Management of pancreatic head adenocarcinoma: From where to where?

Pancreatic head adenocarcinoma (PHAC) is one of the most aggressive malignancies, and it has low long-term survival rates. Surgery is the only option for long-term survival. The difficulties associated with PHAC include higher frequencies of regional or distant lymph node metastases and vascular involvement, and positive resection margins in pancreatic and retroperitoneal tissues. Radical resections increase margin negativity and life expectancy; however, the extend of the surgery applied is controversial. Thus, western and eastern centers may use different approaches. Multiorgan, peripancreatic nerve plexus, and vascular resections have been discussed in relation to radical surgery for pancreatic cancer as have the roles of neoadjuvant and adjuvant therapy regimens. Determining the appropriate limits for surgery, standardizing definitions and surgical techniques according to guidelines, and centralizing pancreatic surgery within high-volume institutions to reduce mortality and morbidity rates are among the most important issues to consider. In this review, we evaluate the basic concepts underlying and the roles of radical surgery for PHAC, and lymphadenectomy, nerve plexus, retroperitoneal tissue, vascular, and multivisceral resections, total pancreatectomy, and liver metastases are discussed.

Comparison of Laparoscopic and Conventional Cystotomy/Partial Cystectomy in Treatment of Liver Hydatidosis.

INTRODUCTION: Hydatidosis is a zoonotic infection and treatment is mandatory to avoid complications. Surgery remains the first choice in the treatment especially for CE2-CE3b cysts. Open or laparoscopic approaches are available. However, comparative studies are limited. MATERIALS AND METHODS: Data of patients who underwent cystotomy/partial cystectomy for liver hydatidosis between January 2012 and September 2016 (n=77) were evaluated retrospectively. Recurrent cases and the patients with previous hepatobiliary surgery were excluded. 23 patients were operated upon laparoscopically and named as Group 1. 48 patients operated conventionally named as Group 2. Demographics, cyst characteristics, operative time, length of hospital stay, recurrences, and surgery related complications were evaluated. RESULTS: Groups were similar in terms of demographics, cyst characteristics, and operative time. The length of hospital stay was 3.4 days in Group 1 and 4.7 days in Group 2 (p=0,007). The mean follow-up period was 17.8 months and 21.7 months, respectively (p=0.170). Overall complication rates were similar in two groups (p=0.764). Three conversion cases occurred (13%). One mortality was seen in Group 2. Four recurrences occurred in each group (17% versus 8.3%, respectively) (p=0.258). CONCLUSIONS: Laparoscopy is a safe and feasible approach for surgical treatment of liver hydatidosis. Recurrence may be prevented by selection of appropriate cases in which exposure of cysts does not pose an intraoperative difficulty.

The Role of C-Reactive Protein in the Early Prediction of Serious Pancreatic Fistula Development after Pancreaticoduodenectomy.

INTRODUCTION: Despite recent advances in surgical techniques, pancreatic fistulas are common. We aimed to determine the role of C-reactive protein in the prediction of clinically relevant fistula development. MATERIALS AND METHODS: Data from patients who underwent pancreaticoduodenectomy between 2012 and 2015 is collected. Postoperative 1st, 3rd, and 5th day (POD1, POD3, and POD5) C-reactive protein (CRP) levels, postoperative pancreatic fistula (POPF) development, other complications, length of hospital stay, and mortality were recorded. RESULTS: Of 117 patients, 43 patients (36.8%) developed complications (including fistulas). Of the patients developing fistulas, 21 (17.9%) had POPF A, 2 (1.7%) had POPF B, and 7 (6.0%) had POPF C. POD5 CRP and POD3 CRP were shown to be significantly correlated with mortality and development of clinically relevant POPF (p = 0.001 and p = 0.0001, resp.) and with mortality (p = 0.017), respectively. The development of clinically relevant POPFs (B and C) could be predicted with 90% sensitivity and 82.2% specificity by POD5 CRP cut-off level of 19 mg/dL and with 100% sensitivity and 63.6% specificity by the difference between POD5 and POD1 CRP cut-off level of >2.5 mg/dL. CONCLUSION: CRP levels can effectively predict the development of clinically relevant pancreatic fistulas.

