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Although the laparoscopic approach to distal pancreatectomy for benign and malignant diseases is largely replacing open surgery in some centers, well-designed studies comparing these approaches are limited. We present a case-matched study that compares the outcomes of laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP).Of 112 patients (51 female) who underwent surgery between January 2002 and December 2011, 44 patients were matched on a 1:1 basis (22 LDP, 22 ODP) according to age, sex, and tumor size. Outcomes were compared on an intention-to-treat basis. Data shown represent median where appropriate.The laparoscopic and open groups were comparable for age (57 vs. 59.9 y, P=0.980), sex distribution (P=1.000), tumor size (3 vs. 4 cm, P=0.904), and the frequency of benign versus malignant disease (P=0.920). LDP was associated with significantly lower blood loss (100 vs. 500 mL, P=0.001), higher spleen preservation rate (45% vs. 18%, P=0.029), as well as shorter high dependency unit stay (1 vs. 5 d, P=0.001) and postoperative hospital stay (5 vs. 14 d, P=0.017). There was no significant difference in operating time (245 vs. 240 min, P=0.602) and postoperative morbidity (13.6% vs. 27.2%, P=0.431). In patients with malignant disease, there were no differences in R0 resection margin status (90% vs. 85.7%, P=0.88), the numbers of lymph nodes retrieved (12.7 vs. 14.1, P=0.82), the 1- and 2-year survival rates (89% vs. 81%, P=0.54 and 74.2% vs. 71.5%, P=0.63, respectively), and the mean duration of survival (45 vs. 31 mo, P=0.157).The laparoscopic approach to distal pancreatectomy offers advantages over open surgery in terms of reductions in operative trauma and duration of postoperative recovery without compromising the oncologic resection.

Introduction Advances in surgical technologies allowed safe laparoscopic pancreaticoduodenectomy (LPD). The aim of this study is to compare the oncologic outcomes of LPD to open pancreaticoduodenectomy (OPD) in terms of safety and recurrence rate. Materials and methods A cohort of 30 patients were matched for age, sex, American Society of Anaesthesiologists, tumor size, pancreatic duct diameter, and histopathologic diagnosis on a 1:1 basis (15 LPD, 15 OPD). Comparison between groups was performed on intention-to-treat basis. Survival following resection was compared using the Kaplan-Meier survival analysis. Results The median operating time for LPD group was longer than for OPD group (470 vs. 310 min; P=0.184). However, estimated blood loss (300 vs. 620 mL; P=0.023), high dependency unit stay (2.0 vs. 6.0 d; P=0.013) and postoperative hospital stay (9.0 vs. 17.4 d; P=0.017) were significantly lower in the LPD group. There was no significant difference in postoperative rates of morbidity (40% vs. 67%; P=0.431) and mortality (0% vs. 6.7%; P=0.99). The surgical resection margins R0 status (87% vs. 73%; P=0.79) and the number of lymph nodes (18 vs. 20; P=0.99) in the resected specimens were comparable between the 2 groups. There was no significant difference in overall survival outcomes. Conclusions In selected patients, the laparoscopic approach to pancreaticoduodenectomy in the hands of the experienced offers advantages over open surgery without compromising the oncologic resection.

Background Pancreatic resection and/or ductal drainage are common surgical options in the management of unremitting abdominal pain of chronic pancreatitis (CP). We describe the results of the largest UK series of laparoscopic approach to pancreatic duct drainage and head resection for CP. Methods Patients with CP and intractable abdominal pain requiring duodenum-preserving pancreatic head resection (Berne modification of Beger procedure) or Puestow procedure were offered laparoscopic surgery by a single surgeon. The results shown represent median (range). Results Six patients (3 males) with CP (alcohol induced, n=4; idiopathic, n=2) underwent surgery between 2009 and 2012. The pancreatic duct diameter was 8.75 (6 to 11) mm. Five patients have had lateral pancreaticojejunostomy and 1 patient underwent Berne modification of Beger procedure, all of which were completed laparoscopically. The operating time was 277.5 (250 to 360) minutes. There were no deaths and 1 patient was readmitted 10 days postoperatively and had laparotomy for pancreatic bleeding after pancreaticojejunostomy (morbidity, 17%). The hospital stay was 5 (5 to 8) days. At a follow-up of 14.2 (10 to 35) months, 4 of the patients were pain free, whereas 2 patients required one third and half of the preoperative oral opioid dose for pain control. Conclusions The laparoscopic approach to pancreatic duct drainage and duodenum-preserving head resection in carefully selected patients and in experienced hands is feasible and safe with good short-term results and potential advantages. Further expansion of experience and longer follow-up is required.

