Abstract
Background
The potential of haemostatic patches to reduce the rate of postoperative pancreatic fistula remains unclear. The aim of this trial was to evaluate the impact of a polyethylene ...glycol-coated haemostatic patch on the incidence of clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy.
Methods
In this randomized, single-centre, clinical trial, patients undergoing pancreatoduodenectomy were randomized 1 : 1 to receive pancreatojejunostomy reinforced with two polyethylene glycol-coated haemostatic patches (patch group) or without any reinforcement (control group). The primary outcome was clinically relevant postoperative pancreatic fistula, defined as grade B/C according to International Study Group of Pancreatic Surgery criteria, within 90 days. Key secondary outcomes were length of hospital stay, total rate of postoperative pancreatic fistula, and overall complication rate.
Results
From 15 May 2018 to 22 June 2020, 72 patients were randomized, and 64 were included in the analyses (31 in the patch group and 33 in the control group). The risk of clinically relevant postoperative pancreatic fistula was reduced by 90 per cent (OR 0.10, 95 per cent c.i. 0.01 to 0.89, P = 0.039). Moreover, the use of the polyethylene glycol-coated patch retained its protective effect on clinically relevant postoperative pancreatic fistula in a multivariable regression model, significantly reducing the risk of clinically relevant postoperative pancreatic fistula by 93 per cent (OR 0.07, 95 per cent c.i. 0.01 to 0.67, P = 0.021), regardless of patient age, sex, or fistula risk score. The incidence of secondary outcomes did not significantly differ between the groups. One patient died within 90 days in the patch group versus three patients in the control group.
Conclusions
A polyethylene glycol-coated haemostatic patch reduced the incidence of clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy.
Registration number
NCT03419676 (http://www.clinicaltrials.gov).
Hemopatch™ significantly reduced the incidence of clinically relevant postoperative pancreatic fistula in patients who underwent a pancreatoduodenectomy. The effectiveness of the patch was related to the fistula risk score.
Abstract
Background
Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of ...patients with synchronous colorectal cancer and liver metastases, with a focus on terminology, diagnosis, and management.
Methods
This project was a multiorganizational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis, and management. Statements were refined during an online Delphi process, and those with 70 per cent agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising 12 key statements.
Results
Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term ‘early metachronous metastases' applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour, the term ‘late metachronous metastases’ applies to those detected after 12 months. ‘Disappearing metastases’ applies to lesions that are no longer detectable on MRI after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards, and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways, including systemic chemotherapy, synchronous surgery, and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed.
Conclusion
The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.
This consensus provides a practical framework for the clinician treating patients with synchronous colorectal cancer and liver metastases.
Abstract
Background
Bilobar liver metastases from colorectal cancer pose a challenge for obtaining a satisfactory oncological outcome with an adequate future liver remnant. This study aimed to assess ...the clinical and pathological determinants of overall survival and recurrence-free survival among patients undergoing surgical clearance of bilobar liver metastases from colorectal cancer.
Methods
A retrospective international multicentre study of patients who underwent surgery for bilobar liver metastases from colorectal cancer between January 2012 and December 2018 was conducted. Overall survival and recurrence-free survival at 1, 2, 3 and 5 years after surgery were the primary outcomes evaluated. The secondary outcomes were duration of postoperative hospital stay, and 90-day major morbidity and mortality rates. A prognostic nomogram was developed using covariates selected from a Cox proportional hazards regression model, and internally validated using a 3:1 random partition into derivation and validation cohorts.
Results
A total of 1236 patients were included from 70 centres. The majority (88 per cent) of the patients had synchronous liver metastases. Overall survival at 1, 2, 3 and 5 years was 86.4 per cent, 67.5 per cent, 52.6 per cent and 33.8 per cent, and the recurrence-free survival rates were 48.7 per cent, 26.6 per cent, 19.2 per cent and 10.5 per cent respectively. A total of 25 per cent of patients had recurrent disease within 6 months. Margin positivity and progressive disease at liver resection were poor prognostic factors, while adjuvant chemotherapy in margin-positive resections improved overall survival. The bilobar liver metastases from colorectal cancer-overall survival nomogram was developed from the derivation cohort based on pre- and postoperative factors. The nomogram’s ability to forecast overall survival at 1, 2, 3 and 5 years was subsequently validated on the validation cohort and showed high accuracy (overall C-index = 0.742).
Conclusion
Despite the high recurrence rates, overall survival of patients undergoing surgical resection for bilobar liver metastases from colorectal cancer is encouraging. The novel bilobar liver metastases from colorectal cancer-overall survival nomogram helps in counselling and informed decision-making of patients planned for treatment of bilobar liver metastases from colorectal cancer.
At a median follow-up of 50.9 months, the 1-year, 2-year, 3-year and 5-year overall survival rates were 86.4 per cent, 67.5 per cent, 52.6 per cent and 33.8 per cent respectively; the corresponding recurrence-free survival rates were 48.7 per cent, 26.6 per cent, 19.2 per cent and 10.5 per cent; the study demonstrates survival advantage of adjuvant chemotherapy in patients with margin-positive resection.
Adenosquamous cancer of the pancreas (ASCP) is an aggressive, infrequent subtype of pancreatic cancer that combines a glandular and squamous component and is associated with poor survival.
...Multicenter retrospective observational study carried out at three Spanish hospitals. The study period was: January 2010–August 2020. A descriptive analysis of the data was performed, as well as an analysis of global and disease-free survival using the Kaplan–Meier statistic.
