Archive of Medical Research

Results of decompression surgery for pain in chronic pancreatitis.

Introduction. A vast majority of patients with chronic pancreatitis require regular opiate/opioid analgesia and recurrent hospital admission for pain. However, the role and timing of operative strategies for pain in chronic pancreatitis is controversial. This study hypothesized that pancreatic decompression surgery reduces analgesia requirement and hospital readmission for pain in selected patients. Patients and methods. This was a retrospective review of patients undergoing longitudinal pancreatico-jejunostomy (LPJ), with or without coring of the pancreatic head (Frey\’s procedure), between 1995 and 2007 in a single UK centre. Surgery was performed for chronic pain with clinical/radiological evidence of chronic pancreatitis amenable to decompression/head coring. Results. Fifty patients were identified. Thirty-six were male with a median age of 46 years and median follow-up of 30 months. Twenty-eight underwent LPJ and 22underwent Frey\’s procedure. No significant difference in reduction of analgesia requirement (71% vs 64%, p=0.761) or hospital readmission for pain (21% vs 23%, p=1.000) was observed when comparing LPJ and Frey\’s procedure. Patients were significantly more likely to be pain-free following surgery if they required non-opiate rather than opiate analgesia preoperatively (75% vs 19%, p=0.0002). Fewer patients required subsequent hospital readmission for pain if taking non-opiate rather than opiate analgesia preoperatively (12.5% vs 31%, p=0.175). Conclusions. In selected patients, LPJ and Frey\’s procedure have equivalent benefit in short-term pain reduction. Patients should be selected for surgery before the commencement of opiate analgesia.

Terrace JD, Paterson HM, Garden OJ, Parks RW, Madhavan KK.

Clinical and Surgical Sciences (Surgery)Edinburgh Royal Infirmary Edinburgh UK.

Analysis of closure of the pancreatic remnant after distal pancreatic resection.

Background. The appropriate management of the pancreatic remnant following distal pancreatic resection remains a clinically relevant problem. We carried out a retrospective analysis which focused on this issue and compared the two favored techniques of suture and staple closure. Patients and methods. Forty-six patients underwent distal pancreatectomy between October 1999 and January 2006. The patients were retrospectively analysed based on the management of the remaining pancreatic gland. Thirty-seven patients had suture and nine patients had staple closure. The morbidity, mortality, incidence of pancreatic fistula, necessity of secondary surgical intervention, and the duration of hospital stay for the two groups were compared. Pancreatic fistula was considered according to the novel international standard definition (ISGPF). In addition, subgroup analysis of patients receiving octreotide was carried out. Results. Overall, postoperative morbidity due to pancreatic fistula occurred in seven patients (19%) after suture and in one patient (11%) after staple closure (p = 0.54), with no deaths. The number of patients with surgical revision related to pancreatic leakage was two (5%) after suture closure vs no revision after staple closure (p = 0.65). The median number of total hospital days for the suture group was 19 (range 7-78 days) vs 21 (range 12-96 days) for the stapler group (p = 0.21). No significant benefit for the octreotide application could be determined. Conclusion. According to the data, no significant difference for either suture or stapler closure was observed, with the tendency for staple closure to be superior.

Lorenz U, Maier M, Steger U, Töpfer C, Thiede A, Timm S.

Centre for Operative Medicine, Department of Surgery I, University of Würzburg Germany.

Continuous veno-venous haemofiltration in the treatment of severe acute pancreatitis: 6-year experience.

