Pierre F. Saldinger

The role of endoscopic ultrasound and cyst fluid analysis in the initial evaluation and follow-up of incidental pancreatic cystic lesions

PURPOSEnTo assess the role of endoscopic ultrasound (EUS) in the initial evaluation and follow-up of incidental pancreatic cystic lesions (PCL).nnnMETHODSnRetrospective analysis of patients with incidental PCL on imaging who were evaluated by EUS and had a minimal follow-up of 1 year.nnnRESULTSnThere were 62 patients (40 females and 22 males). The mean patient age was 67.7 years (range, 30-89). The Median follow-up was 24 months (range, 12-72). The mean PCL size was 21.6 mm. In all, 13 patients underwent surgery (20.9%). Diagnosis included a mucinous cystic tumour (7), mucinous adenocarcinoma (2), intraductal papillary mucinous neoplasm (1) and a cystic neuroendocrine tumour (1). The overall malignancy rate among patients who underwent surgery was 15.3% (two patients). The mean carcinoembryonic antigen (CEA) level from PCL fluid analysis was also significantly higher in surgically treated group (7760) vs. the stable group (184.7) vs. the enlarging PCL group (361.1). A CEA level above 192 ng/ml predicted mucinous PCL with a sensitivity of 90%.nnnCONCLUSIONSnEUS with cystic fluid analysis can be successfully used to rule out pancreatic neoplasms and to follow-up incidentally discovered PCL.

Images in surgery: retroperitoneal ganglioneuroma

Ganglioneuroma is a differentiated tumor of the sympathetic nervous system. We describe a case of retroperitoneal ganglioneuroma without vascular invasion that was resected using laparotomy access. We also provide a short review of the ganglioneuroma as a clinical entity.

Micro-laparoscopic Cholecystectomy: An Alternative to Single-Port Surgery

IntroductionRecent advances in minimally invasive surgery aimed at diminishing incision size have led to the development of single-port surgery (SPS). SPS has an increased level of complexity and requires a higher level of surgical skill compared to traditional laparoscopy. We explored micro-laparoscopy as an alternative to routine laparoscopic cholecystectomy.MethodsThe study is a retrospective review of consecutive elective laparoscopic cholecystectomies performed by a single surgeon at a community teaching hospital over 24xa0months. All surgeries were performed using a 5-mm trocar for the umbilical port and 3-mm trocars for other ports in standard configuration.ResultsSeventy-nine cholecystectomies were performed by micro-laparoscopy during the 24-month period. Three cases required upgrade in trocar size for technical reasons, resulting in a completion rate of 96%. Intraoperative cholangiography was performed in 70 cases (89%). There were no conversions to open surgery. There were no intra- or postoperative complications, and all patients were discharged on the day of surgery.ConclusionMicro-laparoscopic cholecystectomy is safe, feasible, and represents an alternative to other minimally invasive techniques. Future developments in surgical technology will allow the use of even smaller instruments, diminishing the surgical “footprint” even further and contributing to better cosmesis and decreased postoperative pain in cholecystectomy patients.

HPB Surgery Can Be Safely Performed in a Community Teaching Hospital

IntroductionThere is ongoing debate about feasibility of performing hepatobiliopancreatic (HPB) cases in low-volume, community hospitals. We decided to analyze outcomes of HPB surgical cases done in our community hospital and compare it with published data from academic centers and/or national data.Materials and MethodsWe reviewed all HPB cases (liver, pancreas, and bile duct cases) performed in an 8-year-period (2001–2009) by HPB-fellowship-trained general surgeon (P.F.S.) at the Danbury Hospital, CT, USA. All electronic files of the patients, who underwent HPB surgery, were reviewed, and all pertinent clinical information was retrieved. Complications and mortality were recorded for length of hospital stay and 30xa0days after discharge. All complications were graded according to Clavien classification. Pancreatic specific complications—pancreatic fistula/leak and delayed gastric emptying—were graded using International Study Group on Pancreatic Fistula and International Study Group of Pancreatic Surgery definitions.ResultsThere were 140 HPB cases. These included 33 pancreatoduodenectomies, 29 distal pancreatectomies, 52 hepatic cases, and 26 cases of other cases involving pancreas and biliary tract. Overall complication rate was 36.4%. Using Clavien classifications, there were 26 grade 1 complications, 21 grade 2 complications, and four grade 3 complications. Two patients underwent reoperation for postoperative complications. Overall mortality was 0.7% (one patient). Pancreas-specific complications included 6% pancreatic leak rate after pancreatoduodenectomy and 24.1% leak rate for distal pancreatectomy.ConclusionHPB surgery could be safely performed in community setting, with morbidity and mortality comparable to high-volume centers.

Frey procedure for pancreaticopleural fistula.

