The view from 10,000 procedures: technical tips and wisdom from master pancreatic surgeons to avoid hemorrhage during pancreaticoduodenectomy

Pancreaticoduodenectomy remains the exclusive technique for surgical resection of cancers located within both the pancreatic head and periampullary region. Amongst peri-procedural complications, hemorrhage is particularly problematic given that allogenic blood transfusions are known to increase the risk of infection, acute lung injury, cancer recurrence and overall 30-day morbidity and mortality rates. Because blood loss can be considered a modifiable factor that reflects surgical technique, rates of perioperative blood loss and transfusion have been advocated as robust quality indicators. We present a correspondence manuscript that outlines peri-procedural concepts detailing a successful pancreaticoduodenectomy with minimal hemorrhage. These tips were collated from master pancreatic surgeons throughout the globe who have performed over 10,000 cumulative pancreaticoduodenectomies. At risk scenarios for hemorrhage include dissections of the superior mesenteric – portal vein, gastroduodenal artery, and retroperitoneal soft tissue margin. General principles in limiting slow continuous hemorrhage that may accumulate into larger total case losses are also discussed. While many of the techniques and tips proposed by master pancreas surgeons are intuitive and straight forward, when taken as a collective they represent a significant contribution to improved outcomes associated with the pancreaticoduodenectomy over the past 100 years.

Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey

BACKGROUND

Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors.

METHODS

We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care.

RESULTS

A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a university-affiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experience, regional culture and training background impacted treatment (all p < 0.05).

CONCLUSION

Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma.

Pyogenic liver abscess following pancreaticoduodenectomy: risk factors, treatment, and long-term outcome

BACKGROUND

Pancreaticoduodenectomy (PD) remains a challenging operation with a 40% postoperative complication rate. Pyogenic liver abscess (PLA) is an uncommon complication following PD with little information on its incidence or treatment. This study was done to examine the incidence, risk factors, treatment, and long-term outcome of PLA after PD.

METHODS

We retrospectively reviewed 1,189 patients undergoing PD (N = 839) or distal pancreatectomy (DP) (N = 350) at a single institution over a 14-year period (January 1, 1994-January 1, 2008). Pancreatic databases (PD and DP) were queried for postoperative complications and cross-checked through a hospital-wide database using ICD-9 codes 572.0 (PLA) and 006.3 (amebic liver abscess) as primary or secondary diagnoses. No PLA occurred following DP. Twenty-two patients (2.6%) developed PLA following PD. These 22 patients were matched (1:3) for age, gender, year of operation, and indication for surgery with 66 patients without PLA following PD.

RESULTS

PLA occurred in 2.6% (22/839) of patients following PD, with 13 patients (59.1%) having a solitary abscess and 9 (40.9%) multiple abscesses. Treatment involved antibiotics and percutaneous drainage (N = 15, 68.2%) or antibiotics alone (N = 7, 31.8%) with a mean hospital stay of 12 days. No patient required surgical drainage, two abscesses recurred, and all subsequently resolved. Three patients (14%) died related to PLA. Postoperatively, patients with biliary fistula (13.6 vs. 0%, p = 0.014) or who required reoperation (18.2 vs. 1.5%, p = 0.013) had a significantly higher rate of PLA than matched controls. Long-term follow-up showed equivalent 1-year (79 vs.74%), 2-year (50 vs. 57%), and 3-year (38 vs. 33%) survival rates and hepatic function between patients with PLA and matched controls.

CONCLUSIONS

Postoperative biliary fistula and need for reoperation are risk factors for PLA following PD. Antibiotics and selective percutaneous drainage was effective in 86% of patients with no adverse effects on long-term hepatic function or survival.

The role of antimicrobial therapy in severe acute pancreatitis

The role of antimicrobial therapy in patients with severe acute pancreatitis is to treat secondary pancreatic infections to prevent systemic sepsis and death. Infected pancreatic necrosis is diagnosed using image-directed fine needle aspiration with culture and Gram's stain. Prophylactic antibiotics have not proven efficacious, while the precise timely detection of secondary pancreatic infections is often elusive. A high clinical index of suspicion should prompt the empiric initiation of antimicrobial therapy until culture results are available. Positive cultures should guide antimicrobial therapy, and for infected pancreatic necrosis, antibiotics should be used in conjunction with interventional techniques for source control.

A prospective, randomized study of EUS-guided celiac plexus neurolysis for pancreatic cancer: one injection or two?

BACKGROUND

The technique of alcohol injection during EUS-guided celiac plexus neurolysis (CPN) in patients with pancreatic cancer-related pain has not been standardized.

OBJECTIVE

To compare pain relief and safety of alcohol given as 1 versus 2 injections during EUS-guided CPN (EUS-CPN). Secondary outcomes examined were characteristics that predict response and survival.

DESIGN

Single-blinded, prospective, randomized, parallel-group study.

SETTING

Tertiary-care center.

PATIENTS

This study involved patients with pancreatic cancer-related pain.

INTERVENTION

EUS-CPN done by injecting 20 mL of 0.75% bupivacaine and 10 mL 98% alcohol into 1 or 2 sites at the celiac trunk. Participants were interviewed by telephone at 24 hours and weekly thereafter.

MAIN OUTCOME MEASUREMENTS

Time until onset of pain relief, duration of pain relief, complications.

RESULTS

Fifty patients (mean age 63 years; 24 men) were enrolled and randomized (29 in 1-injection, 21 in 2-injections groups). Pain relief was observed in 37 (74%) patients: 20 (69%) in the 1-injection group and 17 (81%) in the 2-injection group (chi-square P = .340). Median onset of pain relief was 1 day for both 1-injection (range 1-28 days) and 2-injection (range 1-21 days) groups (Mann-Whitney P = .943). Median duration of pain relief in the 1-injection and 2-injection groups was 11 weeks and 14 weeks, respectively (log-rank P = .612). Complete pain relief was observed in 4 (8%) patients total, 2 in each group. There were no long-term complications.

LIMITATIONS

Single-blinded study.

CONCLUSION

There were no differences in onset or duration of pain relief when either 1 or 2 injections were used. There was no difference in safety or survival between the 2 groups.

Natural history of pancreatitis-induced splenic vein thrombosis: a systematic review and meta-analysis of its incidence and rate of gastrointestinal bleeding

BACKGROUND

Pancreatitis-induced splenic vein thrombosis (PISVT) is an acquired anatomic abnormality that impacts decision making in pancreatic surgery. Despite this influence, its incidence and the rate of associated gastrointestinal (GI) bleeding are imprecisely known.

