Pancreaticoduodenectomy with preoperative obstructive jaundice: drainage or not

Preoperative biliary drainage for pancreatic cancer

Pancreatic adenocarcinoma is currently one of the leading causes of cancer-related morbidity and mortality with dismal long term survival after diagnosis. Nearly 85% of pancreatic cancer patients present with advanced disease precluding curative surgical resection. In those who are candidates for surgery, preoperative biliary drainage (PBD) has been developed since the 1960s in order to improve surgical outcomes. While obstructive jaundice in resectable pancreatic cancer has been traditionally treated before surgical resection in all patients, data over the past decade demonstrated increased perioperative complications and morbidity with systematic PBD compared to direct surgery. With new evidence of potential adverse events, the role of routine PBD is being reassessed. Current indications for PBD include cholangitis, delayed surgery, and relief of jaundice in patients planned to receive neoadjuvant therapy (NAT). NAT is being increasingly utilized in borderline resectable as well as resectable pancreatic cancer and a higher proportion of patients with likely require PBD in the future. The evidence for endoscopic retrograde cholangiopancreatography as first line for PBD is robust with supporting data from endoscopic ultrasound assisted biliary drainage. Self-expanding metal stent was shown to be cost-effective in recent studies without increase in morbidity compared to plastic stents in this setting. In this review, we will summarize the current evidence for PBD in patients with pancreatic cancer.

Efficacy and safety of preoperative biliary drainage in patients undergoing pancreaticoduodenectomy: an updated systematic review and meta-analysis

OBJECTIVES

This study aimed to evaluate the effect of preoperative biliary drainage (PBD) on outcomes of pancreaticoduodenectomy (PD) in patients with biliary obstruction.

METHODS

We searched PubMed, EMBASE, Cochrane library, and Web of Science from database inception to 11 March 2021. We used the ROBINS-I tool and Cochrane risk of bias tool 2.0 to assess the risk of bias. The data were statistically analyzed using the RevMan software (Version 5.4).

RESULTS

In all, 43 studies, including 23,076 patients, were analyzed, of which 13,922 patients were treated with PBD and 9154 were treated with no preoperative biliary drainage (NPBD). The morbidity     , infection morbidity      , and postoperative pancreatic fistulae (POPF)       in patients undergoing PBD, were significantly higher than those in patients undergoing NPBD. Further, PBD may lead to a significantly worse 2- and 3-year overall survival (OS) rates           . In subgroup meta-analysis, the differences in morbidity, POPF, and OS outcomes lost significance between the PBD and NPBD groups when the mean total serum bilirubin (TSB) concentration was below 15 mg/dl.

CONCLUSIONS

Routine PBD still cannot be recommended because it showed no beneficial effect on postoperative outcomes. However, in patients with < 15 mg/dl TSB concentration, PBD tends to be a better choice.

Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer

Simple Summary

Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life.

Abstract

Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.

Risk factors for delayed hemorrhage after endoscopic sphincterotomy

BACKGROUND

Hemorrhage is one of the most serious complications of endoscopic sphincterotomy (EST). The risk factors for delayed hemorrhage are not clear. This study aimed to explore the risk factors for post-EST delayed hemorrhage and suggest some precautionary measures.

METHODS

This study analyzed 8477 patients who successfully underwent endoscopic retrograde cholangiopancreatography (ERCP) and EST between January 2007 and June 2015 in the First Affiliated Hospital of Nanchang University. Univariate and multivariate analyses were performed to find the risk factors for delayed hemorrhage after EST.

RESULTS

Of the 8477 patients screened, 137 (1.62%) experienced delayed hemorrhage. Univariate analysis showed that male, the severity of jaundice, duodenal papillary adenoma and carcinoma, diabetes, intraoperative bleeding, moderate and large incisions, and directional deviation of incision were risk factors for post-EST delayed hemorrhage (P < 0.05). Multivariate analysis showed that intraoperative bleeding [odds ratio (OR) = 3.326; 95% CI: 1.785-6.196; P < 0.001] and directional deviation of incision (OR = 2.184; 95% CI: 1.266-3.767; P = 0.005) were independent risk factors for post-EST delayed hemorrhage.

CONCLUSIONS

Delayed hemorrhage is the most common and dangerous complication of EST. Intraoperative bleeding and directional deviation of incision are independent risk factors for post-EST delayed hemorrhage.

