Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases.

AIM: To evaluate the evolution, trends in surgical approaches and reconstruction techniques, and important lessons learned from performing 1000 consecutive pancreaticoduodenectomies (PDs) for periampullary tumors. METHODS: This is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period (1993-2002), middle period (2003-2012), and late period (2013-2017). RESULTS: The frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods. CONCLUSION: Surgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.

Tailored pancreatic reconstruction after pancreaticoduodenectomy: a single-center experience of 892 cases.

BACKGROUND: Pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debatable even for pancreatic surgeons. Ideally, pancreatic reconstruction after PD should reduce the risk of postoperative pancreatic fistula (POPF) and its severity if developed with preservation of both exocrine and endocrine pancreatic functions. It must be tailored to control the morbidity linked to the type of reconstruction. This study was to show the best type of pancreatic reconstruction according to the characters of pancreatic stump. METHODS: We studied all patients who underwent PD in our center from January 1993 to December 2015. Patients were categorized into three groups depending on the presence of risk factors of postoperative complications: low-risk group (absent risk factor), moderate-risk group (presence of one risk factor) and high-risk group (presence of two or more risk factors). RESULTS: A total of 892 patients underwent PD for resection of periampullary tumor. BMI >25 kg/m2, cirrhotic liver, soft pancreas, pancreatic duct diameter <3 mm, and pancreatic duct location from posterior edge <3 mm are risk variables for development of postoperative complications. POPF developed in 128 (14.3%) patients. Delayed gastric emptying occurred in 164 (18.4%) patients, biliary leakage developed in 65 (7.3%) and pancreatitis presented in 20 (2.2%). POPF in low-, moderate- and high-risk groups were 26 (8.3%), 65 (15.7%) and 37 (22.7%) patients, respectively. Postoperative morbidity and mortality were significantly lower with pancreaticogastrostomy (PG) in high-risk group, while pancreaticojejunostomy (PJ) decreases incidence of postoperative steatorrhea in all groups. CONCLUSIONS: Selection of proper pancreatic reconstruction according to the risk factors of patients may reduce POPF and postoperative complications and mortality. PG is superior to PJ as regards short-term outcomes in high-risk group but PJ provides better pancreatic function in all groups and therefore, PJ is superior in low- and moderate-risk groups.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: Risk factors and predictors of severity.

AIM: To detect risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and investigate the predictors of its severity. METHODS: This is a prospective cohort study of all patients who underwent ERCP. Pre-ERCP data, intraoperative data, and post-ERCP data were collected. RESULTS: The study population consisted of 996 patients. Their mean age at presentation was 58.42 (± 14.72) years, and there were 454 male and 442 female patients. Overall, PEP occurred in 102 (10.2%) patients of the study population; eighty (78.4%) cases were of mild to moderate degree, while severe pancreatitis occurred in 22 (21.6%) patients. No hospital mortality was reported for any of PEP patients during the study duration. Age less than 35 years (P = 0.001, OR = 0.035), narrower common bile duct (CBD) diameter (P = 0.0001) and increased number of pancreatic cannulations (P = 0.0001) were independent risk factors for the occurrence of PEP. CONCLUSION: PEP is the most frequent and devastating complication after ERCP. Age less than 35 years, narrower median CBD diameter and increased number of pancreatic cannulations are independent risk factors for the occurrence of PEP. Patients with these risk factors are candidates for prophylactic and preventive measures against PEP.

Increased Proliferative Activity Accompanies the Local Inflammatory Response of Gastric Mucosa After Intragastric Balloon Insertion.

BACKGROUND AND AIM: The use of BioEnterics intragastric balloon (BIB) is progressively increasing, owing to the fact that morbid obesity becomes a global epidemic together with risks of bariatric surgery. Yet, the possible local BIB effect on gastric mucosa is not clearly elucidated. The aim of the current study was to assess the histological changes occurring in the gastric mucosa post-BIB insertion. METHODS: Gastric mucosa biopsy was obtained from 87 cases of morbid obesity both pre-BIB and 6 months post-BIB insertion to compare the local changes by histological and immunohistochemical analysis. RESULTS: An inflammatory reaction was detected in the post-BIB mucosa which displayed a positive CD20, CD3 (p < 0.05), and the proliferation index (Ki67) increased significantly compared with that of the pre-BIB cases. The Ki67 index showed a significant positive correlation with CD20 and CD3 immunoexpression in the post-BIB gastric mucosae. CONCLUSION: Our results demonstrated a possible increase in the gastric proliferative activity after BIB insertion accompanied with a remarkable local inflammatory reaction. Although these findings may be reactive and transient, endoscopic follow-up is recommended for early detection of further pathological changes.