METHODS

The MEDLINE, EMBASE, Cochrane Central Register of Clinical Trials and Cochrane Database of Systematic Reviews databases were searched from their inception to June 2010 for abstracts documenting PISVT in acute (AP) or chronic pancreatitis (CP). Two reviewers independently graded abstracts for inclusion in this review. Heterogeneity in combining data was assumed prior to pooling. Random-effects meta-analyses were performed to estimate percentages and 95% confidence intervals.

RESULTS

After review of 241 abstracts, 47 studies and 52 case reports were graded as relevant. These represent a cohort of 805 patients with PISVT reported in the literature. A meta-analysis of studies meeting inclusion criteria shows mean incidences of PISVT of 14.1% in all patients, 22.6% in patients with AP and 12.4% in patients with CP. The incidence of associated splenomegaly was only 51.9% in these patients. Varices were identified in 53.0% of patients and were gastric in 77.3% of cases. The overall rate of GI bleeding was 12.3%.

CONCLUSIONS

Although reported incidences of PISVT vary widely across studies, an overall incidence of 14.1% is reported. Splenomegaly is an unreliable sign of PISVT. Although the true natural history of PISVT remains unknown, the collective reported rate of associated GI bleeding is 12.3%.

Splenic preserving distal pancreatectomy: does vessel preservation matter?

BACKGROUND

Splenic preserving distal pancreatectomy (SPDP) can be accomplished with splenic artery and vein preservation or ligation. However, no data are available on the relative merits of these techniques. The aim of this analysis was to compare the outcomes of splenic preserving distal pancreatectomy with and without splenic vessel preservation.

STUDY DESIGN

From 2002 through 2009, 434 patients underwent distal pancreatectomy and 86 (20%) had splenic preservation. Vessel preservation (VP) was accomplished in 45 and ligation (VL) was performed in 41. These patients were similar with respect to age, American Society of Anesthesiologists class, pathology, surgeons, and minimally invasive approach (79%). For comparison, a matched group of 86 patients undergoing distal pancreatectomy with splenectomy (DP+S) was analyzed.

RESULTS

The VP-SPDP procedure was associated with less blood loss than VL-SPDP or DP+S (224 vs 508 vs 646 mL, respectively; p < 0.05). The VP-SPDP procedure also resulted in fewer grade B or C pancreatic fistulas (2% vs 12% vs 14%; p = NS) and splenic infarctions (5% vs 39%; p < 0.01), less overall morbidity (18% vs 39% vs 38%, respectively; p < 0.05) and need for drainage procedure (2% vs 15% vs 16%; p < 0.05), and shorter post-operative length of stay (4.5 vs 6.2 vs 6.6 days; p < 0.05).

CONCLUSIONS

This analysis suggests that outcomes are (1) best for VP-SPDP and (2) VL-SPDP provides no short-term advantage over distal pancreatectomy with splenectomy. We conclude that splenic VP is preferred when SPDP is performed.

Post-operative morbidity results in decreased long-term survival after resection for hilar cholangiocarcinoma

BACKGROUND

The purpose of the present study was to demonstrate that post-operative morbidity (PM) associated with resections of hilar cholangiocarcinoma (HCCA) is associated with short- and long-term patient survival.

METHODS

Between 1998 and 2008, 51 patients with a median age of 64 years underwent resection for HCCA at a single institution. Associations between survival and clinicopathologic factors, including peri- and post-operative variables, were studied using univariate and multivariate models.

RESULTS

Seventy-six per cent of patients underwent major hepatectomy with resection of the extrahepatic bile ducts. The 30- and 90-day operative mortality was 10% and 12%. The overall incidence of PM was 69%, with 68% of all PM as major (Clavien grades III-V). No difference in operative blood loss or peri-operative transfusion rates was observed for patients with major vs. minor or no PM. Patients with major PM received adjuvant chemotherapy less frequently than patients with minor or no complications 29% vs. 52%, P= 0.15. The 1-, 3- and 5-year overall (OS) and disease-specific survival (DSS) rates for all patients were 65%, 36%, 29% and 77%, 46%, 35%, respectively. Using univariate and multivariate analysis, margin status (27% R1), nodal metastasis (35% N1) and major PM were associated with OS and DSS, P < 0.01. Major PM was an independent factor associated with decreased OS and DSS [hazard ratio (HR) = 3.6 and 2.8, respectively, P < 0.05]. The median DSS for patients with major PM was 14 months compared with 40 months for patients who experienced minor or no PM, P < 0.01.

CONCLUSION

Extensive operations for HCCA can produce substantial post-operative morbidity. In addition to causing early mortality, major post-operative complications are associated with decreased long-term cancer-specific survival after resection of HCCA.

Natural history of intraductal papillary mucinous neoplasia: How much do we really know?

Information on the natural history of intraductal papillary mucinous neoplasia (IPMN) is currently inadequate due to a lack of carefully orchestrated long-term follow-up on a large cohort of patients with asymptomatic disease. Based on the available data, one can draw the conclusions that main duct IPMN is commonly associated with malignancy and an aggressive operative stance should be taken with resection being offered to most patients who are suitable operative candidates. In contrast, the majority of branch type IPMN with a diameter of less than 3 cm can be safely followed with routine surveillance imaging provided they lack the high-risk covariates of age, symptomatology, nodularity or wall thickness.

Does the type of pancreaticojejunostomy after Whipple alter the leak rate?

Despite the overwhelming limitations that plague the literature surrounding the optimal method of reestablishing pancreatico-enteric continuity following a Whipple operation, it is clear that all successful techniques conform to sound surgical principles. These principles include a water-tight and tension-free anastomosis, preservation of adequate blood supply for both organs involved in the anastomosis, and minimal trauma to the pancreas gland. Although surgeon experience, gland texture, and pancreatic duct size are clearly the dominate risk factors from a long list of variables associated with pancreatic leaks following pancreatoduodenectomy, these are nonmodifiable covariates. Although the plethora of current literature cannot provide a single definitive technical solution for restoring pancreatico-enteric continuity, a small number of well-designed RCTs support the use of transanastomotic external stenting for high-risk pancreatic glands and an end-to-side invaginated pancreaticojejunostomy. The truth remains that an individual surgeon's mastery of a specific anastomotic technique, in conjunction with a large personal experience, is likely to be the best predictor of a low pancreas leak rate following pancreatoduodenectomy.