Clinical Impact of Preoperative Cholangitis after Biliary Drainage in Patients who Undergo Pancreaticoduodenectomy on Postoperative Pancreatic Fistula

The objective of this study was to examine whether the development of cholangitis after preoperative biliary drainage (PBD) can increase the incidence of postoperative pancreatic fistula (POPF). The study population included 185 consecutive patients who underwent pancreaticoduodenectomy from April 2006 to March 2011. All patients were divided into two groups, which consisted of a “no PBD” group (73 patients) and a PBD group (112 patients). Moreover, the PBD group was divided into a “cholangitis” group (21 patients) and a “no cholangitis” group (91 patients). Clinical background, clinical outcome, and postoperative complications were compared between groups. All patients received prophylactic antibiotics using cefmetazole until 1 or 2 days postoperatively. There was no difference between noncholangitis and non-PBD groups except the frequency of overall POPF. Clinically relevant POPF and drain infection occurred in the cholangitis group significantly more than in the noncholangitis group ( P < 0.05). Univariate and multivariate analyses showed that development of preoperative cholangitis after preoperative biliary drainage and small pancreatic duct (less than 3 mm diameter) were independent risk factors for clinically relevant POPF. The frequency of clinically relevant POPF was 8 per cent (eight of 99) in patients without two risk factors, 19 per cent (15 of 80) in patients with one risk factor, and 50 per cent (three of six) in patients with both risk factors. The development of preoperative cholangitis after PBD was closely associated with the development of clinically relevant POPF under the limited use of prophylactic antibiotics.

[Malignant obstructive jaundice management via external biliary drainage followed by bile examination]

AIM

To determine optimal terms of biliary decompression and bile reinfusion into gastrointestinal tract in patients with malignant obstructive jaundice.

MATERIAL AND METHODS

179 medical records of patients with obstructive jaundice were analyzed to identify risk factors of postoperative complications. Prospective research included bile examination in 34 patients with malignant obstructive jaundice. New algorithm of preoperative management was proposed.

RESULTS

Hyperbilirubinemia over 50 μmol/l prior to radical surgery and 80 μmol/l before palliative surgery was followed by postoperative morbidity augmentation from 42.1% to 66.7% and from 11.1% to 37.5%, respectively. Normal AST and ALT concentration after biliary decompression was noted after 13.63±2.39 days. Total bilirubin level in the bile was the same within 5 days after external drainage and bile reinfusion into gastrointestinal tract after 1-2 day was associated with advanced intoxication. New approach is associated with reduced postoperative morbidity from 37.9% to 26.5% (p<0.05) and mortality from 5.5% to 2.9%, respectively (p<0.05).

CONCLUSION

Duration of biliary decompression should be at least 13.63±2.39 days to reduce postoperative morbidity and mortality. Bile reinfusion into gastrointestinal tract should be started in 5-6 days after decompression.

[Management of patients with malignant obstructive jaundice using bile examination after external biliary drainage]

AIM

To determine optimal time of biliary tract decompression and bile reinfusion into gastrointestinal tract in patients with malignant obstructive jaundice.

MATERIAL AND METHODS

179 medical records of patients with obstructive jaundice were analyzed in order to identify risk factors of postoperative complications. Prospective trial included bile examination in 34 patients with malignant obstructive jaundice. The new algorithm of preoperative preparation of patients was proposed using these data.

RESULTS

Preoperative hyperbilirubinemia over 50 μmol/l before radical surgery and over 80 μmol/l before palliative surgery is followed by increase of postoperative morbidity from 42.1 to 66.7% and from 11.1 to 37.5%, respectively. The concentration of AST and ALT approaches the norm in 13.63±2.39 days after decompression. Five-day period after external drainage is characterized by the same level of overall bilirubin in the bile while bile reinfusion into gastrointestinal tract after 1-2 days leads to advanced symptoms of intoxication. The proposed tactics allows to reduce postoperative morbidity from 36.9 to 26.5% (p<0.05) and mortality from 5.5 to 2.9%, respectively (p<0.05).

CONCLUSION

Duration of biliary decompression should be at least 13.63±2.39 days to reduce postoperative morbidity and mortality. Bile reinfusion into gastrointestinal tract should be started in 5-6 days after decompression.

Developing and validating a center-specific preoperative prediction calculator for risk of pancreaticoduodenectomy

BACKGROUND

The American College of Surgeons (ACS) Surgical Risk Calculator predicts postoperative risk based on preoperative variables. The ACS model was compared to an institution-specific risk calculator for pancreaticoduodenectomy (PD).

