Iatrogenic oesophageal transection during laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy has been hailed as an easy and safe procedure when compared with other bariatric operations. However, it may be associated with well-recognised early complications such as leaks and bleeding, as well as late ones such as stenosis and weight regain. Iatrogenic complete oesophageal transection has never been reported before as a complication. We report a case of complete oesophageal transection during laparoscopic sleeve gastrectomy that was not recognised intraoperatively. The repair of this iatrogenic injury was staged, with the final stage carried out some 3 months after the initial procedure. This case report highlights the possible occurrence of complete oesophageal transection during laparoscopic sleeve gastrectomy, and suggests steps to avoid and correct such complications.

Cytopathologic evaluation of the in situ margin in patients undergoing hepatectomy.

BACKGROUND: Margin status is a predictor of outcome for patients with liver malignancies, although what constitutes a negative margin is controversial. Traditionally, the completeness of resection is estimated by surgical histopathology of the resected specimen margin, despite the in situ margin being potentially more important. The true margin is often altered by parenchymal transection techniques. The authors propose that cytologic assessment of the in situ margin is more specific for determining the true margin. METHODS: A total of 84 patients with primary or metastatic liver tumors who were undergoing surgical resection were enrolled in this prospective Institutional Review Board-approved study. Specimen and in situ (patient) margins were assessed using a "scrape preparation" cytologic technique and compared with traditional surgical histopathology. Patients were followed for assessment of local disease recurrence. RESULTS: Follow-up data were complete for 64 patients for a median of 37 months (range, 12 months-56 months). Twenty patients were excluded because of perioperative death (6 patients; 7%) or a follow-up of < 12 months. Seven patients (12.2%) had positive histopathologic specimen margins, but only 1 was found to be positive by cytology (1.8%). No in situ cytologically positive margins were identified along the cut edge of the liver remnant. The rate of intra- or extrahepatic recurrences was 56.7%, whereas the local recurrence rate was 1.8%. One patient with local recurrence demonstrated simultaneous intra- and extrahepatic disease recurrences and had negative margins by all methods of evaluation. CONCLUSIONS: To the authors' knowledge, the current study is the first to demonstrate that in situ margins can be assessed using cytopathology. This method is quick and can be universally applied. Given the difficulty of accurately assessing margins after hepatectomy, cytopathologic evaluation may be more reflective of the true margin. Cancer (Cancer Cytopathol) 2012. © 2012 American Cancer Society.

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: a retrospective case series.

CONTEXT: Perioperative outcome of pancreaticoduodenectomy is related to work load volume and to whether the procedure is carried out in a tertiary specialized hepato-pancreatico-biliary (HPB) unit. OBJECTIVE: To evaluate the perioperative outcome associated with pancreaticoduodenectomy in a newly established HPB unit. PATIENTS: Analysis of 32 patients who underwent pancreaticoduodenectomy (PD) for benign and malignant indications. DESIGN: Retrospective collection of data on preoperative, intraoperative and postoperative care of all patients undergoing PD. RESULTS: Thirty-two patients (16 male and 16 female) with a mean age of 59.5±12.7years were analyzed. The overall morbidity rate was high at 53%. The most common complication was wound infection (n=11; 34.4%). Pancreatic and biliary leaks were seen in 5 (15.6%) and 2 (6.2%) cases, respectively, while delayed gastric emptying was recorded in 7 (21.9%). The female sex was not associated with increased morbidity. Presence of co-morbid illness, pylorus-preserving PD, intra-operative blood loss ⩾1L, and perioperative blood transfusion were not associated with significantly increased morbidity. The overall hospital mortality was 3.1% and the cumulative overall (OS) and disease free survival (DFS) at 1year were 80% and 82.3%, respectively. The cumulative overall survival for pancreatic cancer vs ampullary tumor at 1year were 52% vs 80%, respectively. CONCLUSION: PD is associated with a low risk of operative death when performed by specialized HPB surgeons even in a tertiary referral hospital. However, the postoperative morbidity rate remains high, mostly due to wound infection. Further improvement by reducing postoperative infection may help curtail the high postoperative morbidity.

Port site metastases after a laparoscopic abdominoperineal resection of rectal cancer: report of a case.

