Anastomotic leak (AL) after bilioenteric reconstruction (BR) is a feared complication after bile duct resection, especially in combination with liver resection. Literature on surgical outcome is ...sparse. This study aimed to determine the incidence and risk factors for AL after combined liver and bile duct resection with a focus on operative or endoscopic reinterventions.
Data from consecutive patients who underwent liver resection and BR between 2004 and 2018 in 11 academic institutions in Europe were collected from prospectively maintained databases.
Within 921 patients, AL rate was 5.4% with a 30d mortality of 9.6%. Pringle maneuver (p<0.001),postoperative external biliary (p=0.007) and abdominal drainage (p<0.001) were risk factors for clinically relevant AL. Preoperative biliary drainage (p<0.001) was not associated with a higher rate of AL. AL was more frequent in stented patients (76.5%) compared to PTCD (17.6%) or PTCD+stent (5.9%,p=0.017). AL correlated with increased incidence of postoperative liver failure (p=0.036), cholangitis, hemorrhage and sepsis (all p<0.001).
This multicenter data provides the largest series to date of LR with BR and could help in the management of these patients which are often challenging and hampering the patients’ postoperative course negatively.
Despite the International Study Group for Pancreatic Fistulae (ISGPF) definition, there exist reports of postoperative collections of uncertain etiology. There is a recent report questioning the ...ISGPF criteria's ability to accurately predict pancreatic anastomotic failure and outlining new criteria. We decided to validate both proposed criteria based on our experience.
Between January 2003 and November 2007, we retrospectively analyzed patients with postpancreaticoduodenectomy collections at the Tata Memorial Hospital.
Of 149 patients evaluated, 17 (11.4%) had intra-abdominal collections, 9 had early collections (with abdominal drains in situ, ie,< or =7 days postoperative), whereas 8 had delayed collections (after removal of drains, ie, >7 days postoperative). Early collections were attributed to pancreatic anastomotic leaks (n = 5; confirmed by ISGPF guidelines), biliary leaks (n = 3), or chyle leaks (n = 1). In patients with "delayed" collections of unclear etiology (normal drain amylase levels on days 3 and 7), 5 had normal amylase levels in the aspirated/pigtailed collections, whereas 3 had drain amylase content more than 3 times the normal, indicating postoperative pancreatic fistulae.
Assessment of amylase levels in delayed collections (despite initial amylase levels being normal) may aid in uncovering previously undrained, or newly formed, pancreatic anastomotic leaks. This will likely reduce reported rates of uncertain postoperative collections while providing more precise (perhaps higher) rates of postoperative pancreatic fistulae.
Despite a decreasing incidence, stomach cancer is the second leading cause of cancer mortality worldwide. Surgical resection offers the only chance for cure in this aggressive cancer. The surgical ...management of gastric cancer has witnessed numerous debates in the past decades. These include the extent of lymphadenectomy, extent of surgery, role of laparoscopic gastrectomy, and the impact of high volume of centers, on the outcome of surgery. This review attempts to address these controversies with an evidence-based perspective. A literature search in MEDLINE (www.pubmed.org) has been performed with the relevant key words and corresponding MeSH terms. The search has been limited to English publications on human subjects. A manual search of the bibliographies has also been carried out, to identify the relevant publications for possible inclusion.
A diagnosis of pancreatic cancer carries a very dismal prognosis, with
the 5-year survival rate being the lowest of all types of cancer.
Surgical resection offers the only hope for cure in these ...patients.
Pancreatic resectional surgery is technically demanding, and while
mortality has decreased in centers of excellence, the morbidity remains
significant. Numerous controversies exist regarding various aspects of
complex pancreatic resections. This review attempts to address these
controversies with an evidence-based perspective. We performed a
literature search in MEDLINE (www.pubmed.org) with relevant key words
and the corresponding MeSH terms. The search was limited to English
language publications on human subjects. A manual cross-reference
search of the bibliographies of relevant papers was carried out to
identify publications for possible inclusion.
