Postoperative pancreatic fistula after pancreatic resection.

BACKGROUND: The failure of pancreatic anastomosis after the proximal pancreaticoduodenectomy (PD) and the failure of pancreatic stump after the distal pancreatectomy with a resulting postoperative pancreatic fistula remain the most feared complications after pancreatic resection. Surgeons have been trying to find a reliable reconstructive technique of pancreatic anastomosis for decades. METHODS: A literature search was performed to January 2020. Studies giving a detailed description of the pancreatic anastomosis after open PD and pancreatic stump closure techniques after the distal pancreatectomy were included. The aim of this study was review reported data derived from meta-analyses concerning the incidence of POPF according to the International Study Group of Pancreatic Surgery. A comparison of various surgical techniques and their impact on POPF incidence was made. RESULTS: In the group of clinically relevant POPF (CR- POPF), a well established difference between the patients undergoing POPF-associated interventional drainage or reoperation was observed. Meta-analyses showed that the patients with CR- POPF were statistically more likely to have a small duct size, soft gland texture, particular pancreatic neoplasms and an excessive intraoperative blood loss. CONCLUSION: Grade C POPF following PD, although uncommon, occurs with a defined incidence and is associated with a substantial morbidity, prolonged hospitalization, delayed recovery and a significant mortality. According to the results of various meta-analyses, pancreatogastrostomy and pancreatojejunostomy seemed to be comparable anastomotic techniques following PD (Ref. 54).

Ampullary cancer in a patient with familial adenomatous polyposis - a rare case report and current status of management.

Familial adenomatous polyposis (FAP) is an inherited autosomal dominant disorder. Extracolonic manifestations are seen quite often. As prophylactic colectomy has become a standard care in FAP patients, the concerns over the development of associated extracolonic malignancies have become more prevalent. The authors report a case of a patient with the history of subtotal colectomy because of FAP with the development of adenocarcinoma of papilla of Vater twenty-six years later. A radical procedure in form of proximal pancreaticoduodenectomy was indicated. Variable endoscopic surveillance protocols and treatment strategies have been proposed concerning the management of duodenal and periampullary lesions. In case of periampullary malignancies, the radical surgical resection offers the only chance for cure and the only option that may safeguard the long­term survival (Fig. 2, Ref. 30). Keywords: ampulla of Vater, bile duct, obstructive jaundice, pancreatoduodenectomy, periampullary tumors.

Recurrence after sentinel lymph node biopsy in cutaneous melanoma: a single-center experience in Slovak patients.

The standard approach in the management of cutaneous malignant melanoma is considered to be a complete excision of the primary lesion with an appropriate margin of the normal tissue according to Breslow thickness. Usually sentinel lymph node biopsy (SLNB) can help to determine the nodal status, and thus improve the accuracy of staging of the disease. However, the role of SLNB in melanoma treatment remains controversial. NCCN guidelines strongly support routine performance of therapeutic lymphadenectomy in all melanoma patients with clinically positive nodes without radiographic evidence of distant metastases. Patients with positive SLNB should have had completion lymph node dissection (CLND) for regional disease control. Between 2012 and 2016, 168 consecutive patients