Evaluating the efficacy of tumor markers CA 19-9 and CEA to predict operability and survival in pancreatic malignancies.

Aim: Using CA 19-9 and CEA (elevated >2times of normal) as predictors in determining operability and survival in pancreatic tumors. Methods: Levels of CA 19-9 and CEA were measured (pre and post operatively) in 49 patients of pancreatic malignancy. CECT was performed for diagnosis and staging. An experienced surgeon determined the operability. The levels of tumor markers were correlated with the operability and the survival based on CECT and intra-operative findings. Results: 16/24 (67%) patients with CA 19-9 levels (<2times) and 19/24 (79%) patients with CEA levels (<2times) were found to be resectable. 22/25 (88%) patients having elevated CA 19-9 levels (p=0.0002-t) and 17/25(70%) patients having elevated CEA levels (p =0.003) were found to be non-resectable. Of the 27 patients, found resectable on CECT, 5 were non-resectable intra-operatively. All of these had elevated levels of CA 19-9 and 4/5 (80%) had elevated levels of CEA. Only 5/21 (23%) non-resectable patients, with elevated levels of CA 19-9 reported at 1 year follow up. None of the non-resectable patients with CA 19-9 levels >1000U/ml reported at 6 month follow-up. None of the resectable patients pre-operatively showed evidence of recurrence. All achieved normal values post surgery. Conclusion: Elevated levels of CA 19-9 and CEA (>2 times) predict increased chances of inoperability and poor survival in pancreatic tumors. Levels >3times had increased risk of inoperability even in patients deemed resectable on CT-Scan. Diagnostic laparoscopy would be beneficial in these patients. Levels of CA 19-9 (>1000U/ml) indicate a dismal survival in non-resectable group of patients.

Cadaver as a model for laparoscopic training.

BACKGROUND: Though minimally invasive techniques now are routine world over, there is need to develop facilities for training surgeons. Laparoscopy performed on anesthetized animals is an established model but is costly and is not easily available. We report on human cadaver as a training modality for surgeons participating in a laparoscopic training course. METHODS: Unembalmed cadavers were used for training surgeons to appreciate anatomy, practice laparoscopic techniques, and deploy equipment and instruments during a laparoscopic training course. Trainees carried out procedures such as cholecystectomy, appendicectomy, splenectomy, intestinal explorations, mesenteric lymph node biopsy, and varicocele-vein occlusion. We analyzed the trainees' perspective regarding cadaver as a model using the 5-point Likert scale. RESULTS: Thirty-two trainees from five consecutive training courses held at our institution expressed general satisfaction over cadaver as a training model, and 96.9% (31/32) rated the training model as highly satisfactory. The trainees ranked as highly satisfactory their understanding of surgical anatomy (29/32; 90.6%), understanding of laparoscopic technique (29/32; 90.6%) and use of instruments (32/32; 100%). The trainees thought such an approach improved spatial perception of anatomy and they perceived it as a valuable educational experience. CONCLUSIONS: Human cadaveric laparoscopy may offer an ideal surgical environment for laparoscopy training courses, allowing dissection and performance of complicated procedures.

Early morphological and functional changes in pancreas following necrosectomy for acute severe necrotizing pancreatitis.

INTRODUCTION: Morphological and functional changes in the pancreas after surgical pancreatic necrosectomy have not been studied extensively. AIMS: To study morphological changes in the pancreas, and exocrine and endocrine pancreatic function following pancreatic necrosectomy. METHODS: Eighteen adult patients surviving at least one month after pancreatic necrosectomy for acute necrotizing pancreatitis were followed up. Contrast-enhanced computed tomography was done every six months. Stool fat was estimated at 3-month intervals, and need for and response to enzyme supplements were recorded. Blood sugar was measured every fortnight; in patients with hyperglycemia, need for oral hypoglycemic agents or insulin was recorded. Additional pancreatic imaging was done in some cases. RESULTS: Six weeks after surgery, nine of 18 patients had exocrine insufficiency. Thirteen patients developed endocrine insufficiency, including 5 who also had exocrine insufficiency. At the end of the study, 13 patients had endocrine insufficiency and 2 had exocrine insufficiency. Pancreatic size was subnormal in all patients at the end of six months. Pancreatography in three cases did not reveal any ductal abnormality. CONCLUSIONS: Necrotizing pancreatitis affects pancreatic exocrine or endocrine function in more than half the patients.