Vaginal reconstruction with the modified rectosigmoid colon: surgical technique, long-term results and sexual outcomes.

Although vaginal reconstructions with intestinal segments require particularly complex surgical procedures, this technique has become popular with respect to fairly good functional and esthetic outcomes. This study describes cases of vaginal reconstruction performed using a modified rectosigmoid colon held in an ischemic state in order to reduce secretion and denervated in order to prevent defecation problems. Vaginal reconstructions with rectosigmoid colon were performed on 43 patients. In this retrospective study, 34 patients had Müllerian agenesis, while nine had undergone male to female sex reassignment surgery in which adequate vaginal depth had not been achieved. A rectosigmoid colon with its vascular pedicle was used and left in an ischemic state. All nerve structures within the pedicle were excised intraoperatively. Follow-up period was between 12 and 60 months. Partial necrosis occurred in one patient which was reconstructed with local flap. Hematoma developed beneath the skin incision in two cases, but resolved with conservative treatment. A good esthetic outcome was achieved in all cases. Sexual function was assessed using the Female Sexual Function Index (FSFI) in 15 patients. Fourteen out of 15 patients scored above 26.5 on this scale and were determined as having no sexual dysfunction (FSFI score ≥26.5). In conclusion, vaginal reconstruction with denervated rectosigmoid held in an ischemic state appears to be a reasonable option among several available reconstruction techniques.

Endoscopic diagnosis and treatment of biliary obstruction due to acute cholangitis and acute pancreatitis secondary to Fasciola hepatica infection.

In the differential diagnosis of biliary obstruction with unknown etiology, biliary fascioliasis should be considered in endemic and nonendemic regions. After diagnostic evaluation, endoscopic retrograde cholangiopancreatography (ERCP) was performed for etiological evaluation and/or treatment of biliary obstruction in five patients with a mean age of 55.8 years. Endoscopic sphincterotomy and cholangiogram revealed linear filling defects in the biliary system. Fasciola hepatica parasites were extracted using balloon and basket catheters in two and three patients, respectively. No morbidity or mortality was observed. F. hepatica infection should be considered as a differential diagnosis of biliary obstruction with unknown etiology in endemic and non-endemic regions. ERCP can be the standard diagnostic and/or therapeutic procedure in cases of biliary obstruction due to fascioliasis. Due to slippery and gel-like characteristics of the parasite, use of a basket catheter in semi-opened position may be required in case of unsuccessful extraction using a balloon catheter.

The correlation between breast cancer and urinary iodine excretion levels.

Objective To compare urinary iodine excretion levels in patients with breast cancer and control subjects. Methods In this prospective pilot study, patients with breast cancer and normal controls were recruited. Age and menopausal status were recorded. Levels of serum thyroid-stimulating hormone, blood urea nitrogen and creatinine and urine iodine concentration (UIC) were measured. UIC levels were divided into three categories: low (<100 µg/l), normal (100-200 µg/l) or high (>200 µg/l). Results A total of 24 patients with breast cancer and 48 controls were included in the study. There were no statistically significant differences between the two groups with regard to thyroid-stimulating hormone, blood urea nitrogen or creatinine levels. When considered overall, there was no statistical difference in UIC between patients and controls. However, comparisons within each category (low, normal or high UIC) showed a significantly higher percentage of patients with breast cancer had a high UIC compared with controls. Conclusions A high UIC was seen in a significantly higher percentage of patients with breast cancer than controls. UIC may have a role as a marker for breast cancer screening. Further studies evaluating UIC and iodine utilization in patients with breast cancer are warranted.

Laparoscopic surgery in distal pancreatic tumors.