This report describes a case of port site metastases that presented 6 months after a laparoscopic abdominoperineal resection of rectal cancer in a 75-year-old man. A surgical excision was performed to improve stoma function despite disease progression with adjuvant concurrent chemoradiation. Although port site metastases are now reported less frequently, this unfortunate consequence of laparoscopic colorectal surgery for cancer can still occur, and laparoscopic colorectal surgeons should exercise all precautions to prevent its occurrence. This report includes a review of literature on port site metastases.

Leiomyosarcoma of the infra-renal inferior vena cava.

Leiomyosarcoma of the inferior vena cava (IVC) is a rare slow-growing retroperitoneal tumor. Two percent of leiomyosarcomas are vascular in origin, and tumors of the IVC account for the majority of the cases. The diagnosis is frequently delayed, because affected patients remain asymptomatic for a long period. It has an extremely poor prognosis, with 5-year actuarial malignancy-free survival rates of 30% to 50% after a wide surgical resection. The authors present the case of a patient with IVC leiomyosarcoma who underwent en bloc resection of the tumor along with the involved segment of the infrarenal IVC without caval reconstruction. Complete surgical resection offers the only potential of long-term survival, but survival of unresected patients is generally measured in months. Palliative resections may temporarily improve symptoms but do not offer long-term survival.

Long-term efficacy of lymph node reoperation for persistent papillary thyroid cancer.

OBJECTIVE: The objective of the study was to determine the outcome of surgical resection of metastatic papillary thyroid cancer (PTC) in cervical lymph nodes after failure of initial surgery and I(131) therapy. DESIGN: This was a retrospective clinical study. SETTING: The study was conducted at a university-based tertiary cancer hospital. PATIENTS: A cohort of 95 consecutive patients with recurrent/persistent PTC in the neck underwent initial reoperation during 1999-2005. All had previous thyroidectomy (+/-nodal dissection) and I(131) therapy. Twenty-five patients with antithyroglobulin (Tg) antibodies were subsequently excluded. MAIN OUTCOME MEASURES: Biochemical complete remission (BCR) was stringently defined as undetectable TSH-stimulated serum Tg. RESULTS: A total of 107 lymphadenectomies were undertaken in these 70 patients through January 2010. BCR was initially achieved in 12 patients (17%). Of the 58 patients with detectable postoperative Tg, 28 had a second reoperation and BCR was achieved in five (18%), seven had a third reoperation, and none achieved BCR. No patient achieving BCR had a subsequent recurrence after a mean follow-up of 60 months (range 4-116 months). In addition, two more patients achieved BCR during long-term follow-up without further intervention. In total, 19 patients (27%) achieved BCR and 32 patients (46%) achieved a TSH-stimulated Tg less than 2.0 ng/ml. Patients who did not achieve BCR had significant reduction in Tg after the first (P < 0.001) and second (P = 0.008) operations. No patient developed detectable distant metastases or died from PTC. CONCLUSIONS: Surgical resection of persistent PTC in cervical lymph nodes achieves BCR, when most stringently defined, in 27% of patients, sometimes requiring several surgeries. No biochemical or clinical recurrences occurred during follow-up. In patients who do not achieve BCR, Tg levels were significantly reduced. The long-term durability and impact of this intervention will require further investigation.

Bleeding duodenal ulcer after Roux-en-Y gastric bypass surgery: the value of laparoscopic gastroduodenoscopy.

Roux-en-Y gastric bypass is a common surgical procedure used to treat patients with morbid obesity. One of the rare, but potentially fatal complications of gastric bypass is upper gastrointestinal bleeding, which can pose diagnostic and therapeutic dilemmas. This report describes a 39-year-old male with morbid obesity who underwent a Roux-en-Y gastric bypass. Three months postoperatively, he sustained repeated and severe upper attacks of upper gastrointestinal bleeding. He received multiple blood transfusions, and had repeated upper and lower endoscopies with no diagnostic yield. Finally, he underwent laparoscopic endoscopy which revealed a bleeding duodenal ulcer. About 5 ml of saline with adrenaline was injected, followed by electrocoagulation to seal the overlying cleft and blood vessel. He was also treated with a course of a proton pump inhibitor and given treatment for H pylori eradication with no further attacks of bleeding. Taking in consideration the difficulties in accessing the bypassed stomach endoscopically, laparoscopic endoscopy is a feasible and valuable diagnostic and therapeutic procedure in patients who had gastric bypass.