Radiation dose from computed tomography in patients with necrotizing pancreatitis: how much is too much?

OBJECTIVES

Low-dose ionizing radiation from medical imaging has been indirectly linked with subsequent cancer. Computed tomography (CT) is the gold standard for defining pancreatic necrosis. The primary goal was to identify the frequency and effective radiation dose of CT imaging for patients with necrotizing pancreatitis.

METHODS

All patients with necrotizing pancreatitis (2003-2007) were retrospectively analyzed for CT-related radiation exposure.

RESULTS

Necrosis was identified in 18% (238/1290) of patients with acute pancreatitis (mean age = 53 years; hospital/ICU length of stay = 23/7 days; mortality = 9%). A median of five CTs/patient [interquartile range (IQR) = 4] were performed during a median 2.6-month interval. The average effective dose was 40 mSv per patient (equivalent to 2,000 chest X-rays; 13.2 years of background radiation; one out of 250 increased risk of fatal cancer). The actual effective dose was 63 mSv considering various scanner technologies. CTs were infrequently (20%) followed by direct intervention (199 interventional radiology, 118 operative, 12 endoscopic) (median = 1; IQR = 2). Magnetic resonance imaging did not have a CT-sparing effect. Mean direct hospital costs increased linearly with CT number (R = 0.7).

CONCLUSIONS

The effective radiation dose received by patients with necrotizing pancreatitis is significant. Management changes infrequently follow CT imaging. The ubiquitous use of CT in necrotizing pancreatitis raises substantial public health concerns and mandates a careful reassessment of its utility.

Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis

BACKGROUND

Disconnected left pancreatic remnant (DLPR) presents clinically as a pancreatic fistula, pseudocyst, or obstructive pancreatitis. Optimal operative treatment, either distal pancreatectomy (DP) or internal drainage (ID), remains unknown. This paper critically evaluates our operative experience in patients with DLPR.

METHODS

A retrospective analysis of a consecutive case series from a single, high-volume institution was carried out. A total of 76 patients with radiographic-confirmed DLPR (computed tomography + endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography) who had operations between November 1995 and September 2008 were included. Pancreas preservation (the use of ID) was our default unless anatomic, physiologic, or technical factors precluded it. Follow-up to July 2009 was done (median follow-up, 22 months). Standard statistical methodology was used (P < .05 = statistical significance).

RESULTS

The mean age of this cohort was 52 years (range, 18-85); 57% of the patients were male. A total of 59 (73%) had acute pancreatitis, whereas 17 (22%) had chronic pancreatitis. Presentation was pseudocyst in 53%, pancreatic fistula in 34%, and obstructive pancreatitis in 13%. Resection (DP) and drainage (ID) options were utilized equally for each clinical presentation as follows: pseudocyst, 60/40; pancreatic fistula, 50/50; or obstructive pancreatitis, 50/50. The strongest driver for DP (92%) was a small pancreatic remnant and splenic vein thrombosis. In contrast, large pancreatic remnants had ID 70% of the time. No differences in short- or long-term outcomes between DP or ID options were identified.

CONCLUSION

Using anatomic, physiologic, and technical factors to guide operative choice in DLPR, we report a 74% success rate with DP and an 82% success rate with ID at a median follow-up of 22 months. A pancreatic remnant size >6 cm favored ID options over resection.

Pancreatic surgery: evolution at a high-volume center

BACKGROUND

Advances in imaging, minimally invasive techniques, and regionalization have changed pancreatic surgery. Therefore, the aims of this report are to determine whether the pancreatic operations or the spectrum of disease have evolved at a high-volume center.

METHODS

From 1996 through 2009, 2,004 pancreatic operations were performed at Indiana University Hospital. The operations, pathology, and outcomes for 1996-2003 were compared with 2004-2009.

RESULTS

In 2004-2009, more operations/year were performed (215 vs 89; P < .01) and patients were older (58.8 years vs 55.8 years; P < .01). In recent years, more pancreatoduodenectomies (55.0% vs 50.4%) and fewer pancreatojejunostomies (6.2% vs 12.6%) and Beger/Frey procedures (2.6% vs 4.8%) were performed (P < .05). In 2004-2009, pylorus preservation (81.1% vs 64.4%), laparoscopic distal pancreatectomy (33.9% vs 0%), and splenic preservation (25.3% vs 2.2%) were carried out more frequently (P < .001). Pathology review revealed more tumors (68.8% vs 60.4%) and less pancreatitis (29.2% vs 34.4%; P < .01). Thirty-day mortality improved from 2.5% to 1.8%.

CONCLUSION

At a high-volume pancreatic surgery center, the number and age of the patients, the percentage of pancreatic resections, preservation of the pylorus and spleen as well as laparoscopic procedures, and the percentage of patients with tumors all have increased, whereas the outcomes continued to improve.

Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience

OBJECTIVE

To determine the importance of hospital volume, surgeon experience, and surgeon volume in performing pancreaticoduodenectomy (PD).

DESIGN, SETTING, AND PATIENTS

From 1980 through 2007, 1003 patients underwent PD by 19 surgeons at a university hospital.

MAIN OUTCOME MEASURES

Patient morbidity and mortality, quality of resection, and learning curve were examined according to hospital volume (period 1: 1980-2003 vs period 2: 2004-2007), surgeon experience (total number of PDs), and surgeon volume (number of PDs per year).

RESULTS

Perioperative morbidity and mortality for all 1003 PDs were 41% and 3%, respectively. Differences existed between period 1 and period 2 in percentage of PDs performed in elderly patients (7% vs 17%), mortality (4% vs 2%), estimated blood loss (1817 mL vs 780 mL), length of stay (18 days vs 12 days), and proportion of International Study Group on Pancreatic Fistula grade C pancreatic fistulae (29% vs 12%). Surgeons with less experience (<50 PDs) performed PD with higher morbidity (53% vs 39%), pancreatic fistula rate (20% vs 10%), estimated blood loss (1918 mL vs 1101 mL), and operative time (458 minutes vs 335 minutes) compared with surgeons with more experience (> or =50 PDs). Experienced surgeons had comparable outcomes irrespective of annual volume. Mortality, margins, and number of lymph nodes resected were not affected by surgeon experience or surgeon volume. Learning curves projected that less experienced surgeons would achieve morbidity and mortality rates equivalent to those of experienced surgeons when they reached 20 and 60 PDs, respectively.