OBJECTIVE: Laparoscopic distal pancreatectomy is increasingly being used in the surgical treatment of corpus and distal pancreatic tumors. In this study, patients who underwent laparoscopic or open distal pancreatectomy for benign or malignant causes were evaluated in terms of tumor characteristics and perioperative outcomes. MATERIAL AND METHODS: We retrospectively reviewed data from a total of 27 distal pancreatectomy cases performed for benign or malignant causes in the General Surgery Department between January 2013 and December 2015. Groups were compared according to the demographic characteristics of patients, operation type (laparoscopic or open, with splenectomy or spleen preservation), operation time, surgical site infection (superficial, deep wound infection, or intra-abdominal abscess), pancreatic fistula development, and histopathological examination results. RESULTS: Both groups were similar in terms of age, sex, and body mass index (p=0.42). Tumor diameter was similar (p=0.18). The total number of resected lymph nodes was similar in both groups (p=0.6). Pancreatic fistula developed in one patient in each group. Mean hospital stay duration and the amount of intraoperative bleeding were similar in both groups. The laparoscopy group had a markedly lower overall morbidity rate (p=0.08). There was no mortality observed in the study subjects. CONCLUSION: Laparoscopic distal pancreatectomy can be safely performed as a minimally invasive procedure in experienced centers and in selected cases without increasing perioperative complication rates, particularly in benign cases. Although oncological outcomes are acceptable for malignant cases, future prospective controlled studies are necessary for more reliable evaluation.

The role of surgeons on the development and performance of endoscopy.

Endoscopy is being frequently performed for both diagnostic and therapeutic applications in surgical practice. Surgery, as a scientific area, has an important role in the propagation of therapeutic endoscopic procedures. The contribution of surgeons to the evolution of endoscopic applications and its practice is a triggering factor for the improvement of endoscopic instruments and their widespread use. Training and education on basic diagnostic and therapeutic surgical endoscopy should be implemented as part of general surgery residency core program, according to accepted standardized criteria, in order for general surgeons to perform endoscopic applications in the future. In light of this information, it can be concluded that endoscopy training and skills should be standardized within accepted general principles. Standards to be used during post-graduate endoscopic practice should be precisely stated. In addition to accreditation of both surgeons and endoscopic centers, theoretical and practical education programs should be composed and organized.

Problems with the Median Arcuate Ligament Should Be Recognized before Surgery; Its Importance in Pancreaticoduodenectomy.

BACKGROUND: Celiac artery stenosis (CAS) is a not a rare finding in the general population. The median arcuate ligament (MAL) is a fibrous arch that unites the diaphragmatic crura on either side of the aortic hiatus and, while it normally passes cranial to the origin of the celiac truncus, a low-lying ligament may lead to compression of the celiac artery and is the one of the major causes of CAS. CASE REPORT: In this paper, we present a patient with a mass in the gastric bulbus who was diagnosed with celiac artery stenosis during the pancreaticoduodenectomy (PD). MAL was the cause of the celiac artery stenosis, determined based on the findings of preoperative computed tomography (CT). CONCLUSION: Although CAS is usually asymptomatic due to the collateral blood supply, it may be associated with potentially disastrous results due to ischemia of the upper abdominal organs as a result of disruption of the collateral pathways. It is especially important to recognize the presence of CAS and its etiology before interventional procedures. With the increasing use of multidetector computed tomography (MDCT), it becomes essential for radiologists to be aware of this entity and the cross-sectional findings.

Role of endoscopic retrograde cholangiopancreatography in the management of hepatic hydatid disease.

Most cases of hepatic hydatid disease exhibit uncomplicated clinical course and management. However, the diagnosis and management of complicated hepatic hydatid disease is a special issue. One of the most common and serious complications of hepatic hydatid disease is the rupture of the cyst into intrahepatic bile ducts. The clinical appearance of intrabiliary rupture can range from asymptomatic to jaundice, cholecystitis, cholangitis, liver abscess, pancreatitis and septicemia. Current treatments for major ruptures can result in high morbidity and mortality rates. Furthermore, ruptures that cannot be diagnosed preoperatively can induce complications such as biliary fistulae, biloma, cavitary infection and obstructive jaundice. In the past, these complications were diagnosed and treated by surgical methods. Currently, complications in both the pre- and postoperative periods are diagnosed and treated by non-invasive or minimally invasive methods. In clinical practice, endoscopic retrograde cholangiopancreatography (ERCP) is indicated for patients with preoperative frank intrabiliary rupture in which hydatid elements are clearly seen in the bile ducts, or for biliary adverse events after surgery, including persistent biliary fistulae and jaundice. However, controversy concerning routine preoperative ERCP and prophylactic endoscopic sphincterotomy in patients suspected of having minor cystobiliary communications still remains. In this article, the role of ERCP in the diagnosis and management of hepatic hydatid disease during the pre- and postoperative periods is reviewed.