Congenital insensitivity to pain is a rare condition that is often undiagnosed until patients present with a variety of musculoskeletal problems. A major sequel of these orthopaedic manifestations is the development of heterotopic ossification and callus formation following fractures, eventually leading to the development of a Charcot's joint. This case reports on a 7-year-old child who was diagnosed with congenital insensitivity to pain type V, after he presented in our clinic with fractures of the metatarsals in his left foot while continuing to weight bear, without any discomfort. The patient failed to attend the follow-up in paediatric neurology clinic despite multiple invitations. This case highlights the importance of establishing an early diagnosis and keeping a close eye on this rare entity, which can present for the first time in a paediatric fracture clinic.

Background Cystgastrostomy is the commonest method of internal drainage of pancreatic pseudocysts (PPs). While large and persistent retrogastric pancreatic pseudocysts are amenable to laparoscopic cystgastrostomy, the potential benefits of this minimally invasive laparoscopic approach over open surgery remain to be demonstrated. The aim of this study was to compare the outcomes of the laparoscopic and open approaches for cystgastrostomy. Methods Patients who underwent laparoscopic cystgastrostomy (LCG) were matched on a 3:1 basis to those who underwent open cystgastrostomy (OCG) according to age, sex distribution, and size of pseudocyst. The outcomes of the two approaches were compared on an intention-to-treat basis. Data shown represent medians. Results A total of 54 patients underwent cystgastrostomy (35 LCG, 19 OCG) between 1997 and 2011. The final case matched cohort consisted of 40 patients (12 female and 28 male) of which 30 underwent LCG (two converted to open surgery) and 10 underwent OCG. The laparoscopic and open groups were comparable for age (55 vs. 59 years, P = 0.80), sex distribution, and size of pseudocyst (10 vs. 13 cm, P = 0.51). The laparoscopic approach had a significantly shorter operating time (62 vs. 95 min, P = 0.035) and carried a significantly lower risk of postoperative morbidity (10% vs. 60%, P = 0.024) and shorter postoperative hospital stay (6.2 vs. 11 days, P = 0.038). There was one operative death after OCG (10%). Conclusion The laparoscopic approach to cystgastrostomy for large and persistent retrogastric pancreatic pseudocysts is associated with a shorter operating time, smoother and more rapid recovery, and a shorter hospital stay compared with open surgery. The laparoscopic approach should be considered the preferable approach where expertise is available.

Salmonella osteomyelitis occurs infrequently in healthy children and can manifest in the subacute form. This condition has only been reported in few cases previously. We report the first case of primary subacute haematogenous osteomyelitis of the calcaneum in a healthy 12-year-old child. The patient made uneventful recovery following surgical drainage and antibiotic therapy. Histology of the tissue biopsy confirmed a diagnosis of Salmonella livingstone infection. Although the diagnosis of Salmonella osteomyelitis of the calcaneum can be difficult to establish, it should be considered as an aetiological factor even in healthy children.

The common bile duct traditionally is managed with T-tube drainage after choledochotomy and removal of common bile duct (CBD) stones, but this approach carries an associated tube-related morbidity rate, including bile leak, of 10.5–20 %. This study examined the safety and effectiveness of laparoscopic CBD exploration (LCBDE) followed by primary duct closure. This is a retrospective analysis of 120 consecutive patients (81 female) who underwent LCBDE between October 2002 and October 2012. The duct primarily was closed in all patients. The results are given as median (range). Trans-CBD exploration was performed in 120 patients and all cases were successfully completed laparoscopically. The maximum diameter of the CBD was 9.4 (3–30) mm and the number of CBD stones detected was 3 (0–20). The biliary tree was clear at the end of exploration in 116 patients (96.7 %). The operating time was 122 (70–360) min. The mortality rate, morbidity rate, postoperative bile leak rate, rate of retained CBD stones after the primary procedure, and CBD stricture rate at a follow-up of 39.2 (2–82) months were 0, 8.3, 2.5, 3.3, and 0.8 %, respectively. The postoperative hospital stay was 2.1 (1–29) days. Primary duct closure following LCBDE is safe, can be employed routinely as an alternative to T-tube insertion, and has a short hospital stay and low morbidity rate.