Gastrointestinal basidiobolomycosis: an unusual fungal infection mimicking colon cancer.

CONTEXT: -Basidiobolomycosis is a rare disease caused by the fungus Basidiobolus ranarum, an environmental saprophyte found worldwide. Patients with B ranarum infection may present with subcutaneous, gastrointestinal, or systemic lesions. Gastrointestinal basidiobolomycosis poses diagnostic difficulties, as its clinical presentation is nonspecific, with no identifiable risk factors. OBJECTIVE: -To discuss and compare the clinical features and histopathologic findings and other ancillary techniques that could be helpful in identifying gastrointestinal basidiobolomycosis. DESIGN: -We report 3 cases of gastrointestinal basidiobolomycosis and describe the clinical and morphologic findings while emphasizing the importance of identifying this unusual entity on endoscopic biopsies, thus avoiding unnecessary major surgeries. Fungal cultures were also performed, which are of diagnostic significance. Our first patient was lost to follow-up; however, patients 2 and 3 were followed up for 4 and 2 years, respectively. RESULTS: -In all 3 cases, patients presented with a clinical profile suggestive of malignancy. None of the patients gave any specific history. There was widespread abdominal disease with peritoneal involvement and colonic masses. Colonoscopic biopsy specimens showed nonspecific inflammation in 1 case; however, they showed only granulomatous inflammation in a second case and granulomas associated with fungal hyphae in a third. Typical morphology included hyphae, irregularly branched, thin-walled, occasionally septated and surrounded by a thick eosinophilic cuff (Splendore-Hoeppli phenomenon). CONCLUSION: -Gastrointestinal basidiobolomycosis can be detected on small endoscopic biopsy. The unequivocal diagnosis requires microbiologic cultivation of the fungus obtained from tissues. The prognosis for this disease is usually favorable as seen in 3 of our cases; however, cases with fatal outcome are on record.

Radioimmunoguided surgery (RIGS), PET/CT image-guided surgery, and fluorescence image-guided surgery: past, present, and future.

(125)I-labeled anti-TAG-72 antibodies were applied in radioimmunoguided surgery (RIGS) to remove gross and occult tumors. It is challenging to handle (125)I-labeled materials. PET/CT image-guided surgery utilizes (18)FDG to monitor the biochemical activity of the tumor and to integrate pre- and postoperative imaging for complete tumor removal. PET/CT image-guided surgery only detects later stage disease. Fluorescence image-guided surgery using anti-TAG-72 antibodies may provide opportunities for intraoperative cancer detection of both gross and occult tumors.

Combined use of preoperative 18F FDG-PET imaging and intraoperative gamma probe detection for accurate assessment of tumor recurrence in patients with colorectal cancer.

BACKGROUND: The purpose of this study was to combine intraoperative gamma probe (GP) detection with preoperative fluorine 18-fluoro-2-deoxy-glucose positron emission tomography (18F FDG-PET) imaging in order to improve detection of tumor recurrence in colorectal cancer (CRC) patients. METHODS: Twenty-one patients (12 females, 9 males) with a mean age of 54 years (range 31-78) were enrolled. Patients were suspected to have recurrent CRC by elevated CEA (n = 11), suspicious CT findings (n = 1), and clinically suspicious findings (n = 9). Preoperative FDG-PET scan and intraoperative GP study were performed in all patients. Mean time interval between preoperative FDG-PET scan and surgery was 16 days (range 1-41 days) in 19 patients. For intraoperative GP studies, 19 patients were injected with a dose of 10-15 mCi 18F FDG at approximately 30 minutes before the planned surgery time. In two patients, the intraoperative GP study was performed immediately after preoperative FDG-PET scan. RESULTS: Preoperative FDG-PET and intraoperative GP detected 48 and 45 lesions, respectively. A total of 50 presumed site of recurrent disease from 20 patients were resected. Thirty-seven of 50 presumed sites of recurrent disease were histological-proven tumor positive and 13 of 50 presumed sites of recurrent disease were histological-proven tumor negative. When correlated with final histopathology, the number of true positive lesions and false positive lesions by preoperative FDG-PET and intraoperative GP were 31/9 and 35/8, respectively. Both preoperative FDG-PET and intraoperative GP were true positive in 29 lesions. Intraoperative GP detected additional small lesions in the omentum and pelvis which were not seen on preoperative FDG-PET scan. FDG-PET scan demonstrated additional liver metastases which were not detected by intraoperative GP. Preoperative FDG-PET detected distant metastasis in the lung in one patient. The estimated radiation dose received by a surgeon during a single 18F FDG GP surgery was below the occupational limit. CONCLUSION: The combined use of preoperative FDG-PET and intraoperative GP is potentially helpful to the surgeon as a roadmap for accurately locating and determining the extent of tumor recurrence in patients with CRC. While intraoperative GP appears to be more sensitive in detecting the extent of abdominal and pelvic recurrence, preoperative FDG-PET appears to be more sensitive in detecting liver metastases. FDG-PET is also a valuable method in detecting distant metastases.