METHODS

Observed outcomes were compared with those predicted by the ACS and institutional models. Receiver operating characteristic (ROC) analysis evaluated the models' predictive ability. Institutional models were evaluated with retrospective and prospective internal validation.

RESULTS

Brier scores indicate equivalent aggregate predictive ability. ROC values for the institutional model (ROC: 0.675-0.881, P < 0.01) indicate superior individual event occurrence prediction (ACS ROC: 0.404-0.749, P < 0.01-0.860). Institutional models' accuracy was upheld in retrospective (ROC: 0.765-0.912) and prospective (ROC: 0.882-0.974) internal validation.

CONCLUSIONS

Identifying higher-risk patients allows for individualized care. While ACS and institutional models accurately predict average complication occurrence, the institutional models are superior at predicting individualized outcomes. Predictive metrics specific to PD center volume may more accurately predict outcomes.

Current status of preoperative biliary drainage

Preoperative biliary drainage (PBD) has been thought to be preferable regardless of the site of biliary strictures, e.g., distal or proximal strictures because PBD by endoscopy or interventional radiology decreases postoperative mortality and morbidity rates. However, recently, several studies have revealed that PBD strategy showed an increased mortality rate or a high frequency of surgical site infection. Herein, we reviewed reports in the literature regarding the current status of PBD and investigated the effects of PBD on patients with distal and proximal biliary obstructions due to potentially resectable pancreatobiliary cancers. Our summary demonstrated that there is as yet no optimal PBD method regardless of the distal and proximal biliary strictures because of the small sample size and the lack of better control groups in previous studies. Thus, prospective randomized studies with a large sample size are needed to establish the optimal mode of PBD and to evaluate the potential benefits of PBD in patients with both distal and proximal biliary obstructions.

Effect of Preoperative Biliary Drainage on Complications Following Pancreatoduodenectomy: A Meta-Analysis

Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) is still controversial; therefore, the aim of this study was to examine the impact of PBD on complications following PD. A meta-analysis was carried out for all relevant randomized controlled trials (RCTs), prospective and retrospective studies published from inception to March 2015 that compared PBD and non-PBD (immediate surgery) for the development of postoperative complications in PD patients. Pooled odds ratio (OR) and 95% confidence interval (CI) were estimated using fixed-effect analyses, or random-effects analyses if there was statistically significant heterogeneity (P < 0.05). Eight RCTs, 13 prospective studies, 20 retrospective studies, and 3 Chinese local retrospective studies with 6286 patients were included in this study. In a pooled analysis, there were no significant differences between PBD and non-PBD group in the risks of mortality, morbidity, intra-abdominal abscess, sepsis, hemorrhage, pancreatic leakage, and biliary leakage. However, subgroup analysis of RCTs yielded a trend toward reduced risk of morbidity in PBD group (OR 0.48, CI 0.24 to 0.97; P = 0.04). Compared with non-PBD, PBD was associated with significant increase in the risk of infectious complication (OR 1.52, CI 1.07 to 2.17; P = 0.02), wound infection (OR 2.09, CI 1.39 to 3.13; P = 0.0004), and delayed gastric emptying (DGE) (OR 1.37, CI 1.08 to 1.73; P = 0.009). This meta-analysis suggests that biliary drainage before PD increased postoperative infectious complication, wound infection, and DGE. In light of the results of the study, PBD probably should not be routinely carried out in PD patients.

Use and results of consensus definitions in pancreatic surgery: a systematic review

BACKGROUND

Because of the lack of standardized definitions of complications in gastrointestinal operations, consensus definitions have been developed in recent years. The aim of the current study was to systematically review the available consensus definitions and to report their use, acceptance, and results.

METHODS

A systematic search of the literature was conducted of the Medline, Cochrane, and ISI Web of Science databases. All articles published until August 2011 and that applied the identified consensus definitions were considered. Inclusion criteria for quantitative analysis were studies with correct usage of the definition and 100 or more patients who were treated after the year 2000.

RESULTS

Seven consensus definitions were identified: postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, posthepatectomy liver failure, bile leakage after hepatobiliary and pancreatic surgery, posthepatectomy hemorrhage, and anastomotic leakage after anterior resection of the rectum. Of 1,637 articles retrieved from the literature search, 59 articles that correctly applied the definitions met the inclusion criteria. Subanalyses were feasible for definitions after pancreatic surgery. According to the consensus definitions, the median complication rates of retrospective studies were 21.9% (postoperative pancreatic fistula, n = 11,244 patients), 5.9% (postpancreatectomy hemorrhage, n = 3,311 patients), and 22.8% (delayed gastric emptying, n = 4,553 patients) after pancreatic resections. The incidences were not substantially different in prospective trials. Validation was performed for all three definitions, demonstrating that the severity grades significantly correlated with the clinical course of the patients.