Risk factors of breast cancer-related lymphedema.

INTRODUCTION: Secondary lymphedema is one of the major important long-term complications of breast cancer treatment. The aim of this study is to determine patient- and treatment-related risk factors of lymphedema in breast cancer patients. PATIENTS AND METHODS: Patients, who had been operated on for primary breast cancer at Akdeniz University Hospital and followed regularly between August 1984 and December 2009 were included in the study. In order to evaluate the arm swelling objectively, measurements were performed with a flexible tape measure for both arms, and limb volume was calculated using a truncated cone volume formula. Participants, whose volume difference between the two arms was ≥ 5%, were considered as lymphedema-positive patients. The SPSS program (SPSS inc. Chicago, IL) was used for statistical analysis. RESULTS: The mean age of 455 patients was 50.6 years and the median follow-up time was 53 months. Lymphedema was found in 124 (27%) patients. Most of the patients with a history of postoperative wound infection (52%) and lymphangitis (57%) had lymphedema (p=0.003 and p=0.002, respectively). Addition of radiation therapy increased lymphedema risk 1.83 times (p=0.007). The mean duration of the axillary drainage and number of the removed lymph nodes were 7.8 days and 19, respectively. The rate of lymphedema in patients with early stage breast cancer was less than patients with advanced breast cancer (24% and 35.3%, respectively, p=0.018). Most of the patients (92%) with lymphedema had a high body mass index (BMI ≥ 25 kg/m²), and obesity was another important factor for lymphedema (p<0.001). CONCLUSIONS: The most important treatment and patient-related risk factors for breast cancer-related lymphedema were obesity (≥ 25 kg/m²), axillary lymph node dissection, postoperative radiotherapy, wound infection, history of lymphangitis, and duration of axillary drainage. Elimination or prevention of these risk factors may reduce the incidence of lymphedema.

Uterine preservation and vaginal reconstruction in a patient with congenital vaginal agenesis presenting with cyclic menouria.

Herein we report the case of a patient with primary amenorrhea and cyclic menouria. The patient was a 20-year-old woman with primary amenorrhea and inability to achieve sexual intercourse. Clinical examination revealed normally developed labia majora and minora, clitoris, and external urethral orifice, but no vaginal opening. A mature female pubic hair pattern was present, and axillary hair development was normal. Breasts were normally developed. Abdominopelvic magnetic resonance imaging demonstrated a remnant upper vagina and unicornuate uterus filled with fluid, and left-sided renal agenesis. Intraoperatively, a congenital vesicouterine fistulous tract was observed. The fistulous tract was completely resected. Vaginal reconstruction using a sigmoid colon pedicled flap was performed. The proximal part of the neovagina was connected to the remnant cervix, and a Foley catheter was left in the uterine cavity for 7 days to prevent obstruction. The patient has been menstruating regularly since the operation. Menouria might be an early sign of congenital vesicouterine fistula. Resection of the fistulous tract with uterine preservation might be considered in patients with vaginal agenesis.

Case report: acute pancreatitis caused by postcholecystectomic hemobilia.

