Clinicopathological features and surgical outcome of patients with fibrolamellar hepatocellular carcinoma(experience with 22 patients over a 15-year period)

AIM To evaluate the clinicopathological features and the surgical outcomes of patients with fibrolamellar hepato-cellular carcinoma(FL-HCC)over a 15-year period. METHODS This is a retrospective study including 22 patients with a pathologic diagnosis of FL-HCC who underwent hepatectomy over a 15-year period. Tumor characteristics,survival and recurrence were evaluated. RESULTS There were 11 male and 11 female with a median age of 29 years(range from 21 to 58 years). Two(9%)patients had hepatitis C viral infection and only 2(9%)patients had alpha-fetoprotein level > 200 ng/m L. The median size of the tumors was 12 cm(range from 5-20 cm). Vascular invasion was detected in 5(23%)patients. Four(18%)patients had lymph node metastases. The median follow up period was 42 mo and the 5-year survival was 65%. Five(23%)patients had a recurrent disease,4 of them had a second surgery with 36 mo median time interval. Vascular invasion is the only significant negative prognostic factor CONCLUSION FL-HCC has a favorable prognosis than common HCC and should be suspected in young patients with non cirrhotic liver. Aggressive surgical resection should be done for all patients. Repeated hepatectomy should be considered for these patients as it has a relatively indolent course.

Outcomes of pancreaticoduodenectomy in elderly patients

BACKGROUND： Although the mortality and morbidity of pancreaticoduodenectomy（PD） have improved significantly over the past years, the concerns for elderly patients undergoing PD are still present. Furthermore, the frequency of PD is increasing because of the increasing proportion of elderly patients and the increasing incidence of periampullary tumors. This study aimed to analyze the outcomes of PD in elderly patients.METHODS： We studied all patients who had undergone PD in our center between January 1995 and February 2015. The patients were divided into three groups based on age： group I（patients aged 〈60 years）, group II（those aged 60 to 69 years） and group III（those aged ≥70 years）. The primary outcome was the rate of total postoperative complications. Secondary endpoint included total operative time, hospital mortality, length of postoperative hospital stay, delayed gastric emptying, re-exploration, and survival rate.RESULTS： A total of 828 patients who had undergone PD for resection of periampullary tumor were included in this study. There were 579（69.9%） patients in group I, 201（24.3%） in group II, and 48（5.8%） in group III. The overall incidence of complications was higher in elderly patients（25.9% in group I, 36.8% in group II, and 37.5% in group III; P=0.006）. There were more patients complicated with delayed gastric emptying in group II compared with the other two groups. There was no significant difference in the incidence of postoperative pancreatic fistula, biliary leakage, pancreatitis, pulmonary complications and hospital mortality.CONCLUSIONS： PD can be performed safely in selected elderly patients. Advanced age alone should not be a contraindication for PD. The outcome of elderly patients who have undergone PD is similar to that of younger patients, and the increased rate of complications is due to the presence of associated comorbidities.

Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases

AIM To evaluate the evolution, trends in surgical approaches a n d r e c o n s t r u c t i o n t e c h n i q u e s, a n d i m p o r t a n t lessons learned from performing 1000 consecutive pancreaticoduodenectomies(PDs) for periampullary tumors.METHODS This is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period(1993-2002), middle period(2003-2012), and late period(2013-2017).RESULTS The frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods.CONCLUSION Surgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.

Predictors of long term survival after hepatic resection for hilar cholangiocarcinoma:A retrospective study of 5-year survivors

AIM:To determine predictors of long term survival after resection of hilar cholangiocarcinoma(HC) by comparing patients surviving > 5 years with those who survived < 5 years.METHODS:This is a retrospective study of patients with pathologically proven HC who underwent surgical resection at the Gastroenterology Surgical Center,Mansoura University,Egypt between January 2002 and April 2013.All data of the patients were collected from the medical records.patients were divided into two groups according to their survival:patients surviving less than 5 years and those who survived > 5 years.RESULTS:There were 34(14%) long term survivors(5 year survivors) among the 243 patients.Fiveyear survivors were younger at diagnosis than those surviving less than 5 years(mean age,50.47 ± 4.45 vs 54.59 ± 4.98,p = 0.001).Gender,clinical presentation,preoperative drainage,preoperative serum bilirubin,albumin and serum glutamic-pyruvic transaminase were similar between the two groups.The level of CA 19-9 was significantly higher in patients surviving < 5 years(395.71 ± 31.43 vs 254.06 ± 42.19,p = 0.0001).Univariate analysis demonstrated nine variables to be significantly associated with survival > 5 year,includingyoung age(p = 0.001),serum CA19-9(p = 0.0001),non-cirrhotic liver(p = 0.02),major hepatic resection(p = 0.001),caudate lobe resection(p = 0.006),well differentiated tumour(p = 0.03),lymph node status(0.008),R0 resection margin(p = 0.0001) and early postoperative liver cell failure(p = 0.02).CONCLUSION:Liver status,resection of caudate lobe,lymph node status,R0 resection and CA19-9 were demonstrated to be independent risk factors for long term survival.

