S. M. M. de Castro

Incidence and management of pancreatic leakage after pancreatoduodenectomy

Optimal management of severe pancreatic leakage after pancreatoduodenectomy can reduce morbidity and mortality. Completion pancreatectomy may be adequate but leads to endocrine insufficiency. This study evaluated an alternative management strategy for pancreatic leakage.

Preoperative Biliary Drainage in Patients with Obstructive Jaundice: History and Current Status

RationalePreoperative biliary drainage (PBD) has been introduced to improve outcome after surgery in patients suffering from obstructive jaundice due to a potentially resectable proximal or distal bile duct/pancreatic head lesion. In experimental models, PBD is almost exclusively associated with beneficial results: improved liver function and nutritional status; reduction of systemic endotoxemia; cytokine release; and, as a result, an improved immune response. Mortality was significantly reduced in these animal models. Human studies show conflicting results.FindingsFor distal obstruction, currently the “best-evidence” available clearly shows that routine PBD does not yield the appreciated improvement in postoperative morbidity and mortality in patients undergoing resection. Moreover, PBD harbors its own complications. However, most of the available data are outdated or suffer from methodological deficits.ConclusionThe highest level of evidence for PBD to be performed in proximal obstruction, as well as over the preferred mode, is lacking but, nevertheless, assimilated in the treatment algorithm for many centers. Logistics and waiting lists, although sometimes inevitable, could be factors that might influence the decision to opt for PBD, as well as an extended diagnostic workup with laparoscopy (on indication) or scheduled preoperative chemotherapy.

A systematic review of the efficacy of gum chewing for the amelioration of postoperative ileus

Background: Recent trials have shown promising results for the efficacy of gum chewing for the amelioration of postoperative ileus. This finding could have a major clinical impact since gum chewing is relatively harmless and cheap while postoperative ileus has a significant impact on healthcare. Methods: Systematic review and meta-analysis of randomized controlled trials comparing the efficacy of gum chewing after colorectal surgery to a standard control for the amelioration of postoperative ileus, expressed as time to flatus, time to defecation and overall hospital stay. Results: Five randomized controlled trials with a total number of 158 patients were found. The studies were homogeneous and a meta-analysis was performed. The pooled weighted mean difference (WMD) of time to flatus was significantly shorter for the gum-chewing group (20 h with a 95% confidence interval (CI) of 13–27). The pooled WMD of time to defecation was significantly shorter (29 h, 95% CI of 19–39). There was a non-significant trend towards a shorter postoperative hospital stay (1.3 days shorter, 95% CI of 3.2 days shorter to 0.6 days longer). Conclusion: This meta-analysis shows a favorable effect of gum chewing on time to flatus and defecation but no significant effect on the hospital stay.

Evaluation of the Appendicitis Inflammatory Response Score for Patients with Acute Appendicitis

BackgroundAcute appendicitis is still a difficult diagnosis. Scoring systems are designed to aid in the clinical assessment of patients with acute appendicitis. The Alvarado score is the most well known and best performing in validation studies. The purpose of the present study was to externally validate a recently developed appendicitis inflammatory response (AIR) score and compare it to the Alvarado score.MethodsThe present study selected consecutive patients who presented with suspicion of acute appendicitis between 2006 and 2009. Variables necessary to evaluate the scoring systems were registered. The diagnostic performance of the two scores was compared.ResultsThe present study included 941 consecutive patients with suspicion of acute appendicitis. There were 410 male patients (44%) and 531 female patients (56%). The area under the receiver operating characteristic curve of the AIR score was 0.96 and significantly better than the area under the curve of 0.82 of the Alvarado score (pxa0<xa00.05). The AIR score also outperformed the Alvarado score when analyzing the more difficult patients, including women, children, and the elderly.ConclusionsThis study externally validates the AIR Score for patients with acute appendicitis. The scoring system has a high discriminating power and outperforms the Alvarado score.Acute appendicitis is still a difficult diagnosis. Scoring systems are designed to aid in the clinical assessment of patients with acute appendicitis. The Alvarado score is the most well known and best performing in validation studies. The purpose of the present study was to externally validate a recently developed appendicitis inflammatory response (AIR) score and compare it to the Alvarado score. The present study selected consecutive patients who presented with suspicion of acute appendicitis between 2006 and 2009. Variables necessary to evaluate the scoring systems were registered. The diagnostic performance of the two scores was compared. The present study included 941 consecutive patients with suspicion of acute appendicitis. There were 410 male patients (44%) and 531 female patients (56%). The area under the receiver operating characteristic curve of the AIR score was 0.96 and significantly better than the area under the curve of 0.82 of the Alvarado score (pxa0<xa00.05). The AIR score also outperformed the Alvarado score when analyzing the more difficult patients, including women, children, and the elderly. This study externally validates the AIR Score for patients with acute appendicitis. The scoring system has a high discriminating power and outperforms the Alvarado score.