Outcomes of pancreaticoduodenectomy in elderly patients.

BACKGROUND: Although the mortality and morbidity of pancreaticoduodenectomy (PD) have improved significantly over the past years, the concerns for elderly patients undergoing PD are still present. Furthermore, the frequency of PD is increasing because of the increasing proportion of elderly patients and the increasing incidence of periampullary tumors. This study aimed to analyze the outcomes of PD in elderly patients. METHODS: We studied all patients who had undergone PD in our center between January 1995 and February 2015. The patients were divided into three groups based on age: group I (patients aged <60 years), group II (those aged 60 to 69 years) and group III (those aged ≥70 years). The primary outcome was the rate of total postoperative complications. Secondary endpoint included total operative time, hospital mortality, length of postoperative hospital stay, delayed gastric emptying, re-exploration, and survival rate. RESULTS: A total of 828 patients who had undergone PD for resection of periampullary tumor were included in this study. There were 579 (69.9%) patients in group I, 201 (24.3%) in group II, and 48 (5.8%) in group III. The overall incidence of complications was higher in elderly patients (25.9% in group I, 36.8% in group II, and 37.5% in group III; P=0.006). There were more patients complicated with delayed gastric emptying in group II compared with the other two groups. There was no significant difference in the incidence of postoperative pancreatic fistula, biliary leakage, pancreatitis, pulmonary complications and hospital mortality. CONCLUSIONS: PD can be performed safely in selected elderly patients. Advanced age alone should not be a contraindication for PD. The outcome of elderly patients who have undergone PD is similar to that of younger patients, and the increased rate of complications is due to the presence of associated comorbidities.

Early Versus Late Cholecystectomy After Clearance of Common Bile Duct Stones by Endoscopic Retrograde Cholangiopancreatography: A Prospective Randomized Study.

INTRODUCTION: The time interval between endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) is a matter of debate. This study was planned to compare early LC versus late LC. PATIENTS AND METHODS: This is a prospective randomized study on patients who are presented with concomitant gallbladder and common bile duct stone. The study population was divided into two groups; group (A) managed by early LC within three days after ERCP; and group (B) managed by late LC one month after ERCP. RESULTS: No significant difference between both groups as regards the conversion rate, the degree of adhesion, cystic duct diameter, and intraoperative common bile duct injury or bleeding. Recurrent biliary symptoms were significantly more in delayed LC group in 7 (12.71%) patient versus 1 patient in early LC (P=0.03). CONCLUSIONS: No significant difference between both groups as regards the conversion rate. Recurrent biliary symptoms were significantly more in delayed LC while waiting LC. Morbidity was significantly more in delayed LC.

Management and Outcome of Borderline Common Bile Duct with Stones: A Prospective Randomized Study.

