Tirupporur Govindaswamy Balachandar

Post pancreaticoduodenectomy haemorrhage: outcome prediction based on new ISGPS Clinical severity grading

UNLABELLED OBJECTIVE & BACKGROUND DATA: Mortality following pancreatoduodenectomy (PD) has fallen below 5%, yet morbidity remains between 30 and 50%. Major haemorrhage following PD makes a significant contribution to this ongoing morbidity and mortality. The aim of the present study was to validate the new International Study Group of Pancreatic Surgery (ISGPS) Clinical grading system in predicting the outcome of post pancreaticoduodenectomy haemorrhage (PPH). MATERIAL AND METHODS Between January 1998 and December 2007 a total of 458 patients who underwent Whipples pancreaticoduodenectomy in our department were analysed with regard to haemorrhagic complications. The onset, location and severity of haemorrhage were classified according to the new criteria developed by an ISGPS. Risk factors for haemorrhage, management and outcome were analysed. RESULTS Severe PPH occurred in 14 patients (3.1%). Early haemorrhage (<24 hours) was recorded in five (36%) patients, and late haemorrhage (>24 hours) in nine (64%) patients. As per Clinical grading of ISGPS 7 (50%) belongs to Grade C and 7 (50%) belongs to Grade B. Haemostasis was attempted by surgery in 10 (71%) patients; angioembolisation was successful in two (14%) and endotherapy in one (7%) patient. The overall mortality is 29%(n=4). Age >60 years (p=0.02), sentinel bleeding (p=0.04), pancreatic leak (p=0.04) and ISGPS Clinical grade C (p=0.02) were associated with increased mortality. CONCLUSION Early haemorrhage was mostly managed surgically with better outcome when endoscopy is not feasible. Late haemorrhage is associated with high mortality due to pancreatic leak and sepsis. ISGPS Clinical grading of PPH is useful in predicting the outcome.

CENTRAL PANCREATECTOMY FOR BENIGN PANCREATIC PATHOLOGY/TRAUMA: IS IT A REASONABLE PANCREAS‐PRESERVING CONSERVATIVE SURGICAL STRATEGY ALTERNATIVE TO STANDARD MAJOR PANCREATIC RESECTION?

Background:  The aim of this study was to assess the technical feasibility, safety and outcome of central pancreatectomy (CP) with pancreaticogastrostomy or pancreaticojejunostomy in appropriately selected patients with benign central pancreatic pathology/trauma. Benign lesions/trauma of the pancreatic neck and proximal body pose an interesting surgical challenge. CP is an operation that allows resection of benign tumours located in the pancreatic isthmus that are not suitable for enucleation.

Haemosuccus pancreaticus: diagnostic and therapeutic challenges

BACKGROUND Haemosuccus pancreaticus (HP) is a rare cause of upper gastrointestinal bleeding. The objective of our study was to highlight the challenges in the diagnosis and management of HP. METHODS The records of 31 patients with HP diagnosed between January 1997 and June 2008 were reviewed retrospectively. RESULTS Mean patient age was 34 years (11-55 years). Twelve patients had chronic alcoholic pancreatitis, 16 had tropical pancreatitis, two had acute pancreatitis and one had idiopathic pancreatitis. Selective arterial embolization was attempted in 22 of 26 (84%) patients and was successful in 11 of the 22 (50%). Twenty of 31 (64%) patients required surgery to control bleeding after the failure of arterial embolization in 11 and in an emergent setting in nine patients. Procedures included distal pancreatectomy and splenectomy, central pancreatectomy, intracystic ligation of the blood vessel, and aneurysmal ligation and bypass graft in 11, two, six and one patients, respectively. There were no deaths. Length of follow-up ranged from 6 months to 10 years. CONCLUSIONS Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. Diagnosis is based on investigations that should be performed in all patients, preferably during a period of active bleeding. These include upper digestive endoscopy, contrast-enhanced computed tomography (CECT) and selective arteriography of the coeliac trunk and superior mesenteric artery. Contrast-enhanced CT had a high positive yield comparable with that of selective angiography in our series. Therapeutic options consist of selective embolization and surgery. Endovascular treatment can control unstable haemodynamics and can be sufficient in some cases. However, in patients with persistent unstable haemodynamics, recurrent bleeding or failed embolization, surgery is required.

Factors affecting outcome after Frey procedure for chronic pancreatitis

BACKGROUND Debilitating abdominal pain remains the most common presentation of chronic pancreatitis and the treatment remains challenging. OBJECTIVE This prospective study analyzed the outcome of Freys procedure in patients with inflammatory head mass. METHODS For the period between 2002 and 2007, 77 patients with chronic pancreatitis underwent Frey procedure for intractable abdominal pain. The mean follow-up was 14 months. For the purpose of analysis of the outcome, patients were grouped as poor pain control (19%) and good pain control groups (81%) based on the pain scores during follow-up. RESULTS There was no 30-day mortality. The logistic regression analysis showed that decreased volume percentage (48%) of head mass resected (p=0.003) and small diameter of the pancreatic duct (p=0.05) were associated with poor pain outcome. Subgroup analysis revealed that patients with small duct disease were associated with increased operative time (p=0.001), poor pain scores (p=0.001), and increased weight loss (p=0.003) during follow-up. CONCLUSIONS Frey procedure can be performed with zero mortality and low morbidity in a high-volume center. It provides good pain relief in majority of the patients. Volume of the head mass cored affects pain outcome. Correlation between poor results in terms of pain relief and weight loss following Freys procedure, and small duct disease supports the view that duct diameter is an important predictor of pain relief.

Management of Esophageal Perforation: Experience from a Tertiary Center in India

Background/Aim: The management of esophageal perforations remains controversial in large part due to variability in etiology, time of presentation, location, and underlying esophageal disease. We reviewed our experience in treating patients with esophageal perforations and evaluated the etiology, management and outcome of intervention in a tertiary center. Methods: Between 1999 and 2007, 48 patients with esophageal perforation were treated in a tertiary referral center in southern India. Postdilatation corrosive stricture perforations constituted the major etiology. Results: Thirty (62.5%) patients were diagnosed early (<24 h) and the remaining 18 (37.5%) were late (>24 h). The 30-day mortality was 6.2%, and mean hospital stay was 13 ± 9.3 days. Comparing outcomes between early and late groups, statistically significant difference was observed, with increased mortality (p = 0.02) and hospital stay (p = 0.04) following late diagnosis. Conclusion: This report suggests that early diagnosis decreases mortality and hospital stay in esophageal perforation. Preservation of esophagus may be attempted while treating esophageal perforations.

Management of post dilatation oesophageal perforation: an experience from a tertiary centre

BackgroundTreatment of oesophageal perforation remains controversial. This study shows that native oesophagus should be preserved. Early recognition improves survival.AimThe aim of this study was to evaluate the outcome of management of post dilatation oesophageal perforation in a tertiary centre.MethodsBetween 1999 and 2007, 35 patients with oesophageal perforation following dilatation were treated. Post dilatation corrosive stricture perforations constituted the major aetiology.ResultsTwenty-four (69%) underwent early intervention (< 24 hours) and the remaining 11 (31%) were late (>24 hours). The 30-day mortality was found to be 9%, and mean hospital stay was 14 ± 14.7 days. Comparing outcomes between early and late groups, statistically significant difference was observed, with increased mortality (p=0.001) and hospital stay (p=0.001) following late intervention.ConclusionEarly intervention decreases mortality and hospital stay in oesophageal perforation and preservation of oesophagus may be attempted, as native oesophagus is the best conduit.