CONCLUSION

The available consensus definitions were increasingly cited and facilitate scientific comparability and transparency if appropriately applied. The present data update the incidences of major pancreatic complications.

The quandary of preresection biliary drainage for pancreatic cancer

Surgery in patients with obstructive jaundice caused by a tumor in the pancreatic head area is associated with a higher risk of postoperative complications. Preoperative biliary drainage was introduced in an attempt to improve the general condition and reduce morbidity and mortality. Extensive experimental studies have been performed to analyze the beneficial effect of biliary drainage and showed improvement in liver function, nutritional status, and cell-mediated immune function as well as reduction in mortality. However, despite the results seen in the experimental studies, clinical studies reported both beneficial and adverse effects, and most studies advised against routinely performing preoperative biliary drainage. To add clarity to the ongoing controversy, a recent randomized controlled trial was performed and reported more overall complications in patients with jaundice who underwent preoperative biliary drainage followed by surgery compared to those who underwent surgery alone. Many of these complications were stent related. Like most clinical studies, a plastic stent was used to initiate biliary drainage. Patients with jaundice because of a tumor in the pancreatic head area without locoregional irresectability or metastases should be candidates for early surgery. Preoperative biliary drainage should not be performed routinely. However, some selected patients might benefit from preoperative biliary drainage, in cases of severe jaundice, neoadjuvant therapy, or postponed surgery due to logistics. In these cases, the use of metal biliary stents is indicated.

Comparison of prognosis between patients of pancreatic head cancer with and without obstructive jaundice at diagnosis

PURPOSE

The aim of this study was to elicit possible differences in prognoses and clinicopathological factors in pancreatic head cancer with and without obstructive jaundice at diagnosis.

METHODS

The data from 169 patients with pancreatic head cancer were retrospectively analyzed.

RESULTS

Patients were divided into two groups according to serum total bilirubin at diagnosis: ≥3 mg/dL for icteric group and <3 mg/dL for non-icteric group. In all cases, icteric group (n = 104) had a significantly worse prognosis than non-icteric group (n = 65) (median survival time (MST), 7.5 months (M) vs. 13.5 M, respectively; P = 0.049). In 84 resectable cases, icteric group had a significantly worse prognosis than non-icteric group (MST, 14.2 M vs. 20.9 M, respectively; P = 0.049) after almost equivalent treatment intensities. Icteric group had significantly larger T- and N-factors according to the UICC Classification compared to non-icteric group. The total number of lymph node metastases in icteric group was significantly larger than in non-icteric group (P = 0.008). The intrapancreatic nerve invasion in icteric group was significantly stronger than in non-icteric group (P = 0.016). There were no significant differences in the mortality and morbidity between icteric and non-icteric groups. In 85 unresectable cases, there was no significant difference between the survival periods of icteric and non-icteric groups (MST, 5.2 M vs. 5.3 M, respectively).

CONCLUSIONS

The presence of obstructive jaundice at diagnosis in patients with pancreatic head cancer may predict an unfavorable survival compared to such patients without obstructive jaundice.

What is appropriate procedure for preoperative biliary drainage in patients with obstructive jaundice awaiting pancreaticoduodenectomy?

PURPOSE

The aims of this study were to compare the clinical outcomes of the preoperative drainage methods in patients with obstructive jaundice awaiting panreaticoduodenectomy and to determine, which procedure would be more effective for preoperative drainage.

METHODS

Among 239 patients undergoing pancreaticoduodenectomy for periampullary cancer, 77 with obstructive jaundice underwent percutaneous transhepatic biliary drainage (PTBD, n=34) or endoscopic biliary drainage (EBD, n=43).

RESULTS

Median rate of decrease in bilirubin was 0.65 mg/d in PTBD group and 0.34 mg/d in EBD group (P=0.003). Median interval from preoperative drainage to pancreaticoduodenectomy were 11 days in PTBD group and 18 days in EBD group (P=0.009). Overall indwelling catheter-related complication rates were higher in "EBD" group compared with "PTBD" group (23.3% vs. 2.9%, P=0.019). No catheter occlusion developed in "PTBD" group, but 6 stent occlusions (13.3%) developed in "EBD" group (P=0.031). The mortality rate was not significantly different between the 2 groups.