Pancreas-preserving total duodenectomy versus standard pancreatoduodenectomy for patients with familial adenomatous polyposis and polyps in the duodenum†

Pancreas‐preserving total duodenectomy (PPTD) was introduced as a replacement for pancreatoduodenectomy (PD) for familial adenomatous polyposis (FAP). This study analysed the results of PPTD in the Netherlands and reviewed the relevant literature.

Diagnostic laparoscopy for primary and secondary liver malignancies: impact of improved imaging and changed criteria for resection.

BackgroundDiagnostic laparoscopy (DL) combined with laparoscopic ultrasonography (LUS) has previously shown positive results as a staging modality for liver malignancies. Recent improvements in noninvasive diagnostic imaging techniques such as multiphasic spiral computed tomography, together with the policy that bilobar disease or the number of lesions is no longer considered an absolute exclusion criterion for curative resection, could reduce the additional value of DL. This study retrospectively analyzed the efficacy of DL combined with LUS for liver malignancies to assess the effect of improved imaging and changed criteria for resection.MethodsAll patients with primary or metachronous secondary liver malignancy eligible for resection in 1997 to 2002 were included.ResultsDL combined with LUS was performed in 84 consecutive patients (56 men and 28 women; mean age, 59 years) with primary (n = 33) or secondary (n = 51) liver malignancies. DL showed unresectability in 13 patients (39%) with primary malignancy. Exploratory laparotomy showed that an additional 5 (25%) of the remaining 20 patients had unresectable disease. DL showed unresectability in 5 patients (12%) with colorectal liver metastasis (n = 43). At laparotomy, another 7 (18%) of the remaining 38 patients had unresectable disease. In five patients (13%) from the latter group, LUS could not be performed because of adhesions from previous surgery.ConclusionsDL combined with LUS is an adequate staging modality for primary liver malignancies. For colorectal liver metastasis, more liberal resection criteria, a high failure rate due to adhesions from previous surgery, and better preoperative imaging probably resulted in a lower efficacy.

Evaluation of O-POSSUM in predicting in-hospital mortality after resection for oesophageal cancer†

The aims of the present study were to validate the Physiological and Operative Severity Score for the enUmeration of Mortality adjusted for oesophagogastric surgery (O‐POSSUM).

Prognostic nomogram for patients undergoing oesophagectomy for adenocarcinoma of the oesophagus or gastro-oesophageal junction

Tumour node metastasis (TNM) staging predicts survival on the basis of the pathological extent of a tumour. The aim of this study was to develop a prognostic model with improved survival prediction after oesophagectomy.

Evaluation of POSSUM for Patients Undergoing Pancreatoduodenectomy

BackgroundComparison of operative morbidity rates after pancreatoduodenectomy between units may be misleading because it does not take into account the physiological variable of the condition of the patients. The aim of the present study was to evaluate the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) for pancreatoduodenectomy patients and to look for risk factors associated with morbidity in a high-volume center.MethodsBetween January 1993 and April 2006, 652 patients underwent a pancreatoduodenectomy, 502 of them for malignant disease. POSSUM performance was evaluated by assessing the “goodness-of-fit” with the linear analysis method.ResultsOverall, 332 of the 652 patients (50.9%) had one or more complication after pancreatoduodenectomy, and 9 patients (1.4%) died. POSSUM had a significant lack of fit using goodness-of-fit analysis. In multivariate analysis, one statistically significant factor associated with morbidity and not incorporated in POSSUM (Pxa0<xa00.05) was identified: ampulla of Vater adenocarcinoma (ORxa0=xa01.73, 95% CI: 1.07–2.80).ConclusionsOverall, there is a lack of calibration of POSSUM among patients who undergo pancreatoduodenectomy.

Validation of a nomogram for predicting survival after resection for adenocarcinoma of the pancreas

Nomograms are statistical tools providing the overall probability of a specific outcome; they have shown better individual discrimination than the tumour node metastasis staging system in several cancers. The pancreatic nomogram, originally developed in the Memorial Sloan–Kettering Cancer Center (MSKCC) in the USA, combines clinicopathological and operative data to predict disease‐specific survival at 1, 2 and 3 years from initial resection.