Intraoperative endoscopic retrograde cholangiopancreatography: A useful tool in the hands of the hepatobiliary surgeon

AIM: To evaluate the efficacy of intraoperative endoscopic retrograde cholangio-pancreatography(ERCP) combined with laparoscopic cholecystectomy(LC) forpatients with gall bladder stones(GS) and common bile duct stones(CBDS).METHODS: Patients treated for GS with CBDS were included. LC and intraoperative transcystic cholangiogram(TCC) were performed in most of the cases. Intraoperative ERCP was done for cases with proven CBDS.RESULTS: Eighty patients who had GS with CBDS were included. LC was successful in all cases. Intraoperative TCC revealed passed CBD stones in 4 cases so intraoperative ERCP was performed only in 76 patients. Intraoperative ERCP showed dilated CBD with stones in 64 cases(84.2%) where removal of stones were successful; passed stones in 6 cases(7.9%); short lower end stricture with small stones present in two cases(2.6%) which were treated by removal of stones with stent insertion; long stricture lower 1/3 CBD in one case(1.3%) which was treated by open hepaticojejunostomy; and one case(1.3%) was proved to be ampullary carcinoma and whipple's operation was scheduled. CONCLUSION: The hepatobiliary surgeon should be trained on ERCP as the third hand to expand his field of therapeutic options.

Predictors of long-term survival after pancreaticoduodenectomy for peri-ampullary adenocarcinoma: A retrospective study of 5-year survivors

Background: Pancreaticoduodenectomy(PD) is the standard curative treatment for periampullary tumors. The aim of this study is to report the incidence and predictors of long-term survival( ≥ 5 years) after PD. Methods: This study included patients who underwent PD for pathologically proven periampullary adenocarcinomas. Patients were divided into 2 groups: group(I) patients who survived less than 5 years and group(II) patients who survived ≥ 5 years. Results: There were 47(20.6%) long-term survivors( ≥ 5 years) among 228 patients underwent PD for periampullary adenocarcinoma. Patients with ampullary adenocarcinoma represented 31(66.0%) of the long-term survivors. Primary analysis showed that favourable factors for long-term survival include age < 60 years old, serum CEA < 5 ng/mL, serum CA 19-9 < 37 U/mL, non-cirrhotic liver, tumor size < 2 cm, site of primary tumor, postoperative pancreatic fistula, R0 resection, postoperative chemotherapy, and no recurrence. Multivariate analysis demonstrated that CA 19-9 < 37 U/mL [OR(95% CI) = 1.712(1.24 8–2.34 8), P = 0.001], smaller tumor size [OR(95% CI) = 1.335(1.032–1.726), P = 0.028] and R0 resection [OR(95% CI) = 3.098(2.095–4.582), P < 0.001] were independent factors for survival ≥ 5 years. The prognosis was best for ampullary adenocarcinoma, for which the median survival was 54 months and 5-year survival rate was 39.0%, and the poorest was pancreatic head adenocarcinoma, for which the median survival was 27 months and 5-year survival rate was 7%. Conclusions: The majority of long-term survivors after PD for periampullary adenocarcinoma are patients with ampullary tumor. CA 19-9 < 37 U/mL, smaller tumor size, and R0 resection were found to be independent factors for long-term survival ≥ 5 years.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: Risk factors and predictors of severity

AIM To detect risk factors for post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis(PEP) and investigate the predictors of its severity.METHODS This is a prospective cohort study of all patients who underwent ERCP.Pre-ERCP data,intraoperative data,and post-ERCP data were collected.RESULTS The study population consisted of 996 patients.Their mean age at presentation was 58.42(± 14.72) years,and there were 454 male and 442 female patients.Overall,PEP occurred in 102(10.2%) patients of the study population; eighty(78.4%) cases were of mild to moderate degree,while severe pancreatitis occurred in 22(21.6%) patients.No hospital mortality was reported for any of PEP patients during the study duration.Age less than 35 years(P = 0.001,OR = 0.035),narrower common bile duct(CBD) diameter(P = 0.0001) and increased number of pancreatic cannulations(P = 0.0001) were independent risk factors for the occurrence of PEP.CONCLUSION PEP is the most frequent and devastating complication after ERCP.Age less than 35 years,narrower median CBD diameter and increased number of pancreaticcannulations are independent risk factors for the occurrence of PEP.Patients with these risk factors are candidates for prophylactic and preventive measures against PEP.

How does epidemiological and clinicopathological features affect survival after gastrectomy for gastric cancer patientssingle Egyptian center experience

AIM:To investigate the clinicopathological features and the significance of different prognostic factors which predict surgical overall survival in patients with gastric carcinoma.METHODS:This retrospective study includes 80 patients diagnosed and treated at gastroenterology surgical center,Mansoura University,Egypt between February 2009 to February 2013.Prognostic factors were assessed by cox proportional hazard model.RESULTS:There were 57 male and 23 female.The median age was 57 years(24-83).One,3 and 5 years survival rates were 71%,69% and 46% respectively.The median survival was 69.96 mo.During the follow-up period,13 patients died(16%).Hospital morbidity was reported in 10 patients(12.5%).The median number of lymph nodes removed was 22(4-41).Lymph node(LN) involvement was found in 91% of cases.After R0 resection,depth of wall invasion,LN involvement and the number(> 15) of retrieved LN,LN ratio and tumor differentiation predict survival.In multivariable analysis,tumor differentiation,curability of resection and a number of resected LN superior to 15 were found to beindependent prognostic factors.CONCLUSION:Surgery remains the cornerstone of treatment.Tumor differentiation,curability of resection and a number of resected LN superior to 15 were found to be independent prognostic factors.Extended LN dissection does not increase the morbidity or mortality rate but markedly improves long term survival.