CONCLUSIONS

Percutaneous biliary drainage may be preferred for preoperative drainage in patients with obstructive jaundice awaiting pancreaticoduodenectomy due to rapid biliary decompression and lower frequency of catheter-related complications.

Pancreaticoduodenectomy versus duodenum-preserving pancreatic head resection for the treatment of chronic pancreatitis

OBJECTIVE

The objective of this study was to assess the efficacy and safety of pancreaticoduodenectomy (PD) and duodenum-preserving pancreatic head resection (DPPHR) for the treatment of chronic pancreatitis (CP).

METHODS

The 123 patients with CP who underwent pancreatic head resection between January 2004 and June 2009 were retrospectively analyzed. The preoperative variables, operative data, postoperative complications, and follow-up information were examined.

RESULTS

There were no significant differences in clinical and morphological characteristics, pain relief, and jaundice status between the PD and DPPHR groups. The duration of operation was shorter (251.8 [SD, 43.1] vs 324.5 [SD, 41.4] minutes, P < 0.001), blood loss was less (464.4 [SD, 203.6] vs 646.5 [SD, 242.9] mL, P < 0.001), and overall postoperative morbidity was lower (3% vs 19%, P = 0.006) in DPPHR group. The duration of hospital stay was also significantly different (9.9 [SD, 1.8] vs 13.7 [SD, 2.8] days, P < 0.001). Most functional and symptom scales revealed a better quality of life in DPPHR group. The proportion of patients with exocrine and endocrine insufficiency was higher in PD group as compared with DPPHR group.

CONCLUSIONS

Both procedures are equally effective in pain relief, but DPPHR is superior to PD in operative data, postoperative morbidity, improving quality of life, and preservation of exocrine and endocrine function.

Effects of Ganoderma lucidum on obstructive jaundice-induced oxidative stress

OBJECTIVE

Obstructive jaundice develops after occlusion of the common bile duct. Direct hyperbilirubinaemia, which occurs secondary to the condition, causes various life-threatening pathologies. Cytoprotective effects of Ganoderma lucidum (GL) have previously been shown. In this study, the effects of GL on oxidative stress and oxidant DNA damage in experimental obstructive jaundice were evaluated.

METHODS

Sixty Wistar albino adult female rats were randomly divided into six weight-matched equal groups: sham group, bile duct ligated group (BDL); after sham operation 250 mg/kg/d of GL administered group, after sham operation 500 mg/kg/d of GL administered group, after bile duct ligation 250 mg/kg/d of GL administered (GL1BDL) group, and after bile duct ligation 500 mg/kg/d of GL administered (GL2BDL) group. GL polysaccharide was orally administered to the rats via gavage tube once a day for 14 days after bile duct ligation.

RESULTS

The plasma malondialdehyde levels of the GL1BDL and GL2BDL groups were significantly lower than those of the BDL group (p < 0.01). The plasma 8-hydroxy-2'-deoxyguanosine levels of the GL1BDL and GL2BDL groups were significantly lower than those of the BDL group (p < 0.001). The liver tissue Cu-Zn superoxide dismutase level of the GL2BDL group was significantly higher than that of the BDL group (p < 0.05).

CONCLUSION

GL protected against DNA and liver tissue damage by reducing oxidative stress in obstructive jaundice.

Effect of preoperative biliary drainage on malignant obstructive jaundice: A meta-analysis

AIM: To evaluate the effect of preoperative biliary drainage (PBD) on obstructive jaundice resulting from malignant tumors.

METHODS: According to the requirements of Cochrane systematic review, studies in the English language were retrieved from MEDLINE and Embase databases from 1995 to 2009 with the key word “preoperative biliary drainage”. Two reviewers independently screened the eligible studies, evaluated their academic level and extracted the data from the eligible studies confirmed by cross-checking. Data about patients with and without PBD after resection of malignant tumors were processed for meta-analysis using the Stata 9.2 software, including postoperative mortality, incidence of postoperative pancreatic and bile leakage, abdominal abscess, delayed gastric emptying and incision infection.

RESULTS: Fourteen retrospective cohort studies involving 1826 patients with malignant obstructive jaundice accorded with our inclusion criteria, and were included in meta-analysis. Their baseline characteristics were comparable in all the studies. No significant difference was found in combined risk ratio (RR) of postoperative mortality and incidence of pancreatic and bile leakage, abdominal abscess, delayed gastric emptying between patients with and without PBD. However, the combined RR for the incidence of postoperative incision infection was improved better in patients with PBD than in those without PBD (P < 0.05).

