Biliary leakage following pancreaticoduodenectomy:Prevalence,risk factors and management

Background: Few studies investigated biliary leakage after pancreaticoduodenectomy(PD) especially when compared to postoperative pancreatic fistula(POPF). This study was to determine the incidence of biliary leakage after PD, predisposing factors of biliary leakage, and its management. Methods: We retrospectively studied all patients who underwent PD from January 2008 to December 2017 at Gastrointestinal Surgery Center, Mansoura University, Egypt. According to occurrence of postoperative biliary leakage, patients were divided into two groups. Group(1) included patients who developed biliary leakage and group(2) included patients without identified biliary leakage. The preoperative data, operative details, and postoperative morbidity and mortality were analyzed. Results: The study included 555 patients. Forty-four patients(7.9%) developed biliary leakage. Ten patients(1.8%) had concomitant POPF. Multivariate analysis identified obesity and time needed for hepaticojejunostomy reconstruction as independent risk factors of biliary leakage, and no history of preoperative endoscopic retrograde cholangiopancreatiography(ERCP) as protective factor. Biliary leakage from hepaticojejunostomy after PD leads to a significant increase in development of delayed gastric emptying, and wound infection. The median hospital stay and time to resume oral intake were significantly greater in the biliary leakage group. Non-surgical management was needed in 40 patients(90.9%). Only 4 patients(9.1%) required re-exploration due to biliary peritonitis and associated POPF. The mortality rate in the biliary leakage group was significantly higher than that of the non-biliary leakage group(6.8% vs 3.9%, P = 0.05). Conclusions: Obesity and time needed for hepaticojejunostomy reconstruction are independent risk factors of biliary leakage, and no history of preoperative ERCP is protective factor. Biliary leakage increases the risk of morbidity and mortality especially if concomitant with POPF. However, biliary leakage can be conservatively managed in majority of cases.

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.

Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury:A multicenter study

Background:Bile duct injury(BDI)after cholecystectomy remains a significant surgical challenge.No guideline exists to guide the timing of repair,while few studies compare early versus late repair BDI.This study aimed to analyze the outcomes in patients undergoing immediate,intermediate,and delayed repair of BDI.Methods:We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020.The patients were divided into three groups based on the time of BDI reconstruction.Group 1 underwent an immediate reconstruction(within the first 72 hours post-cholecystectomy,n=156);group 2 underwent an intermediate reconstruction(from 4 days to 6 weeks post-cholecystectomy,n=75),and group 3 underwent delayed reconstruction(after 6 weeks post-cholecystectomy,n=181).Results:Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3.Favorable outcome was observed in 111(71.2%)patients in group 1,31(41.3%)patients in group 2,and 157(86.7%)patients in group 3(P=0.0001).Multivariate analysis identified that complete ligation of the bile duct,level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1,the use of external stent was an independent factor of favorable outcome in group 2,and level E4 BDI was an independent factor of unfavorable outcome in group 3.Transected BDI and level E4 BDI were independent factors of unfavorable outcome.Conclusions:Favorable outcomes were more frequently observed in the immediate and delayed reconstruction of post-cholecystectomy BDI.Complete ligation of the bile duct,level E1 BDI and the use of external stent were independent factors of a favorable outcome.

Problem of living liver donation in the absence of deceased liver transplantation program:Mansoura experience

We report our experience with potential donors for living donor liver transplantation(LDLT), which is the first report from an area where there is no legalized deceased donation program. This is a single center retrospective analysis of potential living donors(n = 1004) between May 2004 and December 2012. This report focuses on the analysis of causes, duration, cost, and various implications of donor exclusion(n = 792).Most of the transplant candidates(82.3%) had an experience with more than one excluded donor(median = 3). Some recipients travelled abroad for a deceased donor transplant(n = 12) and some died before finding a suitable donor(n = 14). The evaluation of an excluded donor is a time-consuming process(median = 3 d, range 1 d to 47 d). It is also a costly process with a median cost of approximately 70 USD(range 35 USD to 885 USD). From these results, living donor exclusion has negative implications on the patients and transplant program with ethical dilemmas and an economic impact. Many strategies are adopted by other centers to expand the donor pool; however, they are not all applicable in our locality. We conclude that an active legalized deceased donor transplantation program is necessary to overcome the shortage of available liver grafts in Egypt.

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.

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.