparisons between studies difficult if not impossible. Conclusion: Because of the heterogeneity and lack of high-level evidence, the current literature does not allow us any conclusion: neither is there proof that fibrin sealants are of any real utility in pancreatic surgery, nor that they do not work. Further large-scale controlled trials are necessary before concluding that they do or do not provide any advantages in pancreatic surgery.

Laparoscopic Approach to Colonic Cancer: Critical Appraisal of the Literature

Background/Aims: As laparoscopic colectomy finds its place in the surgical armamentarium, the literature concerning the safety, efficacy, and oncological rational for treatment of colonic cancer is also enriched. A review and critical appraisal of the literature on this subject was the aim of this paper. Methods: A systematic research and a hand search were conducted to gain access to all controlled studies involving laparoscopic colectomy using the Medline, Embase, HealthSTAR, Cumulative Index for Nursing and Allied Health Literature, CancerLit data bases and the Cochrane Central Register of Controlled Trials for the years 1991–2006. Results: Over 40 controlled randomized trials and ten systematic reviews and/or meta-analyses were found. Several of the completed controlled randomized trials have published either short- or long-term results; only partial and short-term results are available in rectal cancer. The principal conclusions are that the laparoscopic approach affords better short-term outcomes including surgical site morbidity, but with increased operative times and direct costs. Among the proven long-term outcomes, cancer recurrence and survival do not seem to be worse. Whether conversion, a source of increased operative time and costs, is responsible for poorer outcomes or whether specific settings associated with poorer outcomes are among the causes of conversion remains to be shown. However, there are still concerns as regards specific laparoscopic-related complications. Conclusion: There seems to no real safety problems in performing laparoscopic colectomy for cancer; improvement in operative times, conversion rates, and complications should make laparoscopy the best cost-effective approach to colectomy.

Double Resection for Patients with Pancreatic Cancer and a Second Primary Renal Cell Cancer

Background: Reports of synchronous or metachronous double kidney-pancreas cancers are very rare. Methods: We present 2 patients with renal cell carcinoma and synchronous (1 patient) or metachronous (1 patient) primary pancreatic ductal adenocarcinoma. The patients underwent resection for both cancer types with a worthwhile outcome. Results: The appearance of different primaries in an individual may indicate a genetic predisposition to different neoplasms. The study of double primary cancers is important because it might provide understanding of a shared genetic basis of different solid tumors. Conclusions: The association between these two cancers demands more detailed epidemiological and molecular investigation. From a clinical viewpoint a resectional policy is recommended.