Hepatic artery chemoembolization in 122 patients with metastatic carcinoid tumor: lessons learned.

BACKGROUND: Hepatic artery chemoembolization (HACE) is a treatment option in the management of metastatic carcinoid. We reviewed our experience to identify potential factors that influence survival. METHODS: The records of 122 patients with metastatic carcinoid tumor undergoing HACE were reviewed. Log-rank analysis and Cox proportional hazards were applied to identify factors predictive of decreased survival. RESULTS: Median follow-up after HACE was 21.5 months. Complications occurred in 23% with periprocedural mortality of 5%. Radiographic tumor regression was seen in 82%, with stabilization of disease in 12%. Median duration of CT response was 19 months. Improvement in symptoms occurred in 92% for median duration of 13 months. HACE resulted in complete normalization of serum pancreastatin in 14%, with greater than 20% reduction in another 66%. Median overall survival was 33.3 months after HACE. Only pancreastatin level > or =5,000 pg/ml was associated with decreased survival by multivariate analysis. CONCLUSION: HACE offers symptom palliation and long-term survival in patients with incurable carcinoid metastases. Although safe, it should be approached cautiously in patients with significant tumor burden as evidenced by pancreastatin levels > or =5,000 pg/ml. We do not recommend whole-liver embolization in these patients but prefer a staged approach to each lobe of the liver.

Image guidance during abdominal exploration for recurrent colorectal cancer.

BACKGROUND: Real-time intraoperative image guidance has been successfully applied to malignancies of the head, neck and central nervous system. Few attempts have been made to apply this technology to gastrointestinal cancers. Our purpose was to determine if a computer-assisted navigation system could be accurately used at the time of abdominal exploration. METHODS: Fourteen patients with resectable recurrent colorectal cancer underwent computer tomography (CT) imaging of the abdomen and pelvis. The CT images were uploaded to a StealthStation (Medtronic, Inc., Minneapolis, MN), a device that tracks the motion of a handheld probe in the operating field and displays its position, in real time, on the uploaded images. Various anatomic points were utilized to match, or register, the patient to the images in the navigation system. After four or more anatomic points were registered, the accuracy of the registration process was computed by the navigation system and reported as the global error. RESULTS: A total of 23 different anatomic structures were used for registration. The median number of points used for registration per patient was 6.5 (range 5-9). The anatomic sites most commonly used were the anterior superior iliac spines, aortic bifurcation, sacral promontory, symphysis pubis, and iliac artery bifurcation. The median global error was 10.0 mm (range 6.7 mm-27.0 mm). CONCLUSION: Computer-assisted navigation systems can be used to accurately deliver image guidance at the time of abdominal exploration. Future work will be directed at determining the value of this technology in the localization and resection of tumors.

Stromal osteonectin overexpression is associated with poor outcome in patients with ampullary cancer.