Of a total of 668 pancreatic cancers treated surgically, twelve were ASCP (1.8%). Patient mean age was 69.2±7.4 years. Male/female ratio was 1:1. The main symptom was jaundice (seven patients). Correct preoperative diagnosis was obtained in only two patients. Nine pancreatoduodenectomies and three distal pancreatosplenectomies were performed. 25% had major complications. Mean tumor size was 48.6±19.4mm. Nine patients received adjuvant chemotherapy. Median survival time was 5.9 months, and median disease-free survival was 4.6 months. 90% of patients presented recurrence. Ten of the twelve patients in the study (83.3%) died, with disease progression being the cause in eight. Of the two surviving patients, one is disease-free and the other has liver metastases.
ASCP is a very rare pancreatic tumor with aggressive behavior. It is rarely diagnosed preoperatively. The best treatment, if feasible, is surgery followed by the standard chemotherapy regimens for pancreatic adenocarcinoma.
El cáncer adenoescamoso de páncreas (CPAS) es un subtipo de cáncer de páncreas agresivo e infrecuente que combina un componente glandular y escamoso, y presenta baja supervivencia.
Estudio observacional retrospectivo multicéntrico realizado en tres hospitales españoles. El período de estudio fue: enero 2010 - agosto 2020. Se realizó un análisis descriptivo de los datos, así como un análisis de supervivencia global y libre de enfermedad mediante Kaplan-Meier.
De un total de 668 cánceres de páncreas tratados quirúrgicamente, doce fueron CPAS (1,8%). La edad media de los pacientes fue de 69,2±7,4 años. La proporción hombre /mujer fue de 1: 1. El síntoma principal fue la ictericia (siete pacientes). Se obtuvo un diagnóstico preoperatorio correcto en solo dos pacientes. Se realizaron nueve duodenopancretectomías cefálicas y tres pancreatoesplenectomías distales. El 25% tuvo complicaciones mayores. El tamaño medio del tumor fue de 48,6±19,4mm. Nueve pacientes recibieron quimioterapia adyuvante. La mediana de supervivencia fue de 5,9 meses y la mediana de supervivencia libre de enfermedad fue de 4,6 meses. El 90% de los pacientes presentó recidiva. Diez de los doce pacientes del estudio (83,3%) fallecieron, y la progresión de la enfermedad fue la causa en ocho. De los dos pacientes que sobrevivieron, uno está libre de enfermedad y el otro tiene metástasis hepáticas.
El CPAS es un tumor pancreático muy raro y de comportamiento agresivo. Rara vez se diagnostica antes de la operación. El mejor tratamiento, si es posible, es la cirugía seguida de los regímenes de quimioterapia estándar para el adenocarcinoma de páncreas.
Abstract Objective One of the complications after complete section of the spermatic pedicle in the treatment of adolescent idiopathic varicocele is the formation of a scrotal lymphocele. This can be ...avoided by preserving lymphatic vessels using dye, but there is a risk that dissection may be complicated in patients who have previously undergone embolization. The aim of this study was to determine whether prior embolization limits spermatic dissection. Material and Method We used lymphography with dye (Patent Blue) prior to surgery in order to mark and preserve the lymph vessels during spermatic section. This was done by laparoscopy with a single umbilical port. Results We treated six patients aged 12.5–15 years (mean 13.12 years), two of whom had grade 2 varicoceles and four grade 3. Prior percutaneous embolization with metallic coils had been undertaken in all cases but had not been curative. Post-surgery controls were undertaken for a mean duration of 5 months without any lymphoceles appearing. No testicles were lost, nor did any other complication arise. Conclusion The presence of embolization material in the spermatic veins and perivascular fibrosis does not complicate surgery, enabling the single port laparoscopic technique to be undertaken.
Resumen: ANTECEDENTES: El hematoma espontáneo de la pared abdominal, que aparece durante el embarazo, es una rara colección de sangre que origina síntomas inespecíficos que se asemejan a otros ...padecimientos más frecuentes en el embarazo. Esto dificulta el establecimiento temprano del diagnóstico y favorece que las opciones de tratamiento sean erróneas, con el consecuente aumento en la morbilidad materna y fetal. CASO CLÍNICO: Paciente con 37 + 2 semanas de embarazo, que acudió a Urgencias debido a un dolor intenso en el hipocondrio derecho, de inicio súbito. La paciente cursaba su cuarto embarazo, hasta entonces sin contratiempos. Los análisis de laboratorio practicados al ingreso no demostraron alteraciones. La ecografía abdominal reportó una masa heterogénea, de predominio ecogénico en el hemiabdomen derecho de 12 x 7 x 10 cm aparentemente localizada en la parte anterior de la pared abdominal. En su interior no había vascularizaciones. Se localizó un feto único, en posición cefálica, con latidos cardiacos positivos y placenta anterior con inserción normal. El índice de líquido amniótico también se reportó normal. El registro cardiotocográfico evidenció un trazo reactivo, sin advertir dinámica uterina. Ante la sospecha diagnóstica de hematoma espontáneo en la pared abdominal se optó por la conducta expectante, con controles seriados de hemograma y administración de analgesia intravenosa. Ante la evolución favorable de la paciente se la dio de alta al octavo día del proceso y, posteriormente, en la semana 40+3 el embarazo finalizó mediante parto eutócico, sin contratiempos agregados. CONCLUSIONES: En la embarazada es importante incluir al hematoma espontáneo en el diagnóstico diferencial de dolor abdominal agudo, para poder indicar el tratamiento adecuado.