A 59-year-old woman with alcoholic chronic pancreatitis and multiple readmissions for exacerbation developed acute shortness of breath. Chest X-ray showed massive rightsided pleural effusion, and a thoracocentisis revealed amylase content of 12,000 U/L. Magnetic resonance cholangiopancreatography (MRCP) suggested presence of the pancreatic pseudocyst in the porta hepatitis with possible pancreaticopleural fistula (PPF). Pleural effusion recurred soon after thoracocentesis despite treatment with total parenteral nutrition (TPN) and somatostatin. An endoscopic retrograde cholangiopancreatography (ERCP) was not possible secondary to duodenal stenosis caused by the inflammatory pancreatic head mass. The patient underwent an exploratory laparatomy during which a direct pancreatic ductogram demonstrated the PPF tract (Figs. 1 and 2). Fistula was outlined by the methylene blue injection into the main pancreatic duct. A Frey procedure (pancreatic head local resection and pancreatojejunostomy), to provide decompression of the pancreatic duct, as well a gastrojejunostomy and feeding jejunostomy were performed. Postoperative course was complicated by bleeding from pancreatic branches of the splenic artery, requiring embolization per interventional radiology. There was no recurrence of PPF on subsequent 3 years follow-up. Discussion

Performance Improvement: Getting an Early Start

BACKGROUNDnThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and the Surgical Care Improvement Program (SCIP) can be utilized to develop quality initiatives to improve surgical care. Understanding the fundamentals of quality measures provides insight to the six Accreditation Council on Graduate Medical Education (ACGME) competencies. Resident education needs a robust exposure to quality measures, such as NSQIP and SCIP to prepare surgeons for tomorrows healthcare system.nnnMETHODSnThe resident champion (RC) position is a dedicated research year between the PGY-2 and PGY-3 as a way to introduce residents to NSQIP and the importance of quality improvement. The resident partners with the NSQIP clinical reviewer to analyze data, develop quality improvement projects, implement these initiatives, and re-examine quality performance.nnnRESULTSnOver the last 24 months, there have been numerous performance improvement initiatives and projects implemented at our facility as a direct result of the RCs efforts and their participation within the performance improvement committees. In addition, the projects led to multiple presentations at national conferences.nnnCONCLUSIONSnA dedicated year in performance improvement has benefited our residents with a working knowledge of quality measures and our institution with multiple projects that have yielded significant improvements in the quality of patient care.

Hepatic intraductal oncocytic papillary carcinoma.

The authors report a case of hepatic intraductal oncocytic papillary carcinoma, a very rare subtype of hepatic papillary cholangiocarcinoma with only 8 cases reported so far in the English literature.

Telling the tale of Rapunzel syndrome

Fig 1. Upper gastrointestinal study with oral contrast revealing a mass occupying the stomach and extending through the pylorus into the duodenum. A 26-YEAR-OLD WOMAN was brought to the emergency department with mild abdominal discomfort, increasing nausea, and worsening constipation over the previous several days. She had a history of attention deficit hyperactivity disorder, mild mental retardation, and laparotomy for gastroduodenal trichobezoar at 11 years of age. The physical examination revealed diffuse nonspecific abdominal pain and a firm mass palpable in the epigastric region. Laboratory studies were unremarkable. Abdominal radiography suggested another bezoar, which was confirmed by upper gastrointestinal study with oral contrast (Fig 1). Laparotomy was performed, and a large trichobezoar (490 g) forming a cast of the entire distal esophagus, stomach, and duodenal sweep was removed (Fig 2). She recovered from the surgical procedure without complications and was discharged to home on postoperative day 4 with a recommendation for psychiatric follow-up.

Celiac axis resection for extragastrointestinal stromal tumor

Fig 1. Pre-operative 3-dimensional CT reconstruction. The mass (black arrow) abuts the celiac axis and encases the left gastric artery (white arrow). A 48-YEAR-OLD MAN underwent upper endoscopy for epigastric pain and nausea. Because of endoscopic findings of gastritis and positive biopsy for Helicobacter pylori, he was started on standard triple drug therapy, but failed to respond. His symptoms became more severe and he reported a 10-pound weight loss. Abdominal computed tomography (CT) and magnetic resonance imaging revealed a 3 3 4 cm mass in the gastrohepatic omentum abuting the celiac axis and encasing the left gastric artery (Fig 1). A pre-operative biochemical workup was normal. During exploratory laparotomy, a 5 3 8 cm mass was found to involve the left gastric artery and the celiac axis. Therefore, celiac axis resection was needed to accomplish complete tumor removal (Figs 2 and 3). To test the sufficiency of the collateral blood supply to the liver, a clamp was applied to the common hepatic artery proximal to gastroduodenal artery and proper hepatic artery pulse was verified by Doppler. The tumor was completely mobilized and resected en bloc with the celiac axis. The patient had an uneventful postoperative course with slight elevation of aspartate and alanine aminotransferase levels. Pathologic examination of the specimen demonstrated a mass arranged in solid sheets with myxoid changes and plexiform patterns containing spindle cells with uniform nuclei and ill-defined cytoplasmatic borders. There was no necrosis or lymphovascular invasion. Operative margins were clear of tumor. Immunoperoxidase stains demonstrated positivity for C-kit (CD117), CD34, S-100, and actin. Immunostaining for desmin was negative. The pathologic diagnosis was consistent with extragastrointestinal stromal

Raising The Thinker: New Concept for Dissecting the Cystic Pedicle During Laparoscopic Cholecystectomy

Imprecise dissection due to poor visualization of anatomic structures is among the major causes of biliary injuries during laparoscopic cholecystectomy. Developing new illustrational and rendering techniques represents an important part in decreasing visual deception and subsequent bile duct injuries. We use the model of one of the most well-known pieces of art, Rodins The Thinker, to visualize the gallbladder and cystic pedicle structures. This minimizes visual deception before dissection, especially in cases with obscured structures. Our method, raising The Thinker, is based on the remarkable similarity between the sculpture and the topographic anatomy of the gallbladder. The method can be used not only for better orientation and visualization during laparoscopic cholecystectomy but also as a tool to complement the teaching of laparoscopic biliary anatomy to surgical residents and medical students.