Intraductal papillary neoplasm of the bile duct (IPNB) is a rare disease in Western countries. The main aim of this study was to characterize current surgical strategies and outcomes in the mainly ...European participating centers.
A multi-institutional retrospective series of patients with a diagnosis of IPNB undergoing surgery between 1 January 2010 and 31 December 2020 was gathered under the auspices of the European-African Hepato-Pancreato-Biliary Association. The textbook outcome (TO) was defined as a non-prolonged length of hospital stay plus the absence of any Clavien-Dindo grade at least III complications, readmission, or mortality within 90 postoperative days.
A total of 28 centers contributed 85 patients who underwent surgery for IPNB. The median age was 66 years (55-72), 49.4% were women, and 87.1% were Caucasian. Open surgery was performed in 72 patients (84.7%) and laparoscopic in 13 (15.3%). TO was achieved in 54.1% of patients, reaching 63.8% after liver resection and 32.0% after pancreas resection. Median overall survival was 5.72 years, with 5-year overall survival of 63% (95% CI: 50-82). Overall survival was better in patients with Charlson comorbidity score 4 or less versus more than 4 ( P =0.016), intrahepatic versus extrahepatic tumor ( P =0.027), single versus multiple tumors ( P =0.007), those who underwent hepatic versus pancreatic resection ( P =0.017), or achieved versus failed TO ( P =0.029). Multivariable Cox regression analysis showed that not achieving TO (HR: 4.20; 95% CI: 1.11-15.94; P =0.03) was an independent prognostic factor of poor overall survival.
Patients undergoing liver resection for IPNB were more likely to achieve a TO outcome than those requiring a pancreatic resection. Comorbidity, tumor location, and tumor multiplicity influenced overall survival. TO was an independent prognostic factor of overall survival.
Intraductal papillary neoplasm of the bile ducts (IPNB) is a rare disease in Western countries. The aim of this study was to compare tumor characteristics, management strategies, and outcomes between ...Western and Eastern patients who underwent surgical resection for IPNB.
A multi-institutional retrospective series of patients with IPNB undergoing surgery between January 2010 and December 2020 was gathered under the auspices of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), and at Nagoya University Hospital, Japan.
A total of 85 patients (51% male; median age 66 years) from 28 E-AHPBA centers were compared to 91 patients (64% male; median age 71 years) from Nagoya. Patients in Europe had more multiple lesions (23% vs 2%, P < .001), less invasive carcinoma (42% vs 85%, P < .001), and more intrahepatic tumors (52% vs 24%, P < .001) than in Nagoya. Patients in Europe experienced less 90-day grade >3 Clavien-Dindo complications (33% vs 68%, P < .001), but higher 90-day mortality rate (7.0% vs 0%, P = .03). R0 resections (81% vs 82%) were similar. Overall survival, excluding 90-day postoperative deaths, was similar in both regions.
Despite performing more extensive resections, the low perioperative mortality rate observed in Nagoya was probably influenced by a combination of patient-, tumor-, and surgery-related factors.
Effusive-constrictive pericarditis is typically caused by tuberculosis or other severe inflammatory conditions that affect the pericardium. We report a case of effusive-constrictive pericarditis ...consequent to a motor vehicle accident. A 32-year-old man with gastroesophageal reflux disease presented with severe substernal chest pain of a month's duration and dyspnea on exertion for one week. Echocardiograms revealed a moderate pericardial effusion, and the diagnosis was subacute effusive-constrictive pericarditis. After thorough tests revealed nothing definitive, we learned that the patient had been in a motor vehicle accident weeks before symptom onset, which made blunt trauma the most likely cause of pericardial injury and effusion. Medical management resolved the effusion and improved his symptoms. To our knowledge, this is the first report of effusion from posttraumatic constrictive pericarditis associated with a motor vehicle accident. We encourage providers to consider recent trauma as a possible cause of otherwise idiopathic pericarditis.
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