BACKGROUND: Hemobilia is a rare cause of upper GI bleeding and the reasons for the majority of the cases are iatrogenic. It is also one of the rarest vascular complication following laparoscopic cholecystectomy but acute pancreatitis due to postcholecystectomic hemobilia as a late complication of cholecystectomy is not yet described. CASE PRESENTATION: We presented the case of a 32-year-old female, admitted to our emergency surgery clinic with hematemesis, jaundice and abdominal pain who had a history of laparoscopic cholecystectomy 4 months ago. Patient was diagnosed as acute pancreatitis and obstructive jaundice caused by postcholecystectomic hemobilia. Afterwards she is successfully treated by ERCP, angiographic identification and embolization of right hepatic artery pseudoaneurysm. CONCLUSIONS: We presented that postcholecystectomic hemobilia may cause acute pancreatitis and acute pancreatitis caused by postcholecystectomic hemobilia should also be included to the rare complications which may occur following cholecystectomy.

The role of ERCP in the management of bile leakage: endoscopic sphincterotomy versus biliary stenting.

INTRODUCTION: Bile leakage is a common complication of cholecystectomy. The aim of this study was to compare endoscopic sphincterotomy (EST) and biliary stenting (BS) in the treatment of bile leaks after cholecystectomy. PATIENTS AND METHODS: Twenty-seven patients with bile leakage following cholecystectomy underwent endoscopic retrograde cholangiography (ERCP). Patients were randomized into two groups (EST and BS +/- EST), according to the initial therapeutic endoscopic intervention. The patients were allocated into subgroups once more, according to diameter of the common bile duct (CBD). Outcomes and efficacy of BS and EST on fistula closure and the time to fistula closure were investigated. RESULTS: The median time between cholecystectomy and ERCP in the EST and BS groups was 6.45 +/- 3.41 and 4.50 +/- 1.99 days, respectively. The mean daily amount of biliary leakage in the EST and BS groups was 376.92 +/- 243.77 and 441.07 +/- 216.08 cc/day, respectively. The diameter of the distal part of CBD in the EST and BS groups was 9.07 +/- 3.84 and 8.28 +/- 4.04 mm, respectively. Mean fistula closure was achieved in 6.45 +/- 3.41 in 11 of 13 patients in the EST group and 4.50 +/- 1.99 days in the BS group in all patients. However, mean time of closure was significantly shorter in the BS 4.71 +/- 2.14 group, compared to EST (9.67 +/- 2.51), among patients with distal CBD diameter (< or =8 mm). CONCLUSIONS: BS seems to be a more effective method than EST in the management of postcholecystectomy among patients with bile leakage and without CBD dilatation. BS might be the first-line treatment among such patients. However, further prospective, randomized, clinical trials regarding CBD dilatation are warranted.

The role of the ankle brachial pressure index in the diagnosis of peripheral arterial injury.

BACKGROUND: Angiography is the "gold standard" diagnostic tool for patients presenting soft signs of arterial injury. To reduce the number of unnecessary angiographies, we aimed to evaluate the role of the ankle brachial pressure index (ABPI) in the diagnosis of peripheral arterial injury in extremity trauma with soft signs. METHODS: The data of 1772 patients with the suspicion of peripheral arterial injury was recorded prospectively. Two hundred eighty-three patients (16%) with any hard sign underwent immediate surgery. ABPI was calculated in 1489 patients with soft signs. Patients with ABPI <1 were evaluated by duplex ultrasonography and/or angiography, and if arterial injury was detected, the patients underwent surgery. Patients with an ABPI > or =1 were followed up conservatively. RESULTS: 1343 (90%) patients had ABPI > or =1; seven (0.5%) of them developed symptoms and signs of arterial injury and healed without morbidity. One hundred forty-six (10%) patients had ABPI <1; with DUS/angiography, arterial injury was detected in 39 of them (26.7%), and they underwent surgery. The sensitivity of ABPI <1 was 84.8%; specificity 92.6%; positive predictive value 26.7%; negative predictive value 99.5%; and overall accuracy 92.3%. CONCLUSION: ABPI excludes arterial injury in 99.5% of patients with soft signs of arterial injury and avoids unnecessary examinations in 90% of patients. In the management of extremities with soft signs, ABPI measurement should be the first-line diagnostic choice.

Is endoscopic band ligation superior to injection therapy for Dieulafoy lesion?