Introduction Side branch IPMN (SB-IPMN) of the pancreas has a malignancy rate between 10 and 20%. We hypothesized that surveillance at longer intervals on selected patients with SB-IPMN might be indicated. Methods This is a retrospective study of prospectively collected data of 276 patients presenting from 2000 to 2010. After 2007, we opted to screen our patients with longer intervals, initially at 12 months then 24 months using MR if no “worrisome features” were present. Results Complete data sets for 261 patients were analysed and patients were aged 78 (40–91) years. 232 patients had sole SB-IPMN while 92% were incidental (n = 209) and 8% were symptomatic (n = 24). Single SB-IPMN accounted for 84% (n = 195) of all cases; maximum diameter of 15.5 (5–60) mm. The median follow up duration was 46 (32–53) months. Short interval radiological surveillance (3–9 months) was 39% (n = 90), while long interval surveillance (12–36 months) was performed in 61% (n = 142). The rate of pancreatic resection, due to concern for the development of pancreatic cancer, in the short and long interval surveillance groups was 4.4% (n = 4) and 3.5% (n = 5) respectively; p = 0.78. Conclusion Our data suggests no difference in outcome between long and short interval MR surveillance of SB-IPMN patients.

To the editor, We agree that it is best to avoid laparoscopic common bile duct exploration (LCBDE) in patients with small diameter bile ducts (amongst our 120 patients who underwent LCBDE, one had a diameter of 3 mm, 3 of 4 mm and 4 of 5 mm). However, exploration of these is possible with the use of a 3-mm choledochoscope or via a trans-cystic duct approach. Whilst single-stage LCBDE is not the preferable option in high-risk patients, at times it becomes unavoidable when the endoscopic approach to management of ductal stones has failed. In our experience, LCBDE with primary closure can be performed in both elective and emergency cases. We performed emergency LCBDE in ten patients and encountered a postoperative chest infection in one and urinary tract infection in another but no bile leaks or duct strictures. Clearly though, patients with cholangitis, deep jaundice and coagulopathy should be optimised preoperatively and consideration should be given to preoperative percutaneous transhepatic biliary drainage as a temporising measure before embarking on LCBDE. With the use of a transverse choledochotomy and interrupted 4–0 Vicryl suture closure of non-dilated bile ducts (\6 mm diameter) at LCBDE (n = 8), we have encountered no postoperative bile leaks or bile duct strictures. We agree that endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic nasobiliary drainage have their application in the management of bile leak due to retained stones after LCBDE. However, re-laparoscopy has its role in patients with generalised abdominal signs and systemic disturbance as it facilitates a thorough abdominal washout as well as removal of retained duct stones with re-suturing of the bile duct. Nasobiliary drainage is not commonly adopted in the United Kingdom.

Background Laparoscopic surgery has extended its applications to resection of malignancies with favorable results. We report the first successful simultaneous laparoscopic subtotal colectomy and pancreaticoduodenectomy (PD) in a patient with familial adenomatous polyposis (FAP). Case report A 37-year-old man presented with obstructive jaundice. Gastroscopy and biopsies revealed a large ampullary tubulovillous adenoma with mild dysplasia (Spigelman stage III). A colonoscopy for suspicion of FAP revealed numerous right-sided polyps with left-sided sparing. Computed tomography showed a double duct sign. A simultaneous laparoscopic subtotal colectomy and PD was performed successfully. The operative time was 225 minutes for the colectomy and 390 minutes for the PD. Histology showed an R0 resection of ampullary adenocarcinoma (20 negative nodes) and colonic polyps with low-grade dysplasia. Genetic screening confirmed a diagnosis of FAP. Conclusions A simultaneous laparoscopic subtotal colectomy and PD in patients with FAP and ampullary neoplasia seems safe with favorable clinical and oncologic outcomes.

