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%.

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.

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

AIMTo detect risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and investigate the predictors of its severity. METHODSThis is a prospective cohort study of all patients who underwent ERCP. Pre-ERCP data, intraoperative data, and post-ERCP data were collected. RESULTSThe 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. CONCLUSIONPEP is the most frequent and devastating complication after ERCP. Age less than 35 years, narrower median CBD diameter and increased number of pancreatic cannulations are independent risk factors for the occurrence of PEP. Patients with these risk factors are candidates for prophylactic and preventive measures against PEP.

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy

AIM:To elucidate surgical outcomes of pancreaticoduodenectomy(PD)in patients with liver cirrhosis.METHODS:We studied retrospectively all patients who underwent PD in our centre between January 2002and December 2011.Group A comprised patients with cirrhotic livers,and Group B comprised patients with non-cirrhotic livers.The cirrhotic patients had ChildPugh classes A and B(patient’s score less than 8).Preoperative demographic data,intra-operative data and postoperative details were collected.The primary outcome measure was hospital mortality rate.Secondary outcomes analysed included duration of the operation,postoperative hospital stay,postoperative morbidity and survival rate.RESULTS:Only 67/442 patients(15.2%)had cirrhotic livers.Intraoperative blood loss and blood transfusion were significantly higher in group A(P=0.0001).The mean surgical time in group A was significantly longer than that in group B(P=0.0001).Wound complications(P=0.02),internal haemorrhage(P=0.05),pancreatic fistula(P=0.02)and hospital mortality(P=0.0001)were significantly higher in the cirrhotic patients.Postoperative stay was significantly longer in group A(P=0.03).The median survival was 19 mo in group A and 24 mo in group B.Portal hypertension(PHT)was present in 16/67 cases of cirrhosis(23.9%).The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT(P=0.001).Postoperative morbidity(0.07)and hospital mortality(P=0.007)were higher in cirrhotic patients with PHT.CONCLUSION:Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis.PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis;therefore,it is only recommended in patients with Child A cirrhosis without portal hypertension.

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.