Background. Continuous veno-venous haemofiltration (CVVH) could be reasonable for attenuation of systemic complications in severe acute pancreatitis (SAP). The aim of the study was implementation and feasibility assessment of the CVVH in the treatment protocol of SAP. Patients and methods. CVVH was applied to 111 SAP patients during 2000-2005. APACHE II, systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), serum lipase, C-reactive protein (CRP), complication rate and main outcomes were analysed comparing two periods. Results. Overall, 39 patients corresponded to Balthazar grade E SAP and 72 patients to necrotizing SAP (NSAP), with an average APACHE II score of 7 and 8.5, respectively, on admission. CVVH was started within 48 h in 82% of patients. Duration of CVVH was significantly augmented in NSAP patients during the routine period, comprising 92 h (p=0.006). The clinical presentation of SIRS and MODS was similar in both periods, with more initial pulmonary dysfunctions in NSAP (p=0.048). Peripancreatic infection decreased in the routine period; surgical interventions were performed in 34.8% vs 72.4% of patients. Hospital stay comprised on average 15.9 days for grade E SAP and 29.4 days for NSAP in the routine period, with overall mortality of 10.26% and 30.5%, respectively. Discussion. Application of CVVH in the treatment protocol of SAP is obscure due to relative invasiveness, a poorly understood mechanism of action and scarce clinical experience. We conclude that early pre-emptive application of CVVH is safe and feasible in the treatment of SAP. Duration of the procedure seems to be essential. Randomized clinical trials are justified. Our results are in favour of clinical application of CVVH in the treatment of SAP.

Pupelis G, Plaudis H, Grigane A, Zeiza K, Purmalis G.

Department of Surgery, Clinical Hospital \”Gailezers\” Riga Latvia.

Interferon receptor alpha/beta is associated with improved survival after adjuvant therapy in resected pancreatic cancer.

Aim. Interferons (IFNs) are known to have antiproliferative and immunoregulatory activities that are modulated through specific cell surface ligands, known as IFN-alpha, -beta, and -gamma receptors. The presence of these receptors and their impact on response to adjuvant therapy in patients with pancreatic cancer has not been determined. Patients and methods. Slides were prepared from 46 patients with pancreatic adenocarcinoma. Immunohistochemistry (IHC) was subsequently used to determine the expression of IFN- alpha/beta receptor-chain 2 (IFN-alpha/betaR) and IFN-gamma receptor-chain 1 (IFN-gammaR). The correlation between IFN receptor expression, tumor characteristics, and the overall patient response to adjuvant therapy were determined analytically. Results. The IHC performed for pancreatic adenocarcinoma demonstrated a high IFN-alpha/betaR expression in 4% (2/46) of patients, moderate expression in 20% (9/46) of patients, and faint or no expression in 76% (35/46) of patients. IHC confirmed a high expression of IFN-gammaR in 52% (24/46) of patients, moderate expression in 35% (16/46) of patients, and faint or no expression in the remaining 13% (6/46) of patients. Thirty-two (69.7%) patients received adjuvant therapy. Clinicopathological survey did not demonstrate any significant correlation between IFN-alpha/betaR and IFN-gammaR expression with regard to tumor size, vascular invasion, perineural invasion, lymph node metastases, or stage of disease. Use of adjuvant therapy was associated with increased survival in patients with IFN-alpha/betaR-positive tumors compared with patients with IFN-alpha/betaR-negative tumors (24 months versus 14.7 months in log rank test, p=0.012). The expression of IFN-gammaR, however, had no impact on patient survival (20 months vs 17 months; p=0.656, log rank test). Conclusion. IFN-alpha/betaR is associated with improved survival for patients with resectable pancreatic cancer who received adjuvant therapy.

Saidi RF, Remine SG, Jacobs MJ.

Department of Surgery, Providence Hospital and Medical Centers Southfield MI USA.

Is there a role for estrogen and progesterone receptors in gall bladder cancer?

