HIDA scan for functional gallbladder disorder： ensure that you know how the scan was done

BACKGROUND： Despite the increasing use of fatty meal（FM） as a substitute for cholecystokinin（CCK） in pain reproduction during hepato-imino-diacetic acid（HIDA） scan in functional gallbladder disorder, there are no studies comparing the differences between CCK and FM. The present study was to compare the efficacy of FM in comparison of CCK in FGBD application. METHODS： Patients undergoing HIDA scans from August 2013 to May 2014 were divided into two groups： those undergoing CCK-stimulated HIDA scan versus FM-stimulated HIDA scan. These groups were compared according to demographics and HIDA results.RESULTS： Of 153 patients, 70 received CCK and 83 FM. There was no difference regarding age, gender, gallstones, gallbladder ejection fraction and time to visualization. However, significantly more of the patients receiving CCK than FM experienced pain reproduction（61% vs 30%, P〈0.01）.CONCLUSIONS： Stimulation of gallbladder contractility with a FM during HIDA is less than half as likely to reproduce biliary symptoms compared to CCK, despite similar ejection fractions and other parameters. It is essential that providers account for this difference when counseling patients regarding cholecystectomy for functional gallbladder disorder.

The “Colonial Wig” pancreaticojejunostomy:zero leaks with a novel technique for reconstruction after pancreaticoduodenectomy

BACKGROUND: Postoperative pancreatic fistula(POPF) remains common and morbid after pancreaticoduodenectomy(PD). A major advance in the study of POPF is the fistula risk score(FRS).METHODS: We analyzed 48 consecutive patients undergoing PD. The 'Colonial Wig' pancreaticojejunostomy(CWPJ) technique was used in the last 22 PDs, we compared 22 CWPJ to 26 conventional PDs. RESULTS: Postoperative morbidity was 49%(27% Clavien grade >2). The median length of hospital stay was 11 days. In the first 26 PDs, the PJ was performed according to standard techniques and the clinically relevant POPF(CR-POPF) rate was 15%, similar to the FRS-predicted rate(14%). In the next 22 PJs, the CWPJ was employed. Although the FRS-predicted rates were similar in these two groups(14% vs 13%), the CRPOPF rate in the CWPJ group was 0(P=0.052).CONCLUSION: Early experience with the CWPJ is encouraging, and this anastomosis may be a safe and effective way to lower POPF rates.

Minimally invasive and open gallbladder cancer resections: 30-vs 90-day mortality

BACKGROUND:Minimally invasive surgery is increasingly used for gallbladder cancer resection.Postoperative mortality at 30 days is low,but 90-day mortality is underreported.METHODS:Using National Cancer Database(1998-2012),all resection patients were included.Thirty-and 90-day mortality rates were compared.RESULTS:A total of 36 067 patients were identified,19 139(53%) of whom underwent resection.Median age was 71 years and 70.7% were female.Ninety-day mortality following surgical resection was 2.3-fold higher than 30-mortality(17.1% vs 7.4%).There was a statistically significant increase in 30-and 90-day mortality with poorly differentiated tumors,presence of lymphovascular invasion,tumor stage,incomplete surgical resection and low-volume centers(P<0.001 for all).Even for the 1885 patients who underwent minimally invasive resection between 2010 and 2012,the 90-day mortality was 2.8-fold higher than the 30-day mortality(12.0% vs 4.3%).CONCLUSIONS:Ninety-day mortality following gallbladder cancer resection is significantly higher than 30-day mortality.Postoperative mortality is associated with tumor grade,lymphovascular invasion,tumor stage,type and completeness of surgical resection as well as type and volume of facility.

Clues to predict incidental gallbladder cancer

Background: Consequences of incidental gallbladder cancer(iGBC) following cholecystectomy may include repeat operation(depending on T stage) and worse survival(if bile spillage occurred), both avoidable if iGBC were suspected preoperatively.Methods: A retrospective single-institution review was done. Ultrasound images for cases and controls were blindly reviewed by a radiologist. Chi-square and Student’s t tests, as well as logistic regression and Kaplan–Meier analyses were used. A P ≤ 0.01 was considered significant.Results: Among 5796 cholecystectomies performed 2000–2013, 26(0.45%) were iGBC cases. These patients were older(75.61 versus 52.27 years), had more laparoscopic-to-open conversions(23.1% versus3.9%), underwent more imaging tests, had larger common bile duct diameter(7.13 versus 5.04 mm) and higher alkaline phosphatase. Ultrasound imaging showed that gallbladder wall thickening(GBWT) without pericholecystic fluid(PCCF), but not focal-versus-diffuse GBWT, was associated significantly with iGBC(73.9% versus 47.4%). On multivariable logistic regression analysis, GBWT without PCCF, and age were the strongest predictors of iGBC. The consequences iGBC depended significantly on intraoperative bile spillage, with nearly all such patients developing carcinomatosis and significantly worse survival.Conclusions: Besides age, GBWT, dilated common bile duct, and elevated alkaline phosphatase, number of preoperative imaging modalities and the presence of GBWT without PCCF are useful predictors of iGBC.Bile spillage causes poor survival in patients with iGBC.

Comparison of sexual function and quality of life after pelvic trauma with and without Angioembolization

Background:The aim is to study the safety of Angioembolization on long-term sexual function and quality of life.Methods:IRB approval was gained to review the prospectively collected trauma database as well as prospective questionnaires of patients at least 1 year out from pelvic fractures that occurred between 1996 and 2009.Surveys included the SF36v2,Female Sexual Function Index and the International Index of Erectile Function.Values for each domain were compared between patients treated with AE and 2:1 case-matched control patients as well as between the national norms.Values are presented as percentages or means with 95%CI.P<0.05 was considered statistically significant.Results:Thirty Seven cases and 74 matched controls were identified.42 patients completed the survey.There were 13 cases(12 males),and 29 controls(22 males).There was a higher ISS(Injury Severity Score)(32 vs 27;p=0.048)in the cases,but no difference in pelvic AIS(Abbreviated Injury Severity Score)(3 vs 3).Both groups scored similarly in the SF36 in all domains,but the entire cohort scored lower than the national norms in the physical functioning(41.9(37.8–46.0)vs50),role physical(40.9(36.2–45.7)vs50),body pain 43.8(40.7–46.9)vs50),role emotional 46.3(42.8–49.8)vs50),and physical composite score(42.1(38.0–46.3)vs50).All domains of the sexual function in both questionnaires showed significant impairment in our cohort compared with norms.Male cases had similar scores to the controls.Conclusion:Pelvic fractures portend a worse long-term QOL and sexual function than the general population.AE,however,does not have an additive affect to these indices.