BACKGROUND: Osteonectin has been suggested to be important in the progression of pancreatic cancer but has not been correlated with survival. We determined the osteonectin expression and its influence on survival in patients with ampullary carcinoma. METHODS: Tissue microarrays were constructed from the tumors of 56 patients with ampullary cancer undergoing pancreaticoduodenectomy. Immunohistochemical staining for osteonectin was undertaken and compared with staining in chronic pancreatitis (n = 13) and normal pancreas (n = 19). Survival curves were created by the Kaplan-Meier method and compared by log rank analysis. Median follow-up for all living patients with ampullary cancer was 69.6 months. RESULTS: Osteonectin was significantly (P < .05, Fisher's exact test) overexpressed in the stroma of ampullary cancers (90%) relative to chronic pancreatitis (62%) and normal pancreas (0%). Tumors expressing osteonectin were more likely to have nodal metastases than those lacking osteonectin expression (48% vs. 0%, P = .06, Fisher's exact test) and showed decreased survival. Node-negative status, pylorus preservation at the time of pancreaticoduodenectomy, and lack of osteonectin expression were predictors of prolonged survival by multivariate analysis. CONCLUSIONS: Although the importance of tumor-stroma interactions in periampullary cancers is not fully understood, our data suggest that osteonectin is an integral stromal element in ampullary cancers, and its overexpression is associated with decreased survival.

Cytoreduction results in high perioperative mortality and decreased survival in patients undergoing pancreatectomy for neuroendocrine tumors of the pancreas.

We reviewed our experience with pancreatectomy for neuroendocrine tumors (NE) to determine outcomes after R0/R1 or R2 resection and compare them to patients in whom resection was not attempted. Data were reviewed for all patients presenting with NE tumors of the pancreas between 1990 and 2005. Kaplan-Meier survival curves were compared by log-rank analysis. Multivariate analysis was completed using Cox proportional hazards to identify risk factors for poor survival after resection. Of 120 patients, 65 (54%) had functional tumors. Resection was undertaken in 83: distal pancreatectomy in 41, pancreaticoduodenectomy in 27, enucleation in 14, and central pancreatectomy in 1. Survival was significantly longer after resection (91 months versus 24, P<0.001). R0/R1 resection was accomplished in 64 (77%) and resulted in lower perioperative mortality (2% versus 21%, P<0.01) and longer survival (112 months versus 24, P<0.001) compared to R2 resection. Survival after R2 resection was no better than after no resection. Factors predictive of decreased survival were moderate/poor differentiation, R2 resection, and high-risk features. Long-term survival is possible following complete resection for NE tumors of the pancreas. However, cytoreduction resulting in incomplete tumor removal carries significant perioperative mortality without long-term survival benefit and should be discouraged.

Full-term gestation and transvaginal delivery after wide resection of an abdominal desmoid tumor during pregnancy.

A 29-year-old female was diagnosed with a symptomatic, extra-abdominal desmoid tumor during the first trimester of pregnancy. Computerized tomography (CT) and transabdominal ultrasound (US) noted a mass within the left rectus sheath measuring up to 15 cm in greatest diameter, with mild compression of the uterus. Preoperative diagnosis was confirmed by core-needle biopsy of the lesion. At 20-weeks gestation, wide local resection of the tumor with disease-free margins, as well as abdominal wall reconstruction with polytetrafluoroethylene (PTFE) mesh was successfully undertaken. Histological examination of the tumor ex vivo confirmed that the lesion was a desmoid tumor consisting of spindle cells with dense infiltrating collagenous fibers. Subsequent to her resection, the patient completed a full-term pregnancy without complication, and proceeded with a complication-free transvaginal delivery at 39 weeks. This case illustrates the probable contribution of estrogens towards desmoid tumor development, the durability of abdominal wall reconstruction when subjected to the extraordinary strain of both a gravid uterus and labor, as well as the safety and efficacy of aggressive surgical therapy during pregnancy.

Surgical management of early-stage pancreatic cancer.

BACKGROUND: Pancreatic cancer remains a difficult disease to treat. Diagnosis at an early stage may allow curative treatment with resection. In the past, the mortality associated with surgical treatment of pancreatic carcinoma was prohibitive but mortality associated with resection is now commensurate with all other major oncologic resections. Thus, the focus of surgical management has shifted to address several issues: the diagnosis and evaluation of patients with suspected pancreatic cancer, the role of preoperative endobiliary stenting, the role of laparoscopy, the extent of resection, the role of adjuvant and neoadjuvant treatment, and the role of specialized centers in treating the disease. METHODS: The current literature is reviewed to address these issues and help guide physicians who first encounter patients with suspected pancreatic cancer as well as surgeons who ultimately resect them. Practical evidence-based information to guide the decision-making process is provided. RESULTS: Surgical morbidity and mortality have achieved parity with other types of major oncologic resection, and a distinct survival advantage is possible when such therapy is applied early in the disease stage. Issues regarding the use of stents, extent of resection, and pre- vs post-operative chemoradiation therapy are becoming clearer as our collective experience broadens. CONCLUSIONS: Surgical treatment of pancreatic cancer should be aggressively pursued given the clearly established survival advantage and relief of symptoms achieved when it is applied appropriately.