Background/Aims. The concept of metaplastic and non-metaplastic types of gall bladder cancer and the likelihood of hormone receptor expression in the nuclei of tumour cells raised the possibility of a potential role for anti-estrogen therapy in gall bladder cancer. This study was carried out to determine the hormone receptors (ER/PR) expression level in gall bladder cancer using specific immunohistochemical assays and correlate it with patient and tumour histopathological characteristics. Patients and methods. Histopathological tumour specimens of 62 patients who underwent a radical cholecystectomy were analysed. Pronase pretreatment and primary monoclonal antibodies were used to perform immunohistochemical analysis for ER and PR. Results. The histology was adenocarcinoma - predominantly, moderately to poorly differentiated (91%). Gallstones were present in 90% of the individuals. Of the 62 specimens analysed, 62 (100%) and 61 (98%) were negative for ER and PR, respectively. Conclusion. The high incidence of gallstone-related gall bladder cancer in India is associated with metaplasia and a tendency to poorer differentiation in the tumour histology. These tumours are consequently less likely to express hormone receptors. Thus, there does not seem to be a role for anti-hormone therapy in patients with histogenesis similar to that seen in India.

Shukla PJ, Barreto SG, Gupta P, Neve R, Ramadwar M, Deodhar K, Mehta S, Shrikhande SV, Mohandas KM.

Department of Gastrointestinal and Hepatopancreatobiliary Surgical Oncology, Tata Memorial Hospital Mumbai India.

Bile duct cyst type V (Caroli\’s disease): surgical strategy and results.

Background. Caroli\’s disease (CD) is a benign congenital disorder characterized by segmental cystic dilatation of the intrahepatic biliary ducts. Therapeutic strategy includes medical treatment, percutaneous, endoscopic or surgical drainage of the affected bile ducts, liver resection or transplantation. The aim of this study was to analyse the results and long-term follow-up of a consecutive series of patients who underwent surgical treatment for CD. Patients and methods. Between 1995 and 2005, 10 patients were surgically treated for CD. Variables evaluated were: age, gender, clinical presentation, diagnostic procedures, percutaneous and surgical treatments, histopathological analysis and outcome. Results. The average age of the patients was 45.8 years. Recurrent cholangitis was the main clinical manifestation (70%). In unilateral CD a liver resection was performed in nine patients (left lateral sectionectomy in seven, left hepatectomy in one and right hepatectomy in one). In bilateral disease a cholecystectomy, duct exploration, hepaticojejunostomy and liver biopsy of both lobes were performed. Average follow-up was 60 months. All the patients are alive and free of symptoms without recurrence in the remnant liver. Discussion. Liver resection is the preferred therapeutic option for unilateral CD, demonstrating good results in long-term follow-up. In bilateral disease, hepaticojejunostomy could be considered as an alternative or a previous step to liver transplantation, which still remains the ultimate option.

Lendoire J, Schelotto PB, Rodríguez JA, Duek F, Quarin C, Garay V, Amante M, Cassini E, Imventarza O.

Liver Transplantation Unit, Hospital Dr Cosme Argerich Buenos Aires Argentina.

Recent trends in liver resection surgery activity and population utilization rates in English regions.

Objective. We conducted a study to examine recent trends in population-based utilization rates for liver resection surgery in England, to help identify potentially unmet healthcare need and to help inform future service planning. Materials and methods. Hospital Episodes Statistics data were analysed for the 5-year period 2000-1 to 2004-5 to identify episodes of care relating to liver resection surgery (defined as OPSC IV codes J21 to J24, J31, J38 and J39). Results. In England, the liver excision surgery population access rate was 1.82 and 2.95/100 000 general population in 2000-1 and 2004-5, respectively - a 62% increase during the 5-year study period, or a mean 12% annual increase. About two-thirds of all liver resection surgery (69%) related to metastatic liver disease. Between English regions, utilization rates ranged from 0.5 to 4.5/100 000 general population in 2000-1; and from 0.8 to 4.6/100 000 general population in 2004-5. Discussion. In recent years, a rapid increase in liver resection surgery activity has been observed. Most of the activity was related to metastatic disease. There was substantial regional variation in population utilization rates within the same country. This variation is unlikely to represent regional differences in disease burden and healthcare need.

