Stephanie H. Y. Lau

Measures to Prevent Pancreatic Fistula After Pancreatoduodenectomy: A Comprehensive Review

OBJECTIVE To review the current evidence on the efficacy of various interventions directed toward prevention of pancreatic fistula after pancreatoduodenectomy. DATA SOURCES A MEDLINE database search from January 1, 1990, to August 31, 2008, was performed to identify relevant articles using the keywords pancreatoduodenectomy, pancreaticojejunostomy, pancreaticogastrostomy, pancreatic anastomotic leakage, and pancreatic fistula. Additional articles were identified by a manual search of the references from the key articles. STUDY SELECTION Case reports were excluded from this study. DATA EXTRACTION Of the identified studies, only those published in English describing meta-analyses or randomized controlled trials were considered first. In those aspects with limited or no randomized controlled trials, nonrandomized comparative studies and case series were included also. DATA SYNTHESIS The prophylactic use of perioperative somatostatin and its analogues to prevent pancreas-related complications after pancreatic surgery remains controversial and does not result in a reduction of operative mortality. There is no clear evidence for or against a particular type of pancreaticoenteric anastomosis. Pancreaticoenterostomy cannot be replaced by pancreatic ductal obliteration. Pancreaticogastrostomy is equivalent to pancreaticojejunostomy in perioperative morbidity and mortality. CONCLUSION More large-scale comparative studies and randomized controlled trials are required to determine the optimum pharmacologic interventions and technique of pancreaticoenteric anastomosis after pancreatoduodenectomy.

Management of bile duct injury after laparoscopic cholecystectomy: a review.

Background:  Bile duct injury following cholecystectomy is an iatrogenic catastrophe which is associated with significant perioperative morbidity and mortality, reduced long‐term survival and quality of life, and high rates of subsequent litigation. The aim of this article was to review the management of bile duct injury after cholecystectomy.

A ruptured recurrent small bowel gastrointestinal stromal tumour causing hemoperitoneum

Hemoperitoneum is a rare and potentially life-threatening complication of GIST. We reported a 54-year-old man who developed disseminated intra-abdominal recurrence from a previously resected gastrointestinal stromal tumour (GIST) of the small bowel, and the patient presented with hemoperitoneum. Emergent debulking surgery was performed. A high dose imatinib was prescribed. Despite the presence of residual disease, the patient was well clinically 8 months after the operation. Even though, there is no evidence to support the routine use of debulking surgery in the management of GIST. In our patient, disease progression after second line targeted therapy and the absence of alternative treatment options for spontaneous rupture and hemoperitoneum prompted us to treat the patient aggressively. Resection of the ruptured GIST was carried out for control of bleeding and to prevent recurrent bleeding in this patient with good surgical risks. During the treatment decision-making, the patient’s general condition, the risk of surgery and the extent of dissemination were taken into consideration. In this patient who presented with spontaneous rupture of a small intestinal GIST, the novel use of targeted therapy and aggressive surgical treatment produced reasonably good survival outcome.

Laparoscopic and Open RFA

Tumor diameter, number and position, liver function, and general health of a patient must be considered when evaluating radiofrequency ablation (RFA) for hepatocellular carcinoma. There are three primary approaches to RFA: percutaneous, laparoscopic, and open. The main goal in each of the RFA approaches is capability of safely achieving complete tumor ablation with adequate ablation margins. The choice of the different approaches for RFA should be tailored to the individual patient according to the tumor volume and location.

Anatomy in Liver Resection

The position of the liver varies according to the posture of the body. In erect posture in adult male, the edge of the liver projects about 1 cm below the lower margin of the right costal cartilages, and its inferior margin can often be felt in this situation if the abdominal wall is thin. In supine position, the liver recedes above the margin of the ribs and it cannot be detected by palpation. Its position varies with respiratory movements; during deep inspiration, it descends below the ribs; in expiration it rises. In male, the liver weighs from 1.4 to 1.6 kg, while in female, the liver weighs from 1.2 to 1.4 kg.

Peri-RFA Care and Management of Complications

Radiofrequency ablation (RFA) to treat primary and secondary hepatic malignancies have gained widespread acceptance over the past 10 years. RFA of hepatic tumors can now be performed with low morbidity and mortality rates. Clinicians performing RFA must recognize early and late complications of RFA so as to intervene with appropriate treatment early.

Anatomical Liver Resection

In 1952, Lortat-Jacob reported the first successful anatomic right hepatectomy for cancer [1]. It is through better understanding of hepatic segmental anatomy and refinements in intraoperative ultrasound (IOUS) that anatomical segment-based liver resection gradually matures in the past 30 years [2–5]. Segment-based liver resection allows maximal preservation of non-tumorous liver parenchyma while achieving adequate tumor resection margins. Segment-based liver resection then further develops into subsegment-based liver resection.

Initial Clinical Assessment and Patient Selection

For many years, partial hepatectomy and liver transplantation have been considered as the only forms of curative treatment for hepatocellular carcinoma (HCC). Unfortunately, only 10–20 % of HCC is resectable. Anatomic location, size or number of lesions, inadequate liver remnant, or comorbid conditions preclude surgery in the majority of patients. Orthotopic liver transplantation can cure some patients with poor liver function due to underlying cirrhosis, but few patients are eligible because of advanced stage of HCC at initial diagnosis and because of scarcity of liver donors, especially in some parts of the world. Currently, radiofrequency ablation (RFA) is commonly used in patients with small HCC confined to the liver, especially when the tumors are unresectable because of poor general condition of the patients or because of compromised liver function. Using RFA as a bridge to liver transplantation results in low treatment morbidity and favorable HCC responses and reduces drop-out rate of patients while on the liver transplant waiting list due to HCC progression. Local ablative therapy now competes with partial hepatectomy and liver transplantation as the primary treatment for patients with small HCC. The application of RFA has a number of potential advantages in patients with HCC. The procedure is relatively safe and well tolerated, and its complication rates in most reported series are low. Data have accumulated to support the safety and effectiveness of RFA in selected patients. To achieve good treatment outcomes, proper clinical assessment and patient selection are important. This chapter introduces the clinical assessment and patient selection for RFA [1].