The pattern of indications and complications of splenectomy in Eastern Saudi Arabia.

OBJECTIVE: The indications for splenectomy have changed over the past decade. Trauma and hematological diseases are emerging as common indications since the early eighties of the last century. This study looks at the pattern of indications and complications of splenectomy at Dammam Central Hospital, Dammam, Eastern Province, Kingdom of Saudi Arabia. METHODS: A retrospective study of all patients who underwent splenectomy at Dammam Central Hospital over the 5-year period (1996-2000). RESULTS: There were 55 patients (47 males and 8 females) who underwent splenectomy over the study period. The mean age was 57.5 (range 4-65) years. The most common indication was trauma (43.6%) followed by hematological reasons (25.5%), which were mainly in sickle cell disease (SCD) patients (N=9). Splenic sequestration crises were the most common indication in SCD patients (77.7%). The mean weight of the excised spleen was 882.7 (range 85-1350) grams. There were 16 (29%) postoperative complications mostly encountered in patients with portal hypertension (46.2%). There were 2 deaths (3.6%) as a result of pulmonary embolism in a trauma patient and multi-organ failure in SCD. There was no reported postsplenectomy sepsis after a follow-up period of 18-72 months. CONCLUSION: The most common indication for splenectomy in Dammam is abdominal trauma, followed by hematological diseases. Splenectomy in adult SCD population is uncommon. Conventional splenectomy has 29% complication rate especially in patients with portal hypertension. This calls for rapid introduction of minimally invasive approach to reduce the morbidity associated with open splenectomy.

Who should be doing laparoscopic bariatric surgery?

BACKGROUND: The training and credentialing of surgeons for laparoscopic bariatric surgery is controversial. We sought to determine if there is an association between surgeons' practice and choice of open or laparoscopic bariatric surgery. METHODS: Members of the ASBS were surveyed via email. Associations were tested with Cochran-Mantel-Haenszel or Pearson's chi-square. RESULTS: 104/472 members responded; 65% were in private practice; 47% did 1-5 operations/week, 48% offered open procedures only, and 76% undertook gastric bypass. Respondents believe that laparoscopic procedures: should mimic open ones (77%), are safe (63%), should be evaluated by clinical trials (48%), and that expertise in bariatric surgery is more important than laparoscopic experience. 75% believe that courses and preceptorships are important. Regarding laparoscopic operations, surgeons doing only open procedures believe that: 1) the ASBS should be the main credentialing body; 2) surgeons should do > 25 open before laparoscopic ones; and 3) clinical trials are needed (P < 0.02, all). Surgeons with laparoscopic training or practices believe that laparoscopic surgery is safe and effective (P < 0.002). Both laparoscopic and open surgeons believe bariatric surgeons should be the only surgeons doing laparoscopic bariatric procedures (P < 0.008). CONCLUSIONS: There is consensus that laparoscopic bariatric surgery should be undertaken only by surgeons with strong interest in bariatric surgery. Laparoscopic bariatric surgeons should incorporate lessons learned from open surgery. Both laparoscopic and open bariatric surgeons should seek added expertise via courses and preceptorships. The skepticism of surgeons with 'open' practices could be addressed by clinical trials. The ASBS should maintain its leadership position and foster emerging technologies.

Retroperitoneal abscess as an initial presentation of cecal carcinoma.

We report an unusual case of cecal carcinoma presenting first time as retroperitoneal abscess. As the patient was septic on presentation and the underlying cancer was not clear, she was treated initially by extraperitoneal drainage of the abscess. She later underwent a palliative right hemicolectomy. She presented a month later with recurrence at the drainage site. This case highlights this unusual initial presentation of right colonic cancer, the diagnostic dilemma and the poor prognosis associated with it.

Diabetic foot: presentation and surgical management at Dammam Central Hospital.

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