Introduction Ductal carcinoma in-situ (DCIS) is a heterogeneous entity with an elusive natural history. The objective of radiological, histological and molecular characterisation remains to reliably predict the biological behaviour and optimise clinical management strategies. Increases in diagnostic frequency have followed the introduction of mammographic screening and increased utility of magnetic resonance imaging. However, progress remains limited in distinguishing non-progressive incidental lesions from their progressive and clinically relevant counterparts. This article reviews current management strategies for DCIS in the context of recent randomized trials, including the role of sentinel lymph node biopsy (SLNB), adjuvant radiotherapy (RT) and endocrine treatment. Methods Literature review facilitated by Medline, PubMed, Embase and Cochrane databases. Results DCIS should be managed in the context of a multidisciplinary team. Local control depends upon adequate surgical clearance with margins of at least 2 mm. SLNB is not routinely indicated and should be reserved for those with concurrent or recurrent invasive disease. SLNB can be considered in patients undergoing mastectomy (MX) and those with risk factors for invasion such as palpability, comedo morphology, necrosis or recurrent disease. RT following BCS significantly reduces local recurrence (LR), particularly in those at high-risk. There remains a lack of level-1 evidence supporting the omission of adjuvant RT in selected low-risk cases. Large, multi-centric or recurrent lesions (particularly in cases of prior RT) should be treated by MX with the opportunity for immediate reconstruction. Adjuvant Tamoxifen may reduce the risk of LR in selected cases with hormone sensitive disease. Conclusion Further research is required to determine the role of contemporary RT regimes and endocrine therapies. Biological profiling and molecular analysis represent an opportunity to improve our understanding of the tumour biology of this condition and rationalise its treatment. Reliable identification of low-risk lesions could allow treatment to be less radical or safely omitted.

Introduction: May–Thurner Syndrome (MTS) usually presents with signs and symptoms of deep vein thrombosis or chronic venous insufficiency. We report the first case of MTS in a previously healthy adolescent female associated with a large intra-abdominal cyst arising from the right ovary. Case Report: The patient presented with signs and symptoms suggestive of deep vein thrombosis. Imaging confirmed extensive deep vein thromboses extending into the common iliac vein. Further imaging successfully diagnosed MTS and also identified a cyst arising from the right ovary. Catheter-directed thrombolysis followed by removal of the cyst and the right ovary was performed. Following re-thromboses few days later, the patient underwent further management with surgical thrombectomy with left common iliac vein stenting and IVC filter placement. Conclusion: The present case identifies an unusual presentation of a previously undiagnosed MTS in an adolescent female. In this case, anticoagulation alone was found to be ineffective and required the assistance of endovascular intervention.

Introduction The laparoscopic approach to distal pancreatectomy for benign and malignant diseases appears to offer advantages and is replacing open surgery in some centres. However, well-designed studies comparing laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP) are limited. We present a single-institution study comparing the outcomes of LDP to ODP. Methods The demographic details, clinical characteristics and outcomes of patients who underwent laparoscopic distal pancreatectomy were compared to those who had the surgery performed by open technique. The two approaches were compared on an intention-to-treat basis. Data shown represent medians. Results Between 2002 and 2009, 32 patients (20 female) underwent 16 LDP and 16 ODP respectively. The laparoscopic and open groups were comparable for age (57 vs 63 years, p = 0.584), sex distribution and tumour size (3.9 vs 4 cm, p=0.939). Both groups had a comparable number of malignant cases (56% vs 50%, p=1.0). Although LDP took longer to complete (287.5 vs 240 min, p=0.061), it was associated with significantly lower blood loss (300 vs 500 ml, p=0.031) but comparable perioperative transfusion rate (p=0.471). The laparoscopic approach was associated with a significantly higher spleen-preservation rate (overall: 50% vs 12.5%, p=0.05; benign pathology: 85.7% vs 25%, p=1.0). LDP patients had a significantly lower HDU stay (1 vs 4.5 days, p Conclusion The laparoscopic approach to distal pancreatectomy results in significantly lower blood loss, and shorter HDU and hospital stay compared with open surgery. The postoperative morbidity and R0 resection margin rates were comparably similar. Competing interests None declared.