BACKGROUND: Dieulafoy lesion is a rare but serious cause of gastrointestinal system bleeding. An aberrant submucosal artery, which was described in 1884, causes the bleeding. The lesion can be located anywhere in the gastrointestinal tract but is most commonly found in the proximal stomach up to 6 cm from the gastroesophageal junction. Increased experience in endoscopy has led to an increased frequency of its proper diagnosis. Various methods are used to achieve successful hemostasis by endoscopy in Dieulafoy lesion; however, comparative studies about the success rates of these methods are still needed. In this study, we compared two of these endoscopic hemostatic methods: band ligation, and injection therapy in Dieulafoy lesions. METHODS: In this prospective study, 18 patients admitted to the Emergency Surgical Unit between January 2002 and December 2005 with upper gastrointestinal bleeding diagnosed as Dieulafoy lesion were included. Diagnose of Dieulafoy lesion was made at initial or second-look endoscopy. Patients were randomized in two groups according to therapy method: injection therapy and band ligation groups. Therapy was applied immediately after recognizing the lesion at the same endoscopic procedure. Two groups were compared regarding demographical data, presence of comorbid diseases, history of medication and previous gastrointestinal system bleeding, hemodynamic status, laboratory values, need for transfusion, endoscopic findings, success rate of the treatment method, mean hospital stay, complications, and recurrence of bleeding. RESULTS: Of 588 patients admitted with upper gastrointestinal hemorrhage, Dieulafoy lesion was recognized in 18 cases (3.1%) at initial or second-look endoscopy. All patients were men with a mean age of 62.8 (range, 30-80) years. Band ligation was applied to ten patients and the remaining eight were treated by injection therapy. During the follow-up period, rebleeding occurred in six of the patients (75%) with injection therapy, whereas no rebleeding occurred for the patients in the band ligation group. The rebleeding rate and mean hospital stay was significantly higher for the injection therapy group. CONCLUSIONS: Our study suggests that of the endoscopic treatment methods, band ligation is superior to injection therapy for the treatment Dieulafoy lesions.

Prevalence and importance of amebic infestation in patients with ulcerative colitis in two regions in Turkey.

We investigated the prevalence of amebiasis in patients with ulcerative colitis residing in two geographical regions with different socioeconomic status and climatic conditions, and its effect on the age of onset, duration, localization, and activity of disease. Ninety patients from a high socioeconomic location (group I) and 28 cases from a low socioeconomic location (group II) were enrolled. Median age at disease onset was significantly higher in group I compared with in group II. Prevalence of amebiasis in group I was significantly lower than in group II. A considerably number of patients with amebiasis in group I had a history of travel to the cities with a lower socioeconomic level, mainly located in the east of Turkey. There was a strong relationship between presence of amebiasis and history of travel to eastern parts of Turkey among residents from the northwestern part of Turkey. Median age and age at time of diagnosis were significantly lower in patients with amebiasis compared with those without infection. In patients with mild disease activity, prevalence of amebiasis was significantly lower compared with those with moderate or severe disease activity. In conclusion, prevalence of amebiasis was markedly higher in the southeast compared to the northwest of Turkey. Travel to regions with low socioeconomic status may be considered a risk factor for amebiasis in patients with ulcerative colitis. Amebiasis enhances disease activity in ulcerative colitis.

Primary omental hydatid cyst.

Hydatid disease is still a frequently seen disease in endemic area like South America, Middle Asia and South Europe as well as Turkey. Although the disease occurs more frequently in liver and lungs, it can be seen in any part of the body. In this report we present a case of isolated omental hydatid disease which is a rare entity in the English literature.

Endoscopic transcolonic catheter-free pelvic abscess drainage.

Natural orifice transluminal endoscopic surgery is a novel therapeutic method in development that uses different routes of surgical approach. The use of various methods, instruments and accessories during this procedure are currently being investigated. A case of appendicitis-related intra-abdominal abscess that was resolved by a transcolonic endoscopic approach using a wide-channel colonoscope with the help of precut and standard sphincterotome without radiological percutaneous drainage is presented.