INTRODUCTION: Management of common bile duct stones (CBDS) in patients with borderline CBD presents a surgical challenge. The aim of this study was to compare conservative treatment with endoscopic stone extraction for the treatment of borderline CBD with stones. PATIENTS AND METHODS: This prospective randomized controlled trial includes patients with CBDS in borderline CBD (CBD <10 mm) associated with gallbladder stones who were treated with conservative treatment or endoscopic stone extraction followed by laparoscopic cholecystectomy (LC) and intraoperative cholangiogram (IOC). The primary outcome was successful CBD clearance. The secondary outcomes were the overall complications, cost, and hospital stay. RESULTS: LC and IOC revealed complete clearance of CBDS in 48 (96%) cases in the endoscopic retrograde cholangiopancreatography (ERCP) group (52% of patients by ERCP, and 44% of patient passed the stone spontaneously), and in the remaining two patients, the CBDS was removed by transcystic exploration. In the conservative group, LC and IOC revealed complete clearance of CBDS in 90% of cases, and in the remaining 10% of patients, the CBDS was removed by transcystic exploration. Post-ERCP pancreatitis (PEP) is noticed significantly in the ERCP group (2 [4%] versus 8 [16%]; P = .04). The average net cost was significantly higher in the ERCP group. Recurrent biliary symptoms developed significantly in the ERCP group after 1 year (10% versus 0%; P = .02) in the form of recurrent cholangititis and recurrent CBDS. CONCLUSIONS: Management of CBDS in patients with borderline CBD represents a surgical challenge. Borderline CBD increases the technical difficulty of ERCP and increases the risk of PEP. Conservative management of CBDS in borderline CBD not only avoids the risks inherent in ERCP and unnecessary preoperative ERCP, but it is also effective in clearing CBDS. The hepatobiliary surgeon should consider a conservative line of treatment in CBDS in borderline CBD in order to decrease the cost and avoid unnecessary ERCP.

Long term outcomes of choledochoduodenostomy for common bile duct stones in the era of laparoscopy and endoscopy.

BACKGROUND/AIMS: Choledochoduodenostomy (CDD) has been reported as an effective treatment of Common bile duct stones (CBDS). This study was designed to analyze short term and long term outcomes of CDD for CBDS. METHODOLOGY: Demographic data, preoperative, intraoperative and postoperative variables were collected. The long term assessment was done in a prospective manner included clinical examination, liver function, abdominal ultrasound, MRCP, upper GIT endoscopy and assessment of quality of life using Gastrointestinal Quality of Life Index (GIQLI). RESULTS: A total of 388 consecutive patients underwent CDD, the mean age was 57.92±13.25 years. The mean CBD diameter was 18.22±4.01 mm. The mean operative time was 81.21±20.23 minutes. Two patients had recurrent stone (0.06%) and managed successfully by endoscope. Gastritis was observed in 16.9% patients. No patient developed sump syndrome, deterioration in liver function or cholangiocarcinoma. Total and subgroup scores on the GIQLI before and after CDD differed significantly at follow-up (P=0.0001). CONCLUSION: CDD is a safe and effective method of drainage of CBD after clearance of CBDS. Long term outcomes are acceptable with good quality of life. Sump syndrome is extremely rare; CDD may be associated with mild to moderate gastritis. CDD doesn't lead to development of cholangiocarcioma.

Intraoperative endoscopic retrograde cholangio-pancreatography: a useful tool in the hands of the hepatobiliary surgeon.

AIM: To evaluate the efficacy of intraoperative endoscopic retrograde cholangio-pancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) for patients with gall bladder stones (GS) and common bile duct stones (CBDS). METHODS: Patients treated for GS with CBDS were included. LC and intraoperative transcystic cholangiogram (TCC) were performed in most of the cases. Intraoperative ERCP was done for cases with proven CBDS. RESULTS: Eighty patients who had GS with CBDS were included. LC was successful in all cases. Intraoperative TCC revealed passed CBD stones in 4 cases so intraoperative ERCP was performed only in 76 patients. Intraoperative ERCP showed dilated CBD with stones in 64 cases (84.2%) where removal of stones were successful; passed stones in 6 cases (7.9%); short lower end stricture with small stones present in two cases (2.6%) which were treated by removal of stones with stent insertion; long stricture lower 1/3 CBD in one case (1.3%) which was treated by open hepaticojejunostomy; and one case (1.3%) was proved to be ampullary carcinoma and whipple's operation was scheduled. CONCLUSION: The hepatobiliary surgeon should be trained on ERCP as the third hand to expand his field of therapeutic options.

Mirizzi Syndrome: How it could be a challenge.

