Pancreaticoduodenectomy for the Management of Pancreatic or Duodenal Metastases from Primary Sarcoma.

BACKGROUND/AIM: Sarcomas are rare and heterogeneous solid tumours of mesenchymal origin and frequently have an aggressive course. The mainstay of management for localized disease is surgical excision. Following excision there is approximately 30-50% risk of developing distant metastases. The role of pancreatic resection for metastatic sarcoma is unclear. Therefore, the aim of this study was to asses the outcome of patients with pancreatic metastases of sarcoma treated with surgical resection. PATIENTS AND METHODS: A retrospective analysis of a prospectively maintained single-surgeon, single-centre database was undertaken. Seven patients were identified who underwent pancreaticoduodenectomy for the management of metastatic disease from sarcoma between 2006-2016. RESULTS: The median age was 59 (range=19-73) years, and there were six females and one male. The primary sites included the uterus, broad ligament, femur and inferior vena cava. One patient died in the early postoperative period. The remaining six patients developed further recurrent disease, with a median disease-free interval of 11 (range=4-27) months and median overall survival of 21 months (range=4 days to 86 months). CONCLUSION: To our knowledge, this is the largest series of patients with pancreatic metastases of sarcoma treated with surgical resection. Despite optimal resection with R0 margins, in the absence of effective adjuvant systemic therapies, the benefit of such an approach in metastatic disease remains unclear.

Bariatric Surgery, Polycystic Ovary Syndrome, and Infertility.

Background. Polycystic ovary syndrome (PCOS) is the commonest cause of female infertility. Visceral obesity and insulin resistance are key pathophysiological mechanisms behind PCOS. Women suffering from this syndrome and infertility often seek bariatric surgery hoping that they would be able to conceive postoperatively. Objective. At present, there is no consensus on the role of bariatric surgery in the management of PCOS-associated infertility within the medical community, making it difficult to give specific advice to these women, so a review of the literature was necessary. Results. A detailed review of the literature was performed. Only 6 manuscripts were relevant and contained quantitative data. They demonstrated that bariatric surgery results in postoperative conception rates varying from 33% to 100%. Surgery is also associated with amelioration of menstrual irregularities, hormonal abnormalities, and hirsutism that are associated with PCOS. These studies were retrospective and only had a small number of participants with infertility. Conclusions. Bariatric surgery has been shown to conclusively improve life expectancy, quality of life, and comorbidities like type 2 diabetes and obstructive sleep apnea. However, further research is required to identify whether weight loss surgery results in significant improvement in fertility of women with PCOS and to investigate which operation has the best results.

Unusual aetiology of abdominal wall abscess: cholecystocutaneous fistula presenting 20 years after open subtotal cholecystectomy.

A 68-year-old woman presented to the emergency department, with an abscess in the right upper anterior abdominal wall. She had a medical history of an open cholecystectomy 20 years prior, diabetes, obesity and a laparotomy for perforated sigmoid diverticular disease complicated by a large parastomal hernia. CT revealed this subcutaneous abscess to track intra-abdominally through the liver and communicate with the gallbladder fossa. The abscess was incised and drained. The wound initially drained pus, and then bile. Magnetic resonance cholangiopancreatogram (MRCP) demonstrated a remnant gallbladder containing 2 gallstones, a cholecystocutaneous fistula, portal vein thrombosis and cavernous transformation of the bile duct. The patient improved and was discharged. The patient's case history and imaging were discussed with the tertiary referral centre, in a multidisciplinary team. After an extensive and balanced discussion, the patient declined a completion cholecystectomy and continues to have occasional discharge from the fistula in her right upper quadrant.

An increased frequency of the 5A allele in the promoter region of the MMP3 gene is associated with abdominal aortic aneurysms.

Matrix metalloproteinase 3 (MMP3), is over expressed in the wall of abdominal aortic aneurysms (AAA), while inactivation of the gene expressing this enzyme is associated with reduced aneurysm formation in an experimental model. The 5A allele of the 5A/6A polymorphism in the promoter region of the MMP3 gene is associated with enhanced MMP3 expression. This study aimed to determine whether the presence of the 5A allele in the MMP3 promoter is a risk factor for AAA, and if this allele is associated with an increased expression of MMP3 in the aneurysm wall. We compared the frequencies of the 5A and 6A alleles in AAA (n = 405), aortic occlusive disease (AOD) (n = 123) and controls (n = 405). The 5A allele frequency was higher in AAA compared with controls (odds ratio - OR 1.32, P = 0.005) and AOD (OR 1.684, P = 0.0004), but was similar in AOD compared to controls (OR 0.78, P = 0.1). The ORs of the 5A/6A and the 5A/5A genotypes were 1.35 and 1.79, compared with 6A homozygotes. Although wall from 5A homozygotes contained 17% more MMP3 mRNA than homozygotes (P = 0.049) the significance of this was lost when adjusted for age and sex (P = 0.069), and size (P = 0.30). Wall from 5A homozygotes did however contain over 45% more MMP3 protein than heterozygotes (P = 0.009 when corrected for age and sex and P = 0.043 when corrected for aneurysm size). It appears that an abnormality in the MMP3 gene is part of the genetic profile that predisposes to aneurysmal disease.

Upper limb ischemia: 20 years experience from a single center.

The objective of this study was to review a single center's experience of upper limb revascularization over 20 years. All patients undergoing operative or endovascular upper limb revascularization between June 1983 and July 2003 were identified. One hundred eighty-four upper limb revascularization procedures were carried out on 172 patients. Sixty-one patients had a thromboembolic event (35%), 53 patients presented with a traumatic vascular injury (31%), and 29 patients had symptoms of chronic atherosclerotic upper limb ischemia (17%). Fifteen patients had subclavian steal syndrome, eight patients had thoracic outlet compression, and six patients had iatrogenic injuries of the upper limb arteries. Fifty-five thromboembolectomies were performed, 37 under locoregional anesthesia. Ten patients (18.2%) died from cardiopulmonary causes following embolectomy. Fifteen reversed saphenous vein bypass grafts were performed for traumatic damage. Twenty-seven patients had a primary repair, and five required a vein patch. One patient subsequently had an arm amputation, and two patients died. Twelve patients presenting with chronic arm ischemia had a subclavian angioplasty, 12 patients had a proximal bypass, and in 5 patients, stenoses were stented. The mortality in this group was 6.9% (2 of 29). The mortality for upper limb revascularization was 8.7%. Almost all deaths occurred after upper limb embolectomy, and the mortality of this procedure was similar to that of lower limb embolectomy. Deaths were the result of cardiac comorbidity, and this should be actively sought and treated if outcomes are to improve.