Ramesh Singh Bhandari

Perioperative Outcomes of Pancreaticoduodenectomy: Nepalese Experience

BackgroundPancreaticodudenectomy (PD) is a high-risk, technically demanding operation associated with substantial perioperative morbidity and mortality. This review is intended to evaluate the perioperative outcomes of PD done in a single gastrointestinal surgery unit of a university teaching hospital.Patients and methodsA retrospective review of medical records of patients who underwent PD from April 2005 through May 2009 was done. Perioperative morbidity was defined according to the standard of the International Study Group for Pancreatic Fistula (ISGPF). The patient demographics, type of surgery, and perioperative morbidity and mortality were evaluated. The factors associated with increased morbidity were analyzed.ResultsTwenty-four patients underwent PD, and there were no perioperative deaths. The overall morbidity was 58%, with a pancreatic fistula rate of 13%. None of the associated parameters, like increasing age, the presence of co-morbidity, preoperative biliary drainage, and duration of surgery, were found to increase the morbidity. These results of PD, though a small case series, are comparable to the international standard. Better outcomes can be achieved even in low- to medium-volume centers in developing countries where a dedicated team with special interest in pancreatic surgery is in place.ConclusionsAlthough there were no deaths after PD in our series, the morbidity was higher than that observed in other high-volume centers. To decrease the morbidity associated with PD, various factors must be streamlined, among them, the operative technique and the intensive perioperative management of the patient, as well as uniform definition of complications, use of a multidisciplinary approach, and identification of associated risk factors.

From minimal to maximal surgery in the treatment of hepatocarcinoma: A review

Hepatocellular carcinoma represents one of the most challenging frontiers in liver surgery. Surgeons have to face a broad spectrum of aspects, from the underlying liver disease to the new surgical techniques. Safe liver resection can be performed in patients with portal hypertension and well-compensated liver function with a 5-year survival rate of 50%, offering good long-terms results in selected patients. With the advances in laparoscopic surgery, major liver resections can be performed with minimal harm, avoiding the wound and leak complications related to the laparotomies. Studies have shown that oncological margins are the same as in open surgery. In patients submitted to liver resection (either laparoscopic or open) who experience recurrence, re-resection or salvage liver transplantation has been showing to be an alternative approach in well selected cases. The decision making approach to the cirrhotic patient is becoming more complex and should involve hepatologists, liver surgeons, radiologists and oncologists. Better understanding of the different risk factors for recurrence and survival should be aimed in these multidisciplinary discussions. We here in discuss the hot topics related to surgical risk factors regarding the surgical treatment of hepatocellular carcinoma: anatomical resection, margin status, macrovascular tumor invasion, the place of laparoscopy, salvage liver transplantation and liver transplantation.

Continuous dunking pancreaticojejunostomy: our experience with first fifty cases

Introduction- Different techniques and modifications have been described to bring down the incidence of pancreatic fistula rate. However, no techniques have been accepted as a gold standard. Since 2011, we have been performing pancreaticojejunostomy by continuous dunking technique. Here, we intend to present our experience with the defined technique. Methods: Prospectively maintained medical records of the patients (operated between Sept 2011 to Jan 2016) undergoing pancreaticoduodenectomy and pancreaticoenteric reconstruction by continuous dunking techniques were reviewed and analyzed. Postoperative complications mainly, incidence of post pancreatectomy fistula (POPF), hemorrhage (PPH) and delayed gastric emptying (DGE) along with other major complications were analyzed. Subgroup analysis was also performed to find the difference in fistula rate in patients with or without addition of Braun’s anastomosis. ISGPS definition was used to define the major, surgery specific complications of pancreaticoduodenectomy. Results: Total 51 patients underwent pancreaticojejunostomy with the defined technique with Male to female ratio of 23:28. Total 13.7% (7/51) patients received preoperative biliary drainage. Overall, clinically significant fistula rated was 15.6% (8/51), PPH 13.7% (7/51) and 0% clinically significant DGE (overall DGE 13.7%, 7/51). Mortality rate was 5.8% (3/51). Subgroup analysis performed between patients with or without addition of Braun’s anastomosis revealed 0% clinically significant fistula rate with no mortality in the group. Conclusion: Surgery specific complications following pancreaticoduodenectomy and pancreaticoenteric reconstruction with our technique are comparable to published results from high volume centers. Addition of Braun’s anastomosis is a promising modification to bring down the POPF rate to a minimum.

Managing ampullary tumors: Our experience at University Teaching Hospital

Background: Ampullary tumors have been usually described together with other periampullary tumors. However, they have been found to behave differently in terms of their presentation, management, and perioperative outcomes. In this study, we try to analyze our experience in managing ampullary tumors in the tertiary level university teaching hospital. Materials and Methods: Retrospective review of the patients with ampullary tumors managed surgically over 10 years period (2004 January-2013 December) was carried out. Demographics, preoperative parameters, therapeutic procedures, postoperative morbidity and mortality were reviewed, and overall morbidity and mortality were compared with nonampullary group. Results: A total of 74 patients of ampullary tumors were managed over the study period. Jaundice was present in 65 (92.9%) patients at presentation. Pancreaticoduodenectomy (PD) was performed in 70 (66% of total PDs performed in the same period) cases while 4 patients had palliative bypass. There were no endoscopic resections and transduodenal ampullectomy in our series. On postoperative histology, two patients were found to have benign pathology. Postpancreatectomy fistula (30% vs. 11.1%) and other morbidities such as intra-abdominal collection and surgical site infection were higher in ampullary group. Mortality was comparable in both groups but overall mortality was higher than the published series. Conclusion: In tertiary centers of developing nations like ours, PD is still the main surgical procedure offered to the ampullary tumors. Ampullary tumors have higher perioperative morbidity than the nonampuallry group but have comparable mortality rates.