Search

In selected patients with metastatic renal cell carcinoma, metastasectomy can achieve prolonged survival. Herein we report a patient with concomitant pancreatic and duodenal metastases occurring 12 years after total right nephrectomy for a renal cell carcinoma. The metastases were successfully treated by a pancreas-sparing duodenectomy and distal pancreatectomy. A 66-year-old man was referred to our hospital with a chief complaint of right upper abdominal pain. He had undergone laparoscopic total right nephrectomy for renal cell carcinoma 12 years before. Enhanced computed tomography showed hypervascular tumors in the pancreatic body and the descending duodenum near the papilla of Vater. Histopathological examination of endoscopic ultrasonography-guided fine needle aspiration cytology specimens revealed metastatic clear cell renal cancer. The patient underwent pancreas-sparing duodenectomy and distal pancreatectomy. He developed a pancreatic fistula after surgery that improved with conservative treatment, and has been free of evidence of recurrence up to 20 months postoperatively. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) is the most important cause of an extended hospital stay after pancreatoduodenectomy. Reports suggest that a Roux‐en‐Y gastroenteric anastomosis may have lower incidence of DGE than a Billroth II reconstruction. The primary aim of this RCT was to compare Billroth II (single loop) and Roux‐en‐Y (double loop) after pancreatoduodenectomy to determine whether Roux‐en‐Y reconstruction is associated with a lower incidence of DGE. Secondary endpoints were postoperative complications. Methods: This was a randomized unblinded single‐centre trial without masked evaluation of the main outcome. Patients undergoing pancreatoduodenectomy between 2013 and 2015 were randomized to undergo one of two types of gastroenteric anastomosis for reconstruction. Results: A total of 80 patients were randomized, 40 in each group. The incidence of DGE was the same in patients undergoing Billroth II or Roux‐en‐Y gastroenteric anastomosis (both 18 of 40 patients; P = 1·000). The grade of DGE was also similar in the Billroth II and Roux‐en‐Y groups (grade A, both 10 of 40; grade B, 5 of 40 versus 6 of 40; grade C, 3 of 40 versus 2 of 40; P = 0·962). The mortality rate was 3 per cent, with no significant difference between the two groups. There were no differences in the overall rate of postoperative morbidity, relaparotomy rate or duration of hospital stay. Conclusion: The incidence and severity of DGE does not differ between single‐ or double‐loop gastroenteric anastomosis performed after pancreatoduodenectomy. Registration number: NCT00915863 (http://www.clinicaltrials.gov). No difference in outcomes [ABSTRACT FROM AUTHOR]

Background: Ideal surgical treatment for acute duodenal injuries should offer a definitive treatment, with low morbidity and mortality. It should be simple and easily reproducible by acute care surgeons in an emergency. Duodenal injury, due to major perforated or bleeding peptic ulcers or iatrogenic/traumatic perforation, represents a surgical challenge, with high morbidity and mortality. The aim was to review definitive surgery with pancreas‐sparing, ampulla‐preserving duodenectomy for these patients. Methods: Pancreas‐sparing, ampulla‐preserving D1–D2 duodenectomy was used for patients presenting with major duodenal injuries over a 5‐year interval. The ampulla was identified and preserved using a transcystic/transpapillary tube. The outcomes were recorded. Results: Ten patients were treated with this technique; seven had perforated or bleeding peptic ulcers, two had iatrogenic perforations and one blunt abdominal trauma. Their mean age was 78 (range 65–84) years. Four patients were haemodynamically unstable. The location of the duodenal injury was always D1 and/or D2, above or in close proximity to the ampulla of Vater. The surgical approach was open in nine patients and laparoscopic in one. The mean duration of surgery was 264 (range 170–377) min. All patients were transferred to the ICU after surgery (mean ICU stay 4·4 (range 1–11) days), and the overall mean hospital stay was 17·8 (range 10–32) days. Six patients developed major postoperative complications: cardiorespiratory failure in five and gastrointestinal complications in four. Surgical reoperation was needed in one patient for postoperative necrotizing and bleeding pancreatitis. Two patients died from their complications. Conclusion: Pancreas‐sparing, ampulla‐preserving D1–D2 duodenectomy for emergency treatment of major duodenal perforations is feasible and associated with satisfactory outcomes. [ABSTRACT FROM AUTHOR]

