Liposarcoma is the most common malignant soft tissue tumour in adults occurring predominantly in the retroperitoneum and extremities but very rarely within the gastrointestinal tract. We report on a ...77-year-old gentleman who presented with a history of melaena and anaemia. On oesophagogastric duodenoscopy a duodenal polyp was identified. Surgical excision was performed and on histology, the duodenal polyp revealed a primary duodenal well differentiated liposarcoma. A literature review confirmed the rarity of primary duodenal liposarcomas, with only four cases previously reported.
Abstract Extrapleural solitary fibrous tumor (SFT) is an uncommon mesenchymal neoplasm, presenting most commonly in the intrathoracic sites but which has been reported at numerous extrathoracic ...locations. The majority of intra-thoracic SFTs are benign, but 10%-15% behave aggressively. We report a case of primary hepatic SFT with histologically benign and malignant areas. A 65-year-old man underwent an abdominal CT scan following a cerebrovascular accident, which demonstrated a sharply demarcated large liver mass with a heterogenous enhancing area and occupying most of the left lobe of the liver. Histological examination following a hemihepatectomy showed an SFT with morphological patterns ranging from benign to malignant areas, including pleomorphism, increased cellularity, herringbone pattern, necrosis and a raised mitotic count. On review of the literature, only an occasional case report with malignant areas in a hepatic SFT was identified. This case highlights that SFT should be included in the differential diagnosis of a hepatic spindle cell lesion, and that on rare occasions, malignant areas can occur in this already uncommon neoplasm.
Acute pancreatitis is a common general surgical emergency presentation. Up to 20% of cases are severe and can involve necrosis with high associated morbidity and mortality. It is most commonly due to ...gallstones and excess alcohol consumption. All patients with acute pancreatitis need to be scored for severity and patients with severe acute pancreatitis should be managed on the high dependency unit. The mainstay of early treatment is supportive, with care to ensure strict fluid balance and optimisation of end organ perfusion. There is no role for early antibiotic use in acute necrotising pancreatitis and antibiotics should only be used in the presence of positive cultures. Nutritional support is vitally important in improving outcomes in necrotising pancreatitis. This should ideally be provided enterally using an naso-jejunal tube if the patient cannot tolerate oral intake. Patients with significant early necrosis, persisting organ dysfunction, infected walled off necrosis requiring intervention or haemorrhagic pancreatitis should be referred to a regional hepato-pancreatico-biliary unit for advice or transfer. Percutaneous and endoscopic necrosectomy has replaced open surgery due to improved outcomes. Acute necrotising pancreatitis remains a complex surgical emergency with high morbidity and mortality that requires a multidisciplinary approach to attain optimum outcomes. The mainstay of treatment is supportive care and nutritional support. Patients with significant pancreatic necrosis or infected collections requiring drainage require input from a tertiary HPB unit to guide management.
Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in all patients suffering from obstructive jaundice before pancreatic surgery. The severity of ...jaundice that mandates PBD has yet to be defined. The evaluated paper examines the impact of PBD on intra-operative, and post-operative outcomes in patients initially presenting with severe obstructive jaundice (bilirubin ≥250 μmol/L). In this key paper evaluation, the impact of PBD versus a direct surgery (DS) approach is discussed. The arguments for and against each approach are considered with regards to drainage associated morbidity and mortality, resection rates, survival and the impact of chemotherapy and malnutrition. Concentrating on resectable head of pancreas tumors, this mini-review aims to scrutinize the authors' recommendations, alongside those of prominent papers in the field.
Left hepatic trisectionectomy (LHT) is a complex hepatic resection; its’ role and outcomes in hepatobiliary malignancies remains unclear.
All patients undergoing LHT at the tertiary HPB referral unit ...at RSCH, Guildford, UK from September 1996 to October 2015 were included. Data were collected from a prospectively maintained database.
Twenty-eight patients underwent LHT. The M:F ratio was 1.8:1. Median age was 60 years (range 43–76 years). Diagnoses included colorectal liver metastases (CRLM; n = 20); cholangiocarcinoma (CCA; n = 4); and other (neuroendocrine tumour metastases (NET; n = 3) and breast metastases (n = 1)). Median duration of surgery was 270 min (range 210–585 min). Median blood loss was 750 ml (300–2400 ml) with a perioperative transfusion rate of 21% (n = 6/28). The rate of all post-operative complications was 21% for all patients, and given the extensive resection performed four patients (14%) developed varying degrees of hepatic insufficiency. One patient with cholangiocarcinoma developed severe hepatic insufficiency, which was fatal within 90 days of surgery. 1 and 3-year survivals were 92% and 68% respectively.
This study supports LHT in patients with significant tumour burden. Despite extensive resection, our favourable morbidity and mortality rates show this is a safe and beneficial procedure for patients with all hepatobiliary malignancies. Given the nature of resection the incidence of post-operative hepatic insufficiency is higher than less extensive hepatic resections.
