Saxon Connor

Appendiceal tumors: Retrospective clinicopathologic analysis of appendiceal tumors from 7,970 appendectomies

BACKGROUND: Appendiceal tumors are rare and often unexpectedly discovered in an acute situation, in which decision-making is difficult. To help define the most appropriate management, a retrospective analysis was undertaken to describe the clinicopathologic behavior of appendiceal tumors, and the literature was reviewed of the management of the different types of appendiceal tumors. METHOD: From a single center, a histopathologic database of 7,970 appendectomies, all appendiceal tumors, were identified and case notes reviewed. Analysis of clinical presentation, histopathology, operation, and outcome is presented. RESULTS: During a 16-year period (7,970 appendectomies), 74 patients (0.9 percent) with appendiceal tumors were identified: 42 carcinoid, 12 benign, and 20 malignant. Acute appendicitis was the most common presentation (49 percent), and 9.5 percent were incidental findings. Primary malignant tumors of the appendix were found in 0.1 percent of all appendectomies. Secondary malignant disease was identified in the appendix of 11 patients, most commonly (55 percent) from patients with primary colorectal disease. There was a high incidence of synchronous and metachronous colorectal cancer in all appendiceal tumors: carcinoids, 10 percent; benign tumors, 33 percent; secondary malignancies, 55 percent; primary malignancies, 89 percent. CONCLUSION: Appendiceal tumors are uncommon and most often present as appendicitis. Most are benign and can be managed by appendectomy, except adenocarcinomas and carcinoids larger than 2 cm, which are most appropriately managed by right hemicolectomy. A suggested management algorithm is provided. Controversy exists over the management of carcinoids 1 to 2 cm in size and adenocarcinoids. All types of appendiceal tumors have a high incidence of synchronous and metachronous colorectal cancer.

Bile duct injury in the era of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis, but it is associated with a higher incidence of bile duct injury than the open approach.

Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach.

Objective:Comparison of minimal access retroperitoneal pancreatic necrosectomy (MARPN) versus open necrosectomy in the treatment of infected or nonresolving pancreatic necrosis. Summary of Background Data:Infected pancreatic necrosis may lead to progressive organ failure and death. Minimal access techniques have been developed in an attempt to reduce the high mortality of open necrosectomy. Methods:This was a retrospective analysis on a prospective data base comprising 189 consecutive patients undergoing MARPN or open necrosectomy (August 1997 to September 2008). Outcome measures included total and postoperative ICU and hospital stays, organ dysfunction, complications and mortality using an intention to treat analysis. Results:Overall 137 patients underwent MARPN versus open necrosectomy in 52. Median (range) age of the patients was 57.5 (18–85) years; 118 (62%) were male. A total of 131 (69%) patients were tertiary referrals, with a median time to transfer from index hospital of 19 (2–76) days. Etiology was gallstones or alcohol in 129 cases (68%); 98 of 168 (58%) patients had a positive culture at the first procedure. Of the 137 patients, 34 (31%) had postoperative organ failure in the MARPN group, and 39 of 52 (56%) in the open group (P < 0.0001); 59/137 (43%) versus 40/52 (77%), respectively, required postoperative ICU support (P < 0.0001). Of the 137 patients 75 (55%) had complications in the MARPN group and 42 of 52 (81%) in the open group (P = 0.001). There were 26 (19%) deaths in the MARPN group and 20 (38%) following open procedure (P = 0.009). Age (P < 0.0001), preoperative multiorgan failure (P < 0.0001), and surgical procedure (MARPN, P = 0.016) were independent predictors of mortality. Conclusion:This study has shown significant benefits for a minimal access approach including fewer complications and deaths compared with open necrosectomy.

Minimally Invasive Retroperitoneal Pancreatic Necrosectomy

Introduction: Open surgery for pancreatic necrosis is associated with considerable morbidity and mortality. We report the results of a recently developed minimally invasive technique that we adopted in 1998. Methods: A descriptive explanation of the approach is given together with the results of a retrospective analysis of patients who underwent a minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) between August 1998 and April 2002. Patients: There were 24 patients with a median (range) age of 61 (29–75) years. The initial median (range) APACHE II score was 8 (2–21). All patients had infected pancreatic necrosis with at least 50% pancreatic necrosis. In three patients it was not possible to complete the first MIRP because of technical reasons. Results: A total of 88 procedures were performed with a median (range) of 4 (0–8) per patient. Twenty-one (88%) patients developed 36 complications during the course of their illness. Five patients required an additional open procedure: 2 for subsequent distant collections, 2 for bleeding and 1 for persisting sepsis and a distant abscess. Six (25%) patients who had MIRP died. The median (range) post-operative hospital stay was 51 (5–200) days. Conclusions: MIRP is a new technique that has shown promising results, and could be preferable to open pancreatic necrosectomy in selected patients. However, unresolved issues remain to be overcome and the exact role of MIRP in the management of pancreatic necrosis has yet to be defined.

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.