CONCLUSIONS

Improvement in PD outcomes, including mortality, occurred with increased PD volume at a pancreatic center. Surgeon experience remained an important determinant of overall morbidity. Experienced surgeons, however, had comparable outcomes irrespective of annual volume.

Pancreatic necrosectomy: North American mortality is much lower than expected

BACKGROUND

The aim of this analysis was to explore the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine outcomes of patients undergoing debridement for pancreatic and peripancreatic necrosis. Single-institution series suggest that the mortality of patients undergoing pancreatic necrosectomy has improved but remains at 15% to 20%. But no national data have been available for patients with necrotizing pancreatitis. In 2007, a CPT code specific for debridement of pancreatic necrosis became available.

STUDY DESIGN

The ACS-NSQIP Participant Use File was queried for all patients who had debridement of pancreatic and peripancreatic necrosis (CPT code 48105) from January 1, 2007, through December 31, 2007. Patient demographics, observed (O) and expected (E) morbidity and mortality, and indices (O/E) were evaluated. A multivariate stepwise logistic regression was performed to determine predictors of mortality.

RESULTS

During this 12-month period, data were accumulated on 161 patients. The mean age was 54 years; 71% were male; and 75% were Caucasian. The mean body mass index was 30.3 kg/m(2); 29% had diabetes; and 11% abused alcohol. Forty-two percent were transferred to NSQIP hospitals from other facilities. Overall morbidity was 62%, and 30-day mortality was 6.8%, but morbidity and mortality indices were 0.86 and 0.33, respectively. Increased age and blood urea nitrogen were independent predictors of mortality.

CONCLUSIONS

These data suggest that patients undergoing debridement for pancreatic and peripancreatic necrosis at ACS-NSQIP hospitals provide a new North American sample and have better than predicted outcomes. We concluded that ACS-NSQIP is a powerful tool to assess contemporary outcomes of uncommon, high-risk procedures.

Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial

BACKGROUND

Pancreatic fistula (PF) is one of the most common complications after pancreaticoduodenectomy. There have been no large prospective randomized trials evaluating PF rates comparing invagination versus duct to mucosa pancreaticojejunostomy. We tested the hypothesis that a duct to mucosa pancreaticojejunostomy would reduce the PF rate.

STUDY DESIGN

Between August 2006 and May 2008, 197 patients at two institutions underwent pancreaticoduodenectomy by a total of 8 experienced pancreatic surgeons as part of this prospective randomized trial (clinical trial no. NCT00359320). All patients were stratified by pancreatic texture and randomized to either an invagination or a duct to mucosa pancreaticojejunal anastomosis. Recorded variables included pancreatic duct diameter, operative time, blood loss, complications, and pathology. Primary end point was PF rate, as defined by the International Study Group on Pancreatic Fistula. Secondary end points included PF grade, postoperative length of hospital stay, other morbidities, and mortality.

RESULTS

Rate of PF for the entire cohort was 17.8%. There were 23 fistulas (24%) in the duct to mucosa cohort and 12 fistulas (12%) in the invagination cohort (p < 0.05). The greatest risk factor for a PF was pancreas texture: PF developed in only 8 patients (8%) with hard glands, and in 27 patients (27%) with a soft gland. There were two perioperative deaths (both in the duct to mucosa group), with the proximate causes of death being PF, followed by bleeding and sepsis.

CONCLUSIONS

This dual-institution prospective randomized trial reveals considerably fewer fistulas with invagination compared with duct to mucosa pancreaticojejunostomy after pancreaticoduodenectomy. Results confirm increased PF rates in soft as compared with hard glands. Additional studies are needed to define the optimal technique of pancreatic reconstruction after pancreaticoduodenectomy.

Middle segment pancreatectomy can be safely incorporated into a pancreatic surgeon's clinical practice

Middle segment pancreatectomy (MSP) is a new operation where the advantages of parenchymal preservation are counterbalanced by a high postoperative complication rate and unease among surgeons with adopting a new technique. This study reviews our experience incorporating MSP into our clinical practice focusing on the initial 34 consecutive patients operated on by one surgeon at a single institution between 1998 and 2007. Patients were divided into early (initial 17 operations) and late (subsequent 17 operations) groups for analysis. Thirty-one reconstructions were by Roux-en-y pancreaticojejunostomy and three were by pancreaticogastrostomy. Using multiple linear regression and logistic regression, we found no significant differences in performance outcomes (operative time, blood loss, tumor size, margin negative resection rate, pancreatic fistula rate, hospital length of stay, postoperative complications, and hospital readmission rate) between our early and late experience even after adjusting for potential confounding variables (patient demographics, co-morbidities, neoplasm, pancreatitis). The pancreatic fistula rate in this series was 29.4% (10/34) and they were all International Study Group on Pancreatic Fistula (ISGPF) Grade A (60%) or B (40%). In summary, MSP is an operation with a flat learning curve and acceptable morbidity rate that can be safely incorporated as a parenchymal preserving option by pancreatic surgeons in their clinical practice.

Spontaneous duodenal hematoma: a rare cause of upper gastrointestinal tract obstruction

Intramural duodenal hematoma is a rare cause of proximal gastrointestinal tract obstruction most frequently encountered in the setting of abdominal trauma or coagulation deficiencies. Here we report a case of a 75-year-old man who spontaneously developed an intramural duodenal hematoma with no apparent inciting event or risk factors.

Pancreatic cystic neuroendocrine tumors: preoperative diagnosis with endoscopic ultrasound and fine-needle immunocytology

BACKGROUND

Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Computed tomography (CT) occasionally demonstrates the hypervascular border characteristic of NETs. Endoscopic ultrasound (EUS) with fine-needle aspiration and immunocytology may be a more consistent means to establish the diagnosis, but no data on the role of EUS are available. This report represents the largest series of CNETs treated to date, documents the role of EUS in preoperative diagnosis, and describes current management.

METHODS

Retrospective review of our experience with CNETs treated at an academic center between 1999 and 2006.

RESULTS

Thirteen patients with CNETs were identified. One had symptoms consistent with a functional tumor; the others were nonfunctional. Twelve were detected by CT; only three had peripheral hypervascularity. Nine were studied with preoperative EUS/immunocytology; each of these demonstrated strong staining for chromogranin and synaptophysin. All were resected: four by pancreaticoduodenectomy, one by total pancreatectomy, and one by enucleation. Perioperative morbidity occurred in 39%. Perioperative mortality was 0%. Average follow-up was 3.3 + 0.5 years. One patient had late hepatic recurrence and ultimately died of disease. Two developed recurrent NET in the context of MEN I and required additional surgery. Twelve are alive with no evidence of disease.