BACKGROUND/AIMS: Mirizzi syndrome (MS) is a rare complication of cholelithiasis. This entity should be considered in the differential diagnosis of all patients with obstructive jaundice. Failure to recognize this condition preoperatively can result in a major bile duct injury. In this study, our aim is to describe the clinical presentations, investigations, operative details, endoscopic management and the complications of both procedures. METHODOLOGY: We performed a retrospective analysis on the records of 65 patients with MS. All patients had a cholangiogram; either magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). We used a McSherry classification to divide patients with MS into type I MS and type II MS. Those patients had undergone different types of management either ERCP and/or surgery. RESULTS: The incidence of MS was 0.98% from a total of 4600 patients who had undergone cholecystectomy. From 65 patients with MS, 20 patients underwent ERCP where it was the sole treatment (18 of which had stent while 2 had the stone extracted). The overall surgically treated patients were 45 (23 patients with preliminary ERCP with stent and 22 patients with primary surgical treatment), 18 patients had MS type I while 27 patients had MS type II. Patients with different types of MS underwent different types of surgical procedures.

Risk factors for conversion during laparoscopic cholecystectomy: retrospective analysis of ten years' experience at a single tertiary referral centre.

BACKGROUND/PURPOSE: Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic benign gallbladder disease. The identification of factors that reliably predict the need to convert LC to open cholecystectomy (OC) would help with patient education and counseling. METHODS: Between January 2000 and December 2009, 4,698 patients underwent cholecystectomy. LC was attempted in 4,434 patients (94.4%) and OC from the start was performed in 264 patients (5.6%). The causes for conversion were evaluated. The change in conversion rate between 2000 and 2004 and between 2005 and 2009 was analyzed. Factors predictive of conversion were identified by univariate and multivariate analysis. RESULTS: Conversion to OC from an initial LC approach was required in 234 patients (5.3%). The main cause for conversion was dense adhesions (54.7%). Independent risk factors in multivariate analysis were male gender (p < 0.001), increased age (p < 0.001), a history of previous upper abdominal surgery (p < 0.001), a WBC count >9 × 10(3)/µl, and urgently indicated cholecystectomy (p <0.001). The conversion rate decreased significantly from 6.7 to 3.6% over the two time intervals (p < 0.001). CONCLUSIONS: Those at highest risk for conversion are elderly male patients with prior abdominal surgery who present emergently with laboratory evidence of biliary inflammation.

Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience).

BACKGROUND: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a challenge even at high-volume centers. METHODS: This study was designed to analyze perioperative risk factors for POPF after PD and evaluate the factors that predict the extent and severity of leak. Demographic data, preoperative, intraoperative, and postoperative variables were collected. RESULTS: A total of 471 consecutive patients underwent PD in our center. Fifty-seven patients (12.1 %) developed a POPF of any type; 21 patients (4.5 %) had a fistula type A, 22 patients (4.7 %) had a fistula type B, and the remaining 14 patients (3 %) had a POPF type C. Cirrhotic liver (P = 0.05), BMI > 25 kg/m(2) (P = 0.0001), soft pancreas (P = 0.04), pancreatic duct diameter <3 mm (0.0001), pancreatic duct located <3 mm from the posterior border (P = 0.02) were significantly associated with POPF. With the multivariate analysis, both BMI and pancreatic duct diameter were demonstrated to be independent factors. The hospital mortality in this series was 11 patients (2.3 %), and the development of POPF type C was associated with a significantly increased mortality (7/14 patients). The following factors were predictors of clinically evident POPF: a postoperative day (POD) 1 and 5 drain amylase level >4,000 IU/L, WBC, pancreatic duct diameter <3 mm, and pancreatic texture. CONCLUSIONS: Cirrhotic liver, BMI, soft pancreas, pancreatic duct diameter <3 mm, pancreatic duct near the posterior border are risk factors for development of POPF. In addition a drain amylase level >4,000 IU/L on POD 1 and 5, WBC, pancreatic duct diameter, pancreatic texture may be predictors of POPF B, C.

Pancreatic cystic neoplasms: predictors of malignant behavior and management.