Surgery in the Treatment of Acute Pancreatitis Minimal Access Pancreatic Necrosectomy

Between 5% and 10% of patients with acute pancreatitis will develop infected pancreatic necrosis. Traditional open surgery for this condition carries a mortality rate of up to 50%, and therefore a number of less invasive techniques have been developed, including radiological drainage and a minimal access retroperitoneal approach. No randomised controlled trials have been published which compare these techniques. Indications for minimal access surgery are the same as for open surgery, i.e. infected pancreatic necrosis or failure to improve with extensive sterile necrosis. Access is obtained to the pancreatic necrosis via the left loin and necrosectomy performed using an operating nephroscope, and this often requires several procedures to remove all necrotic tissue. The cavity is continuously irrigated on the ward in between procedures. The results of this approach are encouraging, with less systemic upset to the patient, a lower incidence of post-operative organ failure when compared with open surgery, and a reduced requirement for ITU support. There is also a trend towards a lower mortality rate, although this does not reach statistical significance on the data published so far. Current evidence suggests that a minimal access approach to pancreatic necrosis is feasible, well tolerated and beneficial for the patient when compared with open surgery.

The utility of laparoscopic assessment in the preoperative staging of suspected hilar cholangiocarcinoma

The aim of this study was to review the role of laparoscopic assessment in the staging algorithm of suspected hilar cholangiocarcinoma and to identify factors highly likely to be associated with unresectable disease. Data prospectively collected between 1992 and 2003 were analyzed. Demographics, symptoms, preoperative radiologic staging, laparoscopic assessment, and final outcome were recorded. Yield was defined as the number of unresectable patients detected by laparoscopic assessment divided by the total number of patients undergoing laparoscopic assessment. Accuracy was defined as the number of unresectable patients detected by laparoscopic assessment divided by the total number of unresectable cases. Eighty-four patients underwent laparoscopic assessment for suspected hilar cholangiocarcinoma, of which 20 (23.8%) underwent resection. The yield from laparoscopy alone was 24.3% (20 of 82), which increased to 41.5% (35 of 82) with the addition of intraoperative ultrasound. The overall accuracy was 53.1% (35 of 66). The use of a preoperative radiologic staging system predicted the likelihood of unresectable disease (P = 0.007). The use of laparoscopic assessment in the preoperative staging of patients with suspected hilar cholangiocarcinoma is justified given it will spare 42.2% of patients an unnecessary laparotomy. Accurate staging of cholangiocarcinoma remains a challenge, but the use of a preoperative radiologic staging system may help to stratify a patients risk of unresectable disease.

Diagnosis, Treatment and Outcome of Pancreatoblastoma

Background: Pancreatoblastoma is a rare tumour mainly presenting in childhood but also in adults. Objectives: The aim was to determine the clinical course of pancreatoblastoma by an analysis of reported cases. Methods: Patients with pancreatoblastoma were identified from Medline® and combined with patients identified from the Royal Liverpool University Hospital. Results: There were 153 patients with a median (range) age at presentation of 5 (0–68) years and a male:female ratio of 1.14:1. The most frequent site was the head of pancreas (48/123, 39%). The median and 5-year (95% CI) survival rates were 48 months and 50% (37–62%) respectively. At presentation there were 17 (17%) out of 101 patients with metastases, the liver being the commonest site (15/17, 88%). On univariate analysis, factors associated with a worse prognosis were synchronous (p = 0.05) or metachronous metastases (p < 0.001), non-resectable disease at presentation (p < 0.001) and age >16 years at time of presentation (p = 0.02). On multivariate analysis, resection (p = 0.006) and metastases post-resection (p = 0.001) but not local recurrence influenced survival. Conclusions: Pancreatoblastoma is one of the pancreatic tumours with a relatively good prognosis. The treatment of choice is complete resection with long-term follow-up aiming to treat any early local recurrence or metastasis.

Preoperative lymphocyte count as a prognostic factor in resected pancreatic ductal adenocarcinoma

BACKGROUND AND AIMS Recognized prognostic factors for resected pancreatic ductal adenocarcinoma (PDAC) include tumour size, differentiation, resection margin involvement and lymph node metastases. A further prognostic factor of less certain significance is lymphocyte count. The aim of this study was to investigate whether preoperative lymphocyte count is a prognostic indicator in patients with PDAC. MATERIAL AND METHODS Patients who had undergone a potentially curative pancreaticoduodenectomy (PD) for PDAC between 1998 and 2005 were analysed. Standard prognostic factors, preoperative lymphocyte count, preoperative neutrophil count and survival data were collected. RESULTS Of the 44 patients studied, univariate analysis identified predictors of a poor survival as lymph node status (node positive (+ve) 10.3 [5.4-20.9] months versus node negative (-ve) 14.2 [10.9-31.4] months; p=0.038), posterior resection margin invasion (margin +ve 7.0 [5.1-15.0] months versus margin -ve 13.1 [10.0-28.3] months; p=0.025) and lymphocyte count below the reference range (<1.5 x 10(9)/litre 8.8 [7.0-13.1] months versus > or = 1.5 x 10(9)/litre 14.3 [7.0-28.3] months; p=0.029). Low preoperative lymphocyte count (p=0.027) and posterior margin invasion (p=0.023) retained significance on multivariate analysis. Preoperative neutrophil to lymphocyte ratio was not a significant prognostic factor. CONCLUSION Preoperative lymphocyte count is a significant prognostic factor in patients with PDAC.