CONCLUSIONS

EUS-guided immunocytology with staining for neuroendocrine markers is an accurate method to establish the diagnosis of CNET preoperatively. Short- and long-term outcomes after resection are excellent.

Annular pancreas: dramatic differences between children and adults

BACKGROUND

Annular pancreas is rare; only 737 cases have been reported in the English literature. In addition, no large analysis has compared children and adults. Recently, prenatal diagnosis and advances in imaging have led to increased experience with this condition.

STUDY DESIGN

Data from 103 patients (48 children, 55 adults) with annular pancreas, managed from 1992 to 2006, were reviewed. Patients with isolated duodenal atresia, stenosis, or webs were excluded.

RESULTS

Median ages at diagnosis were 1 day in children and 47 years in adults. Annular pancreas was more common in girls and women (children, 58%; adults, 69%). Congenital anomalies were more frequent (p < 0.01) in children (71%) than in adults (16%); Down syndrome, cardiac, and intestinal anomalies were most common. Prenatal diagnosis was suspected in 56% of infants, and adults presented with pain (75%), vomiting (24%), pancreatitis (22%), or abnormal liver tests (11%). All children were managed with duodenal bypass. Children were more likely (p < 0.01) to require surgery for associated anomalies. In contrast, adults had fewer duodenal bypass procedures (24%) but more often required endoscopic pancreatobiliary procedures (67%), cholecystectomy (56%), and other pancreatobiliary surgery (20%; p < 0.01). Adults more commonly (p < 0.01) had pancreas divisum (29%) and pancreatobiliary neoplasia (11%). Five children (6%) with multiple anomalies died; all adults survived their operations. Late deaths occurred in 2 children (4%) with multiple anomalies and 3 adults (5%) with pancreatobiliary cancer.

CONCLUSIONS

Annular pancreas is associated with a spectrum of disease that differs in children and adults. Congenital anomalies are more common in children with annular pancreas; complex pancreatobiliary disorders and malignancy are more frequent in adults.

Small-bowel obstruction: state-of-the-art imaging and its role in clinical management

Small-bowel obstruction (SBO) is a common clinical condition with signs and symptoms similar to other acute abdominal disorders. The radiologic investigation of patients with SBO as well as the indications and timing of surgical intervention have changed over the past 2 decades. This review focuses on modern imaging techniques and their role in both the diagnosis and treatment of patients with SBO.

PGE(2) in pancreatic cyst fluid helps differentiate IPMN from MCN and predict IPMN dysplasia

Current management of intraductal papillary mucinous neoplasm (IPMN) according to recently published International Consensus Guidelines depends upon distinguishing it from mucinous cystic neoplasms (MCNs). We have previously shown that prostaglandin E(2) (PGE(2)) is increased in pancreatic cancer tissue over normal controls. Thus, we hypothesized that PGE(2) level in pancreatic fluid differentiates IPMN and MCN and is a biomarker of IPMN dysplasia. Pancreatic fluid was collected in 65 patients at the time of endoscopy (EUS or ERCP) or operation (OR) and analyzed by PGE(2) enzyme-linked immunosorbent assay (ELISA). PGE(2) level was correlated with surgical pathologic diagnosis and dysplastic stage. Mean PGE(2) level (pg/microl) in IPMNs (2.2 +/- 0.6) was greater than in MCNs (0.2 +/- 0.1) (p < 0.05). Mean PGE(2) level of IPMN by dysplastic stage was 0.1 +/- 0.01 (low grade), 1.2 +/- 0.6 (medium grade), 4.4 +/- 0.9 (high grade), and 5.0 +/- 2.3 (invasive). Among invasive IPMN, PGE(2) level dropped in advanced cases with pancreatic ductal obstruction by tumor (0.3 +/- 0) vs non-obstructed (8.6 +/- 2.9). PGE(2) level may help in distinguishing IPMN from MCN in patients with known mucinous lesions. PGE(2) level may also be an indicator of malignant progression of IPMN before ductal obstruction by tumor. Prospective evaluation will be necessary to evaluate the clinical role of PGE(2) level in pancreatic fluid.

Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology

OBJECTIVE

Determine whether size and other preoperative parameters predict malignant or invasive intraductal papillary mucinous neoplasia (IPMN).

SUMMARY BACKGROUND DATA

From 1991 to 2006, 150 patients underwent 156 operations for IPMN.

METHODS

Prospectively collected, retrospective review of a single academic institution's experience. All preoperative parameters including a detailed radiologic-based classification of IPMN type, location, distribution, size, number, cytology, and mural nodularity were correlated with IPMN pathology.

RESULTS

Malignant IPMN was present in 32% of cases, whereas 19% of cases were invasive. IPMN type and main pancreatic duct diameter were significant predictors of malignant IPMN (P<0.001). Side-branch lesion number was negatively associated with invasive IPMN (P=0.03). Side-branch size, location, and distribution did not predict IPMN pathology. The presence of mural nodules was associated with malignant and invasive IPMN (P<0.001; P<0.02). Atypical cytopathology was significantly associated with malignant and invasive IPMN (P<0.001; P<0.001). Multivariate analysis demonstrated mural nodularity and atypical cytopathology were predictive of malignancy and/or invasion in branch-type IPMN.

CONCLUSIONS

To lower the rate of invasive pathology, surgery should be recommended for fit patients with main-duct IPMN and for branch-duct IPMN with mural nodularity or positive cytology irrespective of location, distribution, or size.

Disconnection of the pancreatic duct: an important but overlooked complication of severe acute pancreatitis

In patients with severe acute pancreatitis, the percentage of necrosis of pancreatic glandular parenchyma is an important predictor of prognosis. However, little attention has been paid to necrosis of ductal epithelium, which may result in disconnection of the main pancreatic duct. In pancreatic duct disconnection, a viable segment of the pancreatic body or tail is isolated from the gastrointestinal tract; the result is a persistent end fistula, that is, an uncontrolled leak of pancreatic secretions into peripancreatic spaces without communication to the gastrointestinal tract. The authors present their experience with clinical and radiologic follow-up of 85 patients with necrotic pancreatitis who either did (n = 46) or did not (n = 39) have pancreatic duct disconnection at surgery. Confident preoperative diagnosis of a disconnected duct requires both imaging tests (computed tomography or magnetic resonance imaging) and pancreatography. However, not all peripancreatic collections signify ductal disconnection, and imaging has poor accuracy in differentiation between pancreatic and peripancreatic necrosis. Early recognition of disconnected pancreatic duct obviates unnecessary and potentially harmful drainage procedures.

Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center

BACKGROUND

Laparoscopic cholecystectomy has a higher incidence of bile-duct injuries than open cholecystectomy. Although a learning curve phenomenon was attributed to biliary injuries early after its introduction, we were interested in trends in biliary injury rates over time as laparoscopic cholecystectomy has become a mature technology.

OBJECTIVE

To analyze the frequency and anatomic distribution of bile-duct injuries referred after laparoscopic cholecystectomy over a 10-year period.

DESIGN

Retrospective, case-series.

SETTING

Tertiary, referral hepatobiliary unit.

PATIENTS

Referrals to ERCP unit for diagnosis and treatment of biliary injuries after laparoscopic cholecystectomy.

INTERVENTION

ERCP to diagnose level and severity of bile duct injury.

MAIN OUTCOME MEASUREMENTS

Type and anatomy of bile-duct injury, reason for cholecystectomy, mean time between injury and diagnosis, presenting symptoms, ratio of bile-duct injuries diagnosed over total ERCPs done per year.

RESULTS

There were 87 bile-duct leaks, 28 leaks with stones, 51 strictures, and 17 complete duct transactions. The bile-duct injury rate calculated per 100 ERCPs per year was 0.84 (1994), 0.99 (1995), 1.36 (1996), 1.41 (1997), 1.03 (1998), 1.31 (1999), 0.84 (2000), 0.75 (2001), 1.15 (2002), and 0.94 (2003).

LIMITATIONS

Single institution, retrospective analysis, unknown denominator of cholecystectomies done in referral area per year to calculate true bile-duct injury rate.

CONCLUSIONS

Static incidence in frequency, anatomic distribution, and rate per 100 ERCPs per year of postcholecystectomy bile-duct injuries at a tertiary referral hepatobiliary unit over a 10-year period of observation.

Improved outcomes in postoperative and pancreatitis-related visceral pseudoaneurysms

Pseudoaneurysm (PSA) of the visceral arterial tree is an uncommon but highly lethal complication of pancreatic surgery and pancreatitis. Surgical and angiographic interventions are used in treatment; however, optimal therapy remains unclear. We hypothesized that the natural history of PSA is different in these discrete clinical settings. From 1995-2005, 37 patients with PSA were treated: 13 after pancreatic surgery and 24 in the setting of pancreatitis. Postoperative patients most frequently presented with bleeding (92%), either from the gastrointestinal (GI) tract or a surgical drain. In this group, the diagnosis was most commonly made by angiography (77%), and 62% had a pancreatic fistula. In patients with pancreatitis, abdominal pain was the only presenting symptom in 62%, and GI bleeding was present in 29%. Eighty-seven percent had an associated pseudocyst or fluid collection. Interventional radiologic therapy successfully arrested hemorrhage in all 35 patients in whom it was employed. There were four false negative angiograms, and two patients required repeated interventions for rebleeding. The overall mortality was 14%. Pseudoaneurysms present differently in these two clinical settings, but transcatheter intervention is the first treatment of choice in clinically stable patients. Early recognition and prompt angiographic occlusion leads to improved outcomes.

Declining morbidity and mortality rates in the surgical management of pancreatic necrosis

Surgical management of patients with pancreatic necrosis (PN) has evolved over the last two decades to include prophylactic antibiotics, initial medical management, and delayed surgical intervention. The purpose of this study is to identify changes in morbidity and mortality rates as our methods of surgical management have evolved. One hundred two consecutive patients (59 males and 43 females, mean age 53 +/- 16 years) with PN managed surgically were classified as group I (1993-2001), after the routine use of prophylactic antibiotics (N = 55), and group II (2002-2005), after the use of International Association of Pancreatology (IAP) guidelines for intervention (N = 47). Age, sex, etiology of pancreatitis, percent of necrosis, infected necrosis, and acute physiology and chronic health evaluation II scores were similar between groups. Despite a significant worsening of Balthazar computed tomography scoring in group II patients (p < 0.0001), operative morbidity (49 [89%] vs 34 [72%], p = 0.03), mortality (10 [18%] vs 2 [4%], p = 0.03), and hospital length of stay (38 +/- 33 days vs 26 +/- 23 days, p = 0.04) were significantly less in group II patients. Current methods of surgical management utilizing IAP guidelines have resulted in a decreased operative morbidity, mortality, and hospital length of stay in patients with PN.

A margin-negative R0 resection accomplished with minimal postoperative complications is the surgeon's contribution to long-term survival in pancreatic cancer

Pancreatic cancer has a poor prognosis with complete surgical resection being the only therapy to offer a realistic chance for long-term survival. The aim of this study is to identify surgery-related variables that influence long-term survival. Between 1990 and 2002, 226 consecutive patients (mean age of 64+/-11 years) had resection for pancreatic adenocarcinoma. Prognostic variables in these patients were analyzed using univariate and multivariate analysis. Two hundred four patients (90%) had pancreaticoduodenectomy, 13 patients (6%) had distal pancreatectomy, and 9 patients (4%) had a TP. Stage I disease was present in 50 (22%), stage II disease in 170 (75%), and stage III disease in 6 (3%). R0 resections were achieved in 70%. Operative morbidity was 36% and 30-day mortality was 6%. Actual 1-year, 3-year, and 5-year survival rates were 49% (n=111), 14% (n=31), and 4% (n=9). Using multivariate analysis: tumor size, tumor differentiation, obtaining an R0 resection, and lack of postoperative complications were variables associated with long-term survival. Long-term survival in patients with pancreatic cancer after resection remains poor. Achieving a margin negative resection (R0) with no postoperative complications are prognostic variables that can be affected by the surgeon.