CONCLUSION: PBD cannot significantly reduce the postoperative mortality and complications of malignant obstructive jaundice, and therefore should not be used as a preoperative routine procedure for malignant obstructive jaundice.

Pre-operative stenting is associated with a higher prevalence of post-operative complications following pancreatoduodenectomy

OBJECTIVES

Whilst there are theoretical benefits from pre-operatively draining the biliary tree prior to pancreatoduodenectomy (PD), the current literature does not support this intervention. The aim of this study was to explore the relationship between pre-operative stenting, bactibilia and outcome in a large United Kingdom tertiary referral practice.

METHODS

Patients undergoing PD were identified from a prospectively maintained database. The presence or absence of a stent prior to PD, and the results of bile cultures taken at PD were related to the subsequent post-operative course and the development of complications.

RESULTS

280 patients underwent PD for periampullary malignancies, all of whom presented with jaundice. 118 patients were stented prior to referral (98 ERCP, 20 PTC). Bile cultures were positive more frequently in the stent group (83% vs. 55%; p = 0.000002) and bactibilia was more common after ERCP than PTC (83% vs. 56%; p = 0.006). The overall prevalence of complications was 54% in the stented and 41% in the non-stented group (p = 0.03) with statistical significance achieved for pancreatic leak (p = 0.013) and haemorrhagic complications (p = 0.03). Comparing stent with no stent, there as no difference in the 30-day mortalities (8.5% vs. 6.8%; p = 0.6) or the 1-year mortality rates (35% vs. 28%; p = 0.21). Mortality rates in the infection versus no infection groups were comparable at 30 days (8.5% vs. 5.5%; p = 0.21), and at 1 year (30.7% vs. 26.4%; p = 0.25).

CONCLUSIONS

Pre-operative stent insertion prior to PD is associated with increased morbidity but not mortality and this is greatest for stents placed at ERCP.

An analysis of four cases of second-stage pancreaticoduodenectomy and one case of combined first-stage pancreaticoduodenectomy and sigmoid cancer radical operation in aged patients

AIM: To evaluate the feasibility and operative characteristics of second-stage pancreaticoduodenectomy (PD) for initially unresectable periampullary cancer and for metastatic pancreatic carcinoma after radical excision of colon carcinoma in senile patients.

METHODS: A total of five senile patients were included in the study. Four patients had malignant obstructive jaundice, of which two underwent first-stage cholecystectomy, common bile duct exploration and T-tube drainage, and the other two underwent cholangiojejunostomy. After jaundice subsidence and liver function recovery, these patients underwent second-stage PD. Another senile patient simultaneously underwent PD and radical resection of sigmoid colon due to cancer recurrence and metastatic pancreatic carcinoma 19 years after initial cancer radical resection.

RESULTS: One patient underwent first-stage T-tube drainage for two months and developed jaundice and cholangitis after T-tube withdrawal. Due to gradual exacerbation, he underwent second-stage PD but died of liver and renal failure 10 days after the operation. The other four patients recovered gradually after PD, underwent regular postoperative regular chemotherapy, and survived for 32, 41, 58 (still alive) and 79 months, respectively.

CONCLUSION: PD is indicated for aged patients with initially unresectable periampullary cancer or metastatic pancreatic carcinoma after radical excision of colon carcinoma, and can significantly prolong their life span and improve their life quality.

Prevalence of Toxocara canis in stray dogs, northern Iran

Toxocara canis is one of the most common parasites living in the intestine of domestic and stray dogs. A dog eliminates thousands of eggs into the environment that are potential etiological factor for human toxocariasis. The present study was undertaken to determine the prevalence of T. canis in stray dogs in Mazandaran, Iran. In this cross-sectional study, during the period from April to September 2007, 50 young and adult stray dogs were collected by shooting from urban areas of Sari city, Northern Iran. They were necropsied and the gastrointestinal tract was opened. Recovered parasites were fixed in alcohol and stained in carmine. Faecal specimens were also examined by the formalin ether concentration method. A total of 27 adult and 23 young dogs were examined with 11 adults (40.7%) and 19 youngs (82.6%) being infected with T. canis with an overall prevalence of 60%. There were significant differences in the prevalence of infection between adult and young dogs (p = 0.003). There were no significant differences in the prevalence of infection between male and female dogs (p > 0.05). Considering the high prevalence of this zoonotic parasite and its hygienic significance in causing human toxocariasis, particularly in children, plus the lack of control of stray dog populations, there is a need to improve personal and food hygiene as well controlling stray dogs in these urban