BACKGROUND/AIM: Pancreatic cystic neoplasms are being increasingly identified with the widespread use of advanced imaging techniques. In the absence of a good radiologic or pathologic test to preoperatively determine the dianosis, clinical characteristics might be helpful. The objectives of this analysis were to define the incidence and predictors of malignancy in pancreatic cysts. PATIENTS AND METHODS: Patients with true pancreatic cysts who were treated at our institution were included. Patients with documented pseudocysts were excluded. Demographic data, clinical manifestations, radiological, surgical, and pathological records of those patients were reviewed. RESULTS: Eighty-one patients had true pancreatic cyst. The mean age was 47 ± 15.5 years. There were 28.4% serous cystadenoma, 21% mucinous cystadenoma, 6.2% intraductal papillary tumors, 8.6% solid pseudopapillary tumors, 1.2% neuroendocrinal tumor, 3.7% ductal adenocarcinoma, and 30.9% mucinous cystadenocarcinoma. Malignancy was significantly associated with men (P = 0.04), older age (0.0001), cysts larger than 3 cm in diameter (P = 0.001), presence of solid component (P = 0.0001), and cyst wall thickening (P = 0.0001). The majority of patients with malignancy were symptomatic (26/28, 92.9%). The symptoms that correlated with malignancy included abdominal pain (P = 0.04) and weight loss (P = 0.0001). Surgical procedures were based on the location and extension of the lesion. CONCLUSION: The most common pancreatic cysts were serous and mucinous cysts. These tumors were more common in females. Old age, male gender, large tumor, presence of solid component, wall thickness, and presence of symptoms may predict malignancy in the cyst.

Post-cholecystectomy biliary injuries: one center experience.

BACKGROUND/AIMS: Post-cholecystectomy bile duct injuries (BDIs) represent a challenge in diagnosis and management. METHODOLOGY: From March 1995 to August 2009, 274 patients with post-cholecystectomy BDIs were managed at our center. All patients were subjected to laboratory tests, sonography, ERCP and MRCP. The management varied according to the type of injury. RESULTS: Seventy-one (25.9%) LC and 203 (74.1%) OC were performed; 8(2.9%) were detected intraoperatively; 270 patients were referred from other hospitals. From those discovered intraoperatively, 7 had hepatico-jejunostomy and one died from severe peritonitis; 11 (4%) presented with generalized and 112 (40.9%) with localized peritonitis. The leak site was the cystic duct (57 cases), accessory duct in the liver bed (5 cases), right hepatic duct (4 cases) and lateral tear in the CBD (12 cases). Endoscopic stenting was performed for all of them. The remaining 34 patients had a completely ligated distal duct and therefore had hepatico-jejunostomy Roux loop; 143 patients (52.2%) presented with early (79 cases) and late (64 cases) jaundice; 126 cases had hepatico-jejunostomy. The remaining 17 patients were treated by balloon dilatation. CONCLUSIONS: Endoscopic stenting can manage cases with cystic or accessory duct leak while, hepatico-jejunostomy Roux loop represents the golden procedure for management of transected or ligated CBD.

Pelvic floor dyssynergia: efficacy of biofeedback training.

BACKGROUND AND STUDY AIMS: Paradoxical contraction of the pelvic floor during attempts to defaecate is described as pelvic floor dyssynergia (anismus). It is a behavioural disorder (no associated morphological or neurological abnormalities); consequently, biofeedback training has been recommended as a behavioural therapy for such a disorder. The aim of the present study was to evaluate long-term satisfaction of patients diagnosed with pelvic floor dyssynergia after biofeedback. PATIENTS AND METHODS: Sixty patients (35 females and 25 males) with a mean age of 30±12years and a 4year duration of constipation were included. Forty-five patients had normal colonic transit and 15 patients had slow colonic transit. History, physical examination and barium enema were done to exclude constipation secondary to organic causes. Colonic and pelvic floor functions (colon-transit time, anorectal manometry, EMG and defaecography) were performed before and after biofeedback treatments. Patients were treated on a weekly basis with an average of (6±2) sessions. RESULTS: At the end of sessions, 55 out of 60 patients (91.6%) reported a subjectively overall improvement. Symptoms of dyschezia were reported less frequently after biofeedback. Age and gender were not predictive factors of outcome. No symptoms at initial assessment were predictive for patient's satisfaction but the only factor of predictive value was the diagnosis of anismus and the motivated patient who wanted to continue the sessions. CONCLUSION: Biofeedback remains a morbidity free, low-cost and effective outpatient therapy for well-motivated patients complaining of functional constipation and diagnosed as pelvic floor dyssynergia.