Pancreatic Disorders in Children: Relationship of Postoperative Morbidity and the Indication for Surgery

Pancreatic surgery in children is a rare occurrence, and this unfamiliarity can be associated with the assumption of significant morbidity and mortality. The indication for pediatric pancreatic surgery and its relationship to postoperative complications and mortality was evaluated. Patients with pancreatic disease requiring surgical intervention from 1992 to 2004 at a tertiary referral center were retrospectively reviewed. Disorders were divided into 3 categories: 1) pancreatitis, 2) trauma, and 3) tumors. Sixty-two patients (28 males and 34 females), average age was 9.5 years (range, 1 week–18 years), underwent 72 operations. Thirty-seven procedures in 30 category I patients, 18 procedures in 15 category II, and 17 operations in 17 category III. There was only one death. A total of 33.9 per cent of the patients had postoperative complications that included: infection (11%), pseudocyst (6%), diabetes mellitus (5.6%), pancreatic fistula (3%), bowel obstruction (1.3%), extracellular fluid (1.3%), pleural effusion (1.3%), and recurrent abdominal pain (13%) (all in category I patients). There was equivalent morbidity between all 3 groups but unique differences with in the categories. Recurrent abdominal pain characterized category I patients, fistulas were more common in category II, and diabetes mellitus was primarily related to near total excisions in category III. Pancreatic surgery in children is associated with a very low mortality (1.6%) and morbidity equal to that of adult patients. Unique types of morbidities occur with each category of disease state.

Pancreatic disorders in children: relationship of postoperative morbidity and the indication for surgery

Pancreatic surgery in children is a rare occurrence, and this unfamiliarity can be associated with the assumption of significant morbidity and mortality. The indication for pediatric pancreatic surgery and its relationship to postoperative complications and mortality was evaluated. Patients with pancreatic disease requiring surgical intervention from 1992 to 2004 at a tertiary referral center were retrospectively reviewed. Disorders were divided into 3 categories: 1) pancreatitis, 2) trauma, and 3) tumors. Sixty-two patients (28 males and 34 females), average age was 9.5 years (range, 1 week-18 years), underwent 72 operations. Thirty-seven procedures in 30 category I patients, 18 procedures in 15 category II, and 17 operations in 17 category III. There was only one death. A total of 33.9 per cent of the patients had postoperative complications that included: infection (11%), pseudocyst (6%), diabetes mellitus (5.6%), pancreatic fistula (3%), bowel obstruction (1.3%), extracellular fluid (1.3%), pleural effusion (1.3%), and recurrent abdominal pain (13%) (all in category I patients). There was equivalent morbidity between all 3 groups but unique differences with in the categories. Recurrent abdominal pain characterized category I patients, fistulas were more common in category II, and diabetes mellitus was primarily related to near total excisions in category III. Pancreatic surgery in children is associated with a very low mortality (1.6%) and morbidity equal to that of adult patients. Unique types of morbidities occur with each category of disease state.

Influence of bactibilia after preoperative biliary stenting on postoperative infectious complications

The aim of this study was to correlate the bactibilia found after preoperative biliary stenting with that of the bacteriology of postoperative infectious complications in patients with obstructive jaundice. One hundred thirty-eight patients (83% malignant and 17% benign etiologies) with obstructive jaundice had both their bile and all postoperative infectious complications cultured. Eighty-six (62%) had preoperative biliary stents (stent group) and 52 (38%) did not (no-stent group). There were no differences for age, sex, incidence of malignancy, type of operation, estimated blood loss, transfusion requirements, hospital length of stay, morbidity, or mortality rates between the two groups. Of 31 infectious complications, 23 were in the stent group and eight were in the no-stent group (P > 0.05), but only 13 (42%) infectious complications had bacteria that were also cultured from the bile. Only wound infection (P = 0.03) and bacteremia (P = 0.04) were more likely to occur in stented patients. Taken together, these data show that preoperative biliary stenting increases the incidence of bactibilia, bacteremia, and wound infection rates but does not increase morbidity, mortality, or hospital length of stay. Jaundiced patients can undergo preoperative biliary stenting while maintaining an acceptable postoperative morbidity rate.

CT of Acute Biliopancreatic Limb Obstruction

OBJECTIVE

Our objective was to report the CT features of biliopancreatic limb (afferent loop) obstruction.

CONCLUSION

Acute biliopancreatic limb obstruction has typical CT features. Given its high morbidity and rate of reoperation, it is useful to make this specific diagnosis instead of reporting the findings as postoperative small bowel obstruction.

Small-bowel complications of major gastrointestinal tract surgery

OBJECTIVE

Gastrointestinal complications of major abdominal surgery often require radiologic assessment. The purpose of this article is to review the expected imaging findings and complications after commonly performed gastric and pancreatic surgery.

CONCLUSION

It is important to understand the postsurgical anatomy to avoid misinterpreting an expected postoperative finding as a complication. Postoperative complications can be categorized as being related to adhesions, anastomosis, an enteric connection, and abnormal bowel position.

Use of a new sealing device to simplify jejunal resection during pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy has undergone numerous technical modifications since the original reported series in 1935, but little focus has been directed to the dissection and ligation of the mesenteric blood supply to the first portion of the jejunum.

METHODS

Sixty-four patients in whom the device was used were compared to a historical cohort of 128 patients who had undergone pancreaticoduodenectomy at our institution.

RESULTS

The technique described provided a rapid, ergonomically efficient method to complete step 5 of pancreaticoduodenectomy. We found no differences in average hospital length of stay (LOS), reoperation rate, morbidity, mortality, or postoperative readmission rates between patients operated on before or after adoption of this technique

CONCLUSION

The Ligasure sealing device (Valleylab, Boulder, CO) provides an excellent, safe alternative to the classic use of clamps and ties when resecting the first portion of the jejunum during pancreaticoduodenectomy.

Surgery for chronic pancreatitis: cross-sectional imaging of postoperative anatomy and complications

OBJECTIVE

Surgery is increasingly undertaken for intractable chronic pancreatitis. We evaluated the postsurgical anatomy and complications of surgical options including Whipple, Puestow, Frey's, and Beger's procedures.

CONCLUSIONS

Knowledge of postsurgical anatomy is important to avoid misdiagnosing expected anatomy as complications on CT examinations. It is important to carefully assess the upper abdominal arteries to detect subtle but potentially lethal complications.

Radiology of small bowel obstruction: contemporary approach and controversies

The radiologic workup of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this complex situation have undergone considerable changes over the past two decades. The diagnosis and treatment of small bowel obstruction, a common clinical condition often associated with signs and symptoms similar to those seen in other acute abdominal disorders, continue to evolve. This article examines the changes related to the use of imaging in the diagnosis and management of patients with this potentially dangerous problem and revisits pertinent controversies.