•LHT is an extended resection reported to have higher incidences of morbidity and mortality compared with less extensive hepatic resections.•This procedure is useful for the surgical management of patients with hepatic lesions that were previously considered unresectable.•We report favourable outcomes following LHT at our institution compared with less extensive hepatic resections.•An initial post-operative lactate of >1.5 mmol/L was associated with an increased risk of developing post-operative complications (p = 0.035).
Upper gastrointestinal emergencies Cresswell, Adrian Ben; Karanjia, Nariman D
Surgery (Oxford),
November 2013, Letnik:
31, Številka:
11
Journal Article
Recenzirano
Abstract Emergency presentation of diseases of the upper gastrointestinal tract represents a significant proportion of the acute general surgical workload with gallstone disease representing only a ...slightly smaller burden than acute appendicitis. Peptic ulcer disease, gallstones and pancreatitis are the three most common emergency conditions of the supra-colic compartment and their initial management should be within the capabilities of all general surgeons who contribute to an emergency service. The clinician’s approach to all three conditions has undergone changes due to new pharmacological and technological advances, however a sound understanding of the clinical presentation and natural history remains essential to their safe management. This article will deal with practical aspects of dealing with these patients in the emergency setting.
Liver resection is proved to offer potential long-term survival for colorectal liver metastases (CRLM). Accurate radiological assessment is vital to enable an appropriate surgical approach. The role ...of intraoperative ultrasound (IOUS) has been controversial. This study was designed to analyse the accuracy of IOUS compared with that of preoperative imaging (POI) in these patients.
A prospective analysis of 51 consecutive patients who underwent liver resection for CRLM was undertaken. The accuracy of POI and IOUS were correlated and compared with histopathological analysis. Statistical analyses included t-tests, to compare continuous variables, and chi-square and Fisher's exact tests to compare categorical variables. p<0.05 was considered significant
POI correlated with histology in 35 patients (68.6%). The sensitivity and specificity were 82.4% and 86.3% respectively. IOUS correlated with histology in 31 (60.8%) patients. The sensitivity and specificity were 84.3% and 76.5% respectively. There was no difference in accuracy between modalities. The accuracy of POI combined with IOUS correlated with histology in 40 patients (78.4%). The sensitivity and specificity were 88.2% and 84.3% respectively. The accuracy of combined modalities was significantly greater than IOUS or POI alone.
POI combined with IOUS may significantly increase the diagnostic accuracy of patients undergoing liver resection for CRLM.
Chemotherapy for metastatic colorectal cancer is constantly advancing. Its use in the adjuvant and neoadjuvant setting is also increasing. However, while long-term survival is improving, clinicians ...must be aware of the possible adverse events that can occur when treating with adjuvant chemotherapy and liver resection. We present a case of a life-threatening delayed bile leak following a liver resection for metastatic colorectal cancer in association with adjuvant treatment with bevacizumab. A 53-year-old man was treated with neoadjuvant bevacizumab followed by liver resection for metastatic colorectal cancer. He made an uneventful recovery. Forty-three days post-surgery he received bevacizumab and developed acute life-threatening bile leaks from the cut surface of the liver. He spent a total of 65 days in hospital, and required ERCP repeatedly and eventually had a repeat liver resection to resolve the bile leak. This case reports a possible association between bevacizumab and a life threatening delayed bile leak following liver resection.
At present, liver resection offers the best long-term outcome and only chance for cure in patients with colorectal liver metastases. However, there are no large series that report the early and ...long-term outcomes of patients who require simultaneous diaphragm excision. This study was designed to investigate these patients.
A total of 285 consecutive liver resections were performed over a 10-year period. Of these, 258 had liver resections alone and 27 underwent liver resection and simultaneous diaphragm excision. Data were collected prospectively and analysed retrospectively. Pre-operative assessment was standardised. The outcomes between the two groups were compared.
There was no difference in age, hospital stay or intra-operative blood loss. The diaphragm was histologically involved in four out of 27 resections. As a result, the cancer involved resection margin incidence was greater in the liver resection and diaphragm excision group (14.8% versus 3.9%; P = 0.12). The median tumour size was also different between the two groups (60 mm versus 30 mm; P = 0.001). The liver and diaphragm resection group had a greater peri-operative complication rate (44.4% versus 21.3%; P = 0.02) and mortality (7.4% versus 1.6%; P = 0.25). Overall and disease-free survival was significantly worse in the group who underwent simultaneous diaphragm excision and liver resection (P = 0.04 and P = 0.005, respectively). Diaphragm invasion was found to be an independent predictor of poor overall outcome (P = 0.02).
Liver resection and simultaneous diaphragm excision have a greater incidence of peri-operative morbidity and mortality and a significantly worse long-term outcome compared with liver resection alone. However, these data suggest that liver resection in the presence of diaphragm invasion may still offer a favourable outcome compared with chemotherapy treatment alone. Therefore, we believe that diaphragm involvement by tumour should not be a contra-indication to hepatectomy.
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