Paul C.M. Verbeek

Benign biliary strictures. Surgery or endoscopy

OBJECTIVE This study compared the results of surgery and endoscopy for benign biliary strictures in one institution, over the same period of time and with the same outcome definitions. SUMMARY BACKGROUND DATA Surgery is considered the treatment of choice, offering more than 80% long-term success. Endoscopic stenting has been reported to yield similar results and might be a useful alternative. METHODS In this nonrandomized retrospective study, 101 patients with benign biliary strictures were included. Thirty-five patients were treated surgically and 66 by endoscopic stenting. Patient characteristics, initial trauma, previous repairs, and level of obstruction were comparable in both groups. Surgical therapy consisted of constructing a biliary-digestive anastomosis in normal ductal tissue. Endoscopic therapy consisted of placement of endoprostheses, with trimonthly elective exchange for a 1-year period. RESULTS Mean length of follow-up was 50 +/- 3.8 and 42 +/- 4.2 months for surgery and endoscopy, respectively. Early complications occurred more frequently in the surgically treated group (p < 0.03). Late complications during therapy, occurred only in the endoscopically treated group. In 46 patients, the endoprostheses were eventually removed. Recurrent stricturing occurred in 17% in both surgical and endoscopic patients. CONCLUSIONS Surgery and endoscopy for benign biliary strictures have similar long-term success rates. Indications for surgery are complete transections, failed previous repairs, and failures of endoscopic therapy. All other patients are candidates for endoscopic stenting as the initial treatment.

Results of pancreaticoduodenectomy for ampullary carcinoma and analysis of prognostic factors for survival

BACKGROUND Results of pancreaticoduodenectomy for ampullary carcinoma were evaluated, and prognostic factors for survival were analyzed. METHODS During the period from 1984 to 1992 67 patients underwent subtotal or total pancreaticoduodenectomy for ampullary carcinoma. All clinicopathologic data and their influence on survival were studied. RESULTS Subtotal pancreaticoduodenectomy was performed in 62 of 67 patients with a mortality of 6% and a morbidity of 65%; the remaining five patients underwent total pancreaticoduodenectomy. Intraabdominal infection was the most important complication. Resection margins were tumor free in 75% of 67 patients. The overall 5-year survival was 50%. Survival was significantly influenced by the involvement of resection margins. After resection with involved margins 5-year survival was 15% and 60% after resection with free margins (p < 0.001). Tumor size, lymph node involvement, and differentiation grade had limited and not significant influence on survival. CONCLUSIONS Subtotal pancreaticoduodenectomy is the type of resection of first choice for ampullary carcinoma. Involvement of resection margins was the strongest prognostic factor for survival. Patients with a tumor size larger than 2 cm, with lymph node involvement, or with a poorly differentiated tumor still had a 5-year survival rate greater than 40%. Patients with involved margins might be candidates for studies on adjuvant therapy.

Endosonography in diagnosing and staging duodenal villous adenoma.

Endosonography was carried out in a patient with an extensive juxtapapillary tumour. Radiology and endoscopy were unable to distinguish a villous adenoma from an invasive carcinoma. Endosonography revealed a mucosal hypoechoic tumour without penetration into the submucosa and muscularis propria. The common bile duct, pancreatic duct, and pancreas were normal. Lymph node abnormalities were not found. Based on the endosonography findings, local surgical tumour resection was undertaken instead of a Whipple procedure. The histology of the resected specimen confirmed the endosonography diagnosis.

Occurrence of Implantation Metastases after Resection of Klatskin Tumors

Background: We found a high proportion of patients with implantation metastases during follow-up after resection of a proximal cholangiocarcinoma. A remarkable fact was that all these patients had undergone preoperative endoscopic retrograde cholangiopancreatography (ERCP) with placement of a stent. ERCP is frequently used in the assessment of the proximal extension of Klatskin tumors and is usually followed by stent insertion for biliary drainage. The aim of this study was to analyze the possible risk factors leading to implantation metastases in this series of patients. Methods: Fifty-two patients who had undergone resection of a Klatskin tumor were divided into 2 groups, comparing patients who had had preoperative ERCP and stent placement (n = 41) and patients without preoperative drainage (n = 11). Results: Eight patients developed implantation metastases within 1 year after resection, all of whom had undergone preoperative stent placement (8/41, 20%). None of the patients without preoperative stenting developed implantation metastases. In 22 patients bile samples were taken during operation. Sixteen (72.7%) patients had malignant cells and 4 (18.2%) patients atypical cells in the bile sample. There was no difference in cytology results between the 2 groups. Conclusion: This study suggests that preoperative ERCP with biliary drainage is associated with a higher frequency of implantation metastases after resection of Klatskin tumors. A properly planned prospective study, however, is needed to determine whether bile duct stenting in patients with resectable bile duct tumors is a true risk factor for the development of implantation metastases.

Is It Necessary to Send Gallbladder Specimens for Routine Histopathological Examination after Cholecystectomy? The Use of Macroscopic Examination

Background/Aims: Gallbladder specimens are routinely sent for histopathological examination after cholecystectomy in order to rule out the presence of gallbladder carcinoma (GBC). However, there is no evidence for the benefit of this costly practice. Our aim was to determine whether a selective strategy based on macroscopic appearance of gallbladder specimens is a reliable strategy to exclude them from histopathological examination. Methods: A retrospective study was conducted from January 2007 until November 2011 in a large community hospital in the Netherlands. All gallbladder specimen reports (n = 1,393) after cholecystectomy were included and searched for abnormal findings. Reports were excluded when a full histopathological report was not available (n = 18). Results: Out of the 1,375 patients, 185 had a macroscopically abnormal gallbladder specimen. Of these patients, 6 had GBC. All patients with GBC had macroscopic abnormalities, giving a negative predictive value of 100% to exclude gallbladder specimens from histopathological examination based on macroscopic abnormalities. Conclusions: Based on our study it seems justified to exclude gallbladder specimens from histopathological examination based on the absence of macroscopic abnormalities. A more selective policy will reduce medical costs, saving EUR 1.3 million a year in the Netherlands alone, whilst maintaining patient safety.

Split pancreaticojejunostomy in the surgical treatment of chronic pancreatitis.

“Split” pancreaticojejunostomy is a procedure consisting of vertical transection of the pancreas and anastomosis of both sides of the cut pancreatic duct with an interposed, Roux-en-Y jejunal loop. In this paper we report the long term results of this procedure in the treatment of eight patients with chronic pancreatitis (CP).

Severity of Diverticulitis Does Not Influence Abdominal Complaints during Long-Term Follow-Up

Background: Diverticulitis can lead to localized or generalized peritonitis and consequently induce abdominal adhesion formation. If adhesions would lead to abdominal complaints, it might be expected that these would be more prominent after operation for perforated diverticulitis with peritonitis than after elective sigmoid resection. Aims: The primary outcome of the study was the incidence of abdominal complaints in the long-term after acute and elective surgery for diverticulitis. Methods: During the period 2003 through 2009, 269 patients were operated for diverticular disease. Two hundred eight of them were invited to fill out a questionnaire composed of the gastrointestinal quality of life index and additional questions and finally 109 were suitable for analysis with a mean follow-up of 7.5 years. Results: Analysis did not reveal any significant differences in the incidence of abdominal complaints or other parameters. Conclusion: This retrospective study on patients after operation for diverticulitis shows that in the long term, the severity of the abdominal complaints is influenced neither by the stage of the disease nor by the fact of whether it was performed in an acute or elective setting.