Endoscopic snare papillectomy for tumors of the duodenal papillae

BACKGROUND

Tumors of the major and the minor duodenal papillae can be malignant or premalignant, and traditionally are treated by surgical excision. This study evaluated the safety and the outcome of endoscopic snare resection of such tumors.

METHODS

All patients with tumors of the major or the minor papilla treated by endoscopic snare resection over a 10-year period (1994-2003) were identified from an ERCP database. Patients with tumors that had endoscopic features of malignancy and those proven to be cancerous by biopsy were excluded. Papillectomy was performed by electrosurgical snare resection. A pancreatic stent usually was placed before or after excision. Residual tumor was eradicated by repeated procedures. Endoscopic surveillance was at the discretion of the endoscopist.

RESULTS

Seventy snare resections were performed in 55 patients (mean age 59 years). Histopathologic diagnoses were the following: adenoma (45 patients; 7 with focal high-grade dysplasia, 6 with intraductal extension), adenocarcinoma (5), carcinoid tumor (2), gastric heterotopia (1), and normal histology (2). Fourteen patients had familial adenomatous polyposis. Of the 39 patients with isolated extraductal adenoma per cholangiogram, two underwent surgical resection because of persistent high-grade dysplasia, and 37 were successfully treated by endoscopic papillectomy alone. During follow-up (mean 30 months), 18 of 37 patients (49%) had no recurrence, 7 had recurrent adenoma (mean time interval to recurrence 27 months), two died of unrelated illnesses, and 10 are awaiting follow-up. Of the 6 patients with intraductal adenoma per cholangiogram, two underwent surgical resection, two had intraductal photodynamic therapy, and two had endoscopic snare resection. Intraductal tumor in the 4 latter patients was eliminated, although it recurred in one of the patients who had photodynamic therapy. Of the 7 patients with adenocarcinoma or carcinoid tumor, pancreaticoduodenectomy was performed in 3 and palliative papillectomy was performed in 4 unsuitable for surgery. One patient with carcinoid tumor of the minor papilla is alive, without recurrence, at 5 years after papillectomy. There were 10 procedure-related complications (14.5%), including pancreatitis (5), bleeding (4), and mild perforation (1). There was no procedure-related death.

CONCLUSIONS

Most adenomas of the duodenal papillae without intraductal extension can be fully resected by snare papillectomy. However, adenoma recurs in about a third of patients. Endoscopic therapy appears to be a reasonable alternative to surgery for management of papillary tumors. Longer follow-up is needed to determine the true recurrence rate and if endoscopic re-treatments are effective.

Pancreatic duct strictures are a common cause of recurrent pancreatitis after successful management of pancreatic necrosis

BACKGROUND

Successful surgical management of pancreatic necrosis can result in structural changes that cause recurrent pancreatitis. The purpose of this study is to review our clinical experience managing recurrent pancreatitis in patients after successful pancreatic debridement.

METHODS

We retrospectively reviewed 98 patients with pancreatic necrosis treated by debridement who made a complete recovery at our institution over an 8-year period (January 1995 to January 2003).

RESULTS

Fourteen patients (14%) developed recurrent pancreatitis 5 to 39 months (median, 15 months) after recovery. Five patients (36%) had pancreatic pseudocysts and 9 (64%) had radiologic evidence of obstructive pancreatitis. All patients had either a high-grade pancreatic duct stricture (N=7) or complete duct cutoff (N=7), localized to the pancreatic neck (N=10) or proximal pancreatic body (N=4) identified by either endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. Two patients failed endoscopic stent therapy. All patients required re-operative treatment: 6 distal pancreatectomy, 6 pancreatico-jejunostomy Roux-en-Y, and 2 cystojejunostomy Roux-en-Y with no recurrence of pancreatitis after a median follow-up of 22 months.

CONCLUSIONS

Recurrent pancreatitis occurs in 14% of patients after successful pancreatic debridement. Pancreatic duct obstruction in the neck or proximal body is the primary etiologic factor. Re-operation directed at alleviating this ductal obstruction by resection or drainage is effective.

Pancreaticoduodenectomy: a 20-year experience in 516 patients

HYPOTHESIS

Pancreaticoduodenectomy (PD) is a safe procedure for a variety of periampullary conditions.

DESIGN

Retrospective review of a prospectively collected database.

SETTING

Academic tertiary care hospital.

PATIENTS

A total of 516 consecutive patients who underwent PD.

MAIN OUTCOME MEASURES

Patient outcomes and survival factors.

RESULTS

Pathological examination demonstrated 57% periampullary cancers, 22% chronic pancreatitis, 12% cystic neoplasms, 4% islet cell neoplasms, and 5% other. Fifty-one percent of patients underwent pylorus preservation. Median operating time was 5 hours; blood loss, 1300 mL; and transfusion requirement, 1.5 U. Postoperative complications occurred in 43% of patients, including cardiopulmonary events (15%), fistula (9%), delayed gastric emptying (7%), and sepsis (6%). Additional surgery was required in 3% of patients, most commonly because of bleeding. Perioperative mortality was 3.9% overall but only 1.8% in patients with chronic pancreatitis; 25% of patients who died had preoperative complications associated with their periampullary condition. Three-year survival was 15% after resection for pancreatic cancer, 42% for duodenal cancer, 53% for ampullary cancer, and 62% for bile duct cancer. Univariate predictors of long-term survival in patients with periampullary adenocarcinoma included elevated glucose levels, liver function test results, abnormal tumor markers, blood loss, transfusion requirement, type of operation, and pathologic findings (periampullary adenocarcinoma type, differentiation, and margin and node status). Multivariate predictors were serum total bilirubin level, blood loss, operation type, diagnosis, and lymph node status.

CONCLUSIONS

Pancreaticoduodenectomy continues to be associated with considerable morbidity. With careful patient selection, PD can be performed safely. Long-term survival in patients with periampullary adenocarcinoma can be predicted by preoperative laboratory values, intraoperative factors, and pathologic findings.

The multifaceted role of radiology in small bowel obstruction

Small bowel obstruction is a common clinical condition, often presenting with signs and symptoms similar to those seen in other acute abdominal disorders. The diagnosis and treatment of this dynamic process continues to evolve. The imaging approach in the work-up of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this disease have undergone considerable changes over the past two decades. This article examines the changes related to the use of imaging technology in the diagnosis and management of patients with small bowel obstruction. The meaning of frequently used but poorly defined terms in describing intestinal obstruction is clarified and illustrated.