Background: The aim of this systematic review andmeta-analysis was to evaluate perioperative outcomes and survival in patients undergoing an artery-first approach to pancreatoduodenectomy in comparison with those having standard pancreatoduodenectomy. Methods: A systematic search of PubMed, MEDLINE, Embase and the Cochrane Database of Systematic Reviews was performed in accordance with PRISMA guidelines. Comparative studies including patients who underwent artery-first pancreatoduodenectomy and standard pancreatoduodenectomy were analysed. Results: Seventeen studies were included in the final analysis. There were 16 retrospective cohort or case-control studies and one RCT. A total of 1472 patients were included in the meta-analysis, of whom 771 underwent artery-first pancreatoduodenectomy and 701 had standard pancreatoduodenectomy. Intraoperative blood loss (mean difference -389 ml; P <0.001) and the proportion of patients requiring intraoperative transfusion (10.6 per cent (54 of 508) versus 40.1 per cent (186 of 464); P <0.001) were significantly lower in the artery-first group. Although rates of perioperative mortality were comparable between the two groups, perioperative morbidity (35.5 per cent (263 of 741) versus 44.3 per cent (277 of 625); P = 0.002), and the incidence of grade B/C pancreatic fistula (7.4 per cent (26 of 353) versus 12.8 per cent (42 of 327); P = 0.031) were significantly lower in the artery-first group. The R0 resection rate (75.8 per cent (269 of 355) versus 67.0 per cent (280 of 418); P <0.001) and overall survival (hazard ratio 0.72, 95 per cent c.i. 0.60 to 0.87; P <0.001) were significantly higher in the artery-first group. Conclusion: The artery-first approach to pancreatoduodenectomy may be associated with improved perioperative outcomes and survival. [ABSTRACT FROM AUTHOR]

Background Fast-track ( FT) programmes are multimodal, evidence-based approaches to optimize patient outcome after surgery. The aim of this study was to evaluate the safety, clinical outcome and patients' experience of a FT programme after pancreaticoduodenectomy ( PD) in a high-volume institution in Sweden. Methods Consecutive patients undergoing PD were studied before and after implementation of the FT programme. FT changes included earlier mobilization, standardized removal of the nasogastric tube and drain, and earlier start of oral intake. Patient experience was evaluated with European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-PAN26 questionnaires 2 weeks before and 4 weeks after surgery. Results Between 2011 and 2014, 100 consecutive patients undergoing PD were studied, of whom 50 received standard care (controls), followed by 50 patients treated after implementation of the FT programme. The nasogastric tube was removed significantly earlier in the FT group, and these patients were able fully to tolerate fluids and solid food sooner after PD. Delayed gastric emptying was significantly reduced in the FT group (26 versus 48 per cent; P = 0·030). Overall morbidity remained unchanged and there were no deaths in either group. Postoperative length of hospital stay was reduced from 14 to 10 days and hospital costs were decreased significantly. Health-related quality-of-life questionnaires showed similar patterns of change, with no significant difference between groups before or after surgery. Conclusion The FT programme after PD was safe. Delayed gastric emptying, hospital stay and hospital costs were all reduced significantly. Although patients were discharged 4 days earlier in the FT group, this did not influence health-related quality of life compared with standard care. [ABSTRACT FROM AUTHOR]