Lyratzopoulos G, Tyrrell C, Smith P, Yelloly J.

Department of Public Health and Primary Care, University of Cambridge Cambridge UK.

Physician predictions of graft survival following liver transplantation.

Introduction. Due to the scarcity of cadaveric livers, clinical judgment must be used to avoid futile transplants. However, the accuracy of human judgment for predicting outcomes following liver transplantation is unknown. The study aim was to assess expert clinicians\’ ability to predict graft survival and to compare their performance to published survival models. Materials and methods. Pre-transplant case summaries were prepared based on 16 actual, randomly selected liver transplants. Clinicians specializing in the care of liver transplant patients were invited to assess the likelihood of 90-day graft survival for each case using (1) a 4-point Likert scale ranging from poor to excellent, and (2) a visual analog scale denoting the probability of survival. Four published models were also used to predict survival for the 16 cases. Results. Completed instruments were received from 50 clinicians. Prognostic estimates on the two scales were highly correlated (median r=0.88). Individual clinicians\’ predictive ability was 0.61+/-0.13, by area under the receiver operating characteristic curve. The performance of published models was MELD 0.59, Desai 0.66, Ghobrial 0.61, and Thuluvath 0.45. For three cases, clinicians consistently overestimated the probability of survival (87+/-10%, 89+/-9%, 86+/-9%); these patients had early graft failures caused by postoperative complications. Discussion. Clinicians varied in their ability to predict survival for a set of pre-transplant scenarios, but performed similarly to published models. When clinicians overestimated the chance of transplant success, either sepsis or hepatic artery thrombosis was involved; such events may be hard to predict before surgery.

Hoot NR, Feurer ID, Austin MT, Porayko MK, Wright JK, Lorenzi NM, Pinson CW, Aronsky D.

Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville TN USA.

A multicentre controlled study of the InLine radiofrequency ablation device for liver transection.

Background. Surgical resection is the most effective therapy for liver cancer. Intraoperative blood loss during liver resection remains a major concern due to association with higher postoperative complications. The InLine radiofrequency ablation device (ILRFA) has achieved promising results in liver surgery with minimal blood loss and no increase of postoperative complications. In this multicentre controlled study, 108 patients undergoing liver resection were investigated. Patients and methods. A total of 108 patients underwent liver resections in 4 medical centres; the prospective sequential cohort study consisted of 54 ILRFA and 54 ultrasonic surgical aspirator transections as the control group. Results. The type of liver resection performed was very similar in both groups. The median number of RFA deployments was 3 (range 1-12) with a median coagulation time of 9 (range 3-36) min. Median blood loss was 165+/-20 ml (range 5-675) in the ILRFA and 654+/-83 ml (range 80-3600) in the control group (p<0.001). The median transection time was 27 (2-219) min in the ILRFA group and 35 (5-62) min in controls. Conclusions. Our study indicates that ILRFA device for liver transection is effective in reducing blood loss and is safe. Precoagulation before parenchymal transection appears to be a valid concept in liver surgery. The avoidance of vascular inflow occlusion during parenchymal transection could also be of value.

Yao P, Chu F, Daniel S, Gunasegaram A, Yan T, Lindemann W, Pistorius G, Schilling M, Machi J, Zuckerman R, Morris DL.

University of New South Wales, Department of Surgery, St George Hospital Sydney Australia.

Cystic tumours of the pancreas.

Pancreatic carcinoma accounts for the most dismal survival among all malignancies with 5-year survival rates approaching 5%. The reason for this, besides the inherent biologic nature of the disease, is the fact that the patients tend to present late in the disease. We present a review of the current published data on cystic neoplasms of the pancreas, which though rare, constitute an important subgroup of pancreatic neoplasms that have a better prognosis and are potentially curable lesions.

Barreto G, Shukla PJ, Ramadwar M, Arya S, Shrikhande SV.

Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital Mumbai India.