Introduction While large and persistent pancreatic pseudocysts are amenable to internal drainage by laparoscopic techniques, the benefits of this minimally invasive approach remain to be demonstrated. The aim of this study was to compare the open and laparoscopic approaches for internal drainage of large and persistent pancreatic pseudocysts. Methods Patients who underwent cystgastrostomy were selected, and the demographic features, clinical characteristics and outcomes of those who had the surgery performed laparoscopically were compared to those who had open surgery. The two approaches were compared on an intention-to-treat basis. Data shown represent medians. Results Between 1997 and 2010, 42 patients (15 female and 27 male) underwent 45 surgical internal drainage procedures for pancreatic pseudocysts (36 laparoscopic with two conversions to open surgery, and nine open). The laparoscopic and open groups were comparable for age (56 vs 53 years, p = 0.448), sex distribution, and size of pseudocyst (12 vs 13 cm, p = 0.305). The two approaches had comparable operating times (90 vs 75 min, p=0.630) but laparoscopic surgery carried a significantly lower risk of postoperative morbidity (5.8% vs 54.5%, p=0.001) and shorter postoperative hospital stay (2 vs 10.5 days, p = 0.065). There was one death in the open group (11.1%) but none in the laparoscopic group. Conclusion The laparoscopic approach to cystgastrostomy for large and persistent retrogastric pancreatic pseudocysts is associated with a smoother and more rapid recovery and a shorter hospital stay compared with open surgery. Competing interests None declared.

Introduction Advances in technology and techniques facilitated the development of laparoscopic liver resection (LLR). The study is aimed at the evaluation of the feasibility and effectiveness of LLR for benign and malignant pathology. Methods This is a retrospective study of 61 patients (27 female) aged 63 (25–83) years who underwent LLR for benign (n=9) and malignant (n=52) between 2003 and 2011 in a single UK tertiary centre. The results shown represent median (range). Results Surgery was completed laparoscopically in 60 patients (98.3%) and converted to open due to extensive abdominal adhesions in one patient. The procedures performed included the resection of one segment ( n =16), two segments (n=36) and three segments (n=9). The overall operative morbidity was 8.5% and there was no mortality. The operating time was 162 (50–300) min. The estimated blood loss was 110 (25–1100) ml and two patients received blood transfusion. The postoperative hospital stay was 3.6 (1–14) days. The resected malignancy in 52 patients included metastases in 47 patients (44 colorectal adenocarcinoma, three others) and hepatocellular carcinoma (n=5), and the R0 resection rate was 86.6% (n=45). At 42 (6–108) months follow-up, 77% were disease-free, 19% showed recurrent metastasis (1 hepatic, 4 hepatic and elsewhere, 5 extra-hepatic) and 4% failed to attend the follow-up. Conclusion Our results support the expanding evidence that LLR is safe and efficient for the treatment of benign and malignant liver lesions in carefully selected patients. Competing interests None declared.

Introduction The common bile duct is traditionally managed with T-tube drainage after choledochotomy and removal of common bile duct (CBD) stones, but this approach carries an associated tube-related morbidity rate, including bile leak, of 10.5–20%. This study examines the safety and effectiveness of laparoscopic CBD exploration (LCBDE) followed by primary duct closure. Methods This is a retrospective analysis of 94 consecutive patients (27 male) who underwent LCBDE between October 2002 and December 2011. The duct was primarily closed in all patients. The results shown represent the median (range). Results All procedures were completed laparoscopically. The maximum diameter of the CBD was 9.7 (3–30) mm, and it was dilated in 93% of patients. The number of CBD stones was 2 (0–20). The exploration was transcystic in 14 patients and trans-CBD in 80 patients. The biliary tree was clear at the end of exploration with no subsequent evidence of retained stones in 92 patients (97.8%). The operating time was 117 (22–395) min. Postoperative bile leak occurred in four patients (4.5%) who were managed successfully with re-laparoscopy and suturing of the choledochotomy (n=2), laparoscopic insertion of biliary stent (n=1) and conservatively (n=1). The overall morbidity rate was 8% and included pulmonary complications (n=3), cholangitis (n=2), myocardial infarction (n=1) and wound infection (n=1). There were no operative deaths, and the postoperative hospital stay was 1 (0–51) day. At a follow-up of 48.2 (24–82) months, 92.5% of patients (n=87) had no biliary symptoms, one patient required endoscopic extraction of a retained stone, one developed bile duct stricture that was managed successfully by endoscopic balloon dilatation, and four patients (4.5%) failed to attend the follow-up. Conclusion Primary duct closure following LCBDE is safe, and can be employed as an alternative to T-tube insertion with short hospital stay and lower morbidityrate. Competing interests None declared.