Background Surgical reconstruction following pancreaticoduodenectomy ( PD) is associated with significant morbidity and mortality. Because of great variability in definitions of specific complications, it remains unclear whether there is a difference in complication rates following the two commonest types of reconstruction, pancreaticogastrostomy ( PG) and pancreaticojejunostomy ( PJ). Published consensus definitions for postoperative pancreatic fistula ( POPF) have led to a series of randomized clinical trials ( RCTs) uniquely placed to address this question. Methods A literature search was carried out to identify all RCTs comparing postoperative complications of PG versus PJ reconstruction following PD published between January 1995 and December 2013. Pooled odds ratios ( ORs) with 95 percent confidence intervals (c.i.) were calculated using fixed-effect or random-effects models. Results In total, seven RCTs with 1121 patients were included. Four of these trials applied definitions as published by the International Study Group on Pancreatic Fistula ( ISGPF). Using ISGPF definitions, the incidence of POPF was lower in patients undergoing PG than in those having PJ ( OR 0·50, 95 per cent c.i. 0·34 to 0·73; P < 0·001). Using definitions applied by each individual study, PG was associated with significantly lower rates of POPF ( OR 0·51, 0·36 to 0·71; P < 0·001), intra-abdominal fluid collection ( OR 0·50, 0·34 to 0·74; P < 0·001) and biliary fistula ( OR 0·42, 0·18 to 0·93; P = 0·03) than PJ. Conclusion Meta-analysis of four RCTs based on ISGPF criteria, and seven RCTs using non-standard criteria, revealed that PG reduced the incidence of POPF after PD compared with PJ. [ABSTRACT FROM AUTHOR]

Guidelines for a rare disease [ABSTRACT FROM AUTHOR]

The article provides information on the complications and follow-up after the pancreas-preserving total duodenectomy (PPTD) for duodenal polyps. It is concluded that the morbidity of PPTD is the same with partial pancreatoduodenectomy but the PPTD preserves the whole pancreas and decreases the number of anastomoses.

The article focuses on Pancreas-preserving total duodenectomy (PPTD) that will replace pancreatoduodenectomy in treating patients with familial adenomatous polyposis (FAP). Patients with FAP develop multiple colonic adenomatous polyps, which if not treated will progress into colonic adenocarcinoma. PPTD will act as an alternative to pancreatoduodenectomy, however, it will result to definitive prevention of duodenal cancer but with lower morbidity and mortality rates.

Evaluates the management of pancreatic leakage after pancreatoduodenectomy. Number of patients in the study; Incidence of pancreatic leakage; Development of endocrine insufficiency.

Compares the results of pylorus-preserving duodenopancreatectomy and the classical Whipple procedure in the resection of pancreatic and periampullary tumors. Comparison of long-term survival, quality of life and weight gain; Minor advantages in the early postoperative period offered by pylorus-preserving Whipple resection.

Examines the effects of preoperative biliary stenting on early outcome after pancreaticoduodenectomy. Association of preoperative biliary stenting with bacterial contamination of bile and an increased rate of infectious complications after pancreaticoduodenectomy; Finding that uncomplicated stenting was not associated with increased morbidity or mortality.

Background Treatment of enterocutaneous fistula in patients with intra-abdominal sepsis and a surgically inaccessible abdomen is frequently unsuccessful. Methods A new approach has been devised: total disconnection of the proximal digestive tract, which can be performed through the bursa omentalis without entering the scarred abdomen. Results The procedure was carried out in four patients with high-output small bowel fistula and an inaccessible abdomen. Output of fistulas stopped promptly, recovery from intra-abdominal sepsis was achieved, the abdomens became accessible again and continuity of the digestive tract could be restored in all patients after intervals of 2–5·5 months. Conclusion Transbursal end-to-side duodenogastrostomy is a useful procedure when traditional surgical interventions have failed or cannot be applied. [ABSTRACT FROM AUTHOR]

Here, we describe the case of a 56-year-old African American male who initially presented to the emergency department with 2 days of abdominal cramping, epigastric pain, loss of consciousness, melena and hematochezia. He underwent coil embolization of his gastroduodenal artery by the interventional radiology team after it was felt he was a high risk for rebleed. The patient then returned to the hospital with 3 weeks of epigastric pain, lightheadedness and melanotic stool. An upper endoscopy revealed a metallic coil embedded into the duodenal bulb. This coil was believed to be from prior embolization to the gastroduodenal artery. The patient then underwent a laparoscopic distal gastrectomy and partial duodenectomy with antecolic antegastric Roux-en-Y reconstruction bypassing the area where erosion occurred. [ABSTRACT FROM AUTHOR]

Bleeding after pancreatico-duodenectomy (PD) is a serious complication with high rates of morbidity and mortality. Interventional radiology techniques' using embolization and/or stenting is the optimal management. In case of hemodynamic instability, surgical treatment is mandatory, but its mortality rate is considerable. Herein, we report the management of massive bleeding in a 52-year-old-male patient, 3 weeks after PD. The patient suffered severe hemorrhage with two cardiac arrests and surgical treatment was performed immediately after resuscitation. A defect in the distal part of the hepatic artery was repaired using a peritoneal patch. A postoperative CT scan confirmed bleeding control and the presence of a pseudoaneurysm within the patch area. The second step of the treatment was to perform selective embolization. The course was uneventful, and the patient was discharged 6 weeks later. [ABSTRACT FROM AUTHOR]

This article discusses a study on pancreatoduodenectomy (PD) for extended duodenal and pancreatic caustic necrosis. The study involved a large single-center cohort of patients with caustic injuries and assessed morbidity, mortality and long-term outcome. It showed the recovery of three patients from nutritional autonomy and recorded functional success in three patients.

Aims: To assess the role of PSDD for neoplasms that arise in the third and fourth parts of the duodenum (D[sub 3], D[sub 4]). Methods: PSDD was performed in 9 men and 5 women with infrapapillary duodenal neoplasms between 1991 and 2002, and clinical outcome reviewed. The operation entails separation of the pancreatic head from D[sub 3], mobilization of the ligament of Treitz and end-to-end duodenojejunal anastomosis 1-3 cm below the papilla. Results: The median age was 54 (27-73) years, presenting with anaemia (n = 8), gastric outlet obstruction (n = 4), epigastric pain or mass (1 each). There were 11 malignant neoplasms (adenocarcinoma 5, stromal turnout 4, recurrent seminoma 1, plasmacytoma 1), 2 benign neoplasms (villous adenoma, lipoma) and one steroid-induced ulceration. In addition to D[sub 3]/D[sub 4], resection included distal D[sub 2] in 5 patients, while 4 required partial colectomy. Median operation time was 240 (180-330) mins and median blood loss 1200 ml, being greater for malignant than benign lesions (1650 vs. 750 ml). Median time to oral intake was 8 (6-21) days. One patient died from gangrenous cholecystitis. There was one early reoperation for anastomotic bleeding and two late reoperations for delayed gastric emptying (1 stricture, 1 'functional'), but no pancreatic complications. At a median follow-up of 20 (2-132) months, two patients had died of recurrent cancer, the others were alive and asymptomatic. Conclusions: PSDD is a useful alternative to pancreatoduodenectomy in patients with neoplasms arising from D[sub 3] and D[sub 4], provided there is a 1-cm clearance at the papilla. Although a major undertaking, it avoids the extra time and risk of a pancreatic resection and anastomosis. [ABSTRACT FROM AUTHOR]

Aims: The pancreatic stump anastomosis is vulnerable to leakage following pancreatico-duodenectomy (PD). A prospective study of patients undergoing mucos to mucos pancreatico-gastrostomy reconstruction after PD was carried out. Methods: 100 consecutive PDs were performed for tumour between 1991 and 2002. There were 53 females and 47 males (age range 43-88 years). Reconstruction was via a roux-en-Y hepatodochojejunostomy and gastroenterostomy. The pancreatic remnant was anastomosed into the back of the stomach via a mucos to mucos pancreaticogastrostomy over a plastic stent (removed at endoscopy 2-6 weeks after surgery). No somatostatin analogues were used in the perioperative period. Long-term follow up has been obtained for all patients. Results: There was one postoperative death due to necrotizing enteritis (60 day mortality: 1%). There were no clinical or sub clinical pancreatic fistulae (drainage fluid with >3 × amylase level c.f. serum after 4th postoperative day). Median hospital stay was 13 days. Major complications occurred in 17% and minor complications in 21%. At long-term follow up 19% of patients have required pancreatic enzyme supplements, 4% have developed diabetes and 3% have had an episode of acute pancreatitis. Conclusions: Mucos to mucos pancreaticogastrostomy is a safe method of reconstruction following PD, and there is no need for the use of perioperative somatostatin analogues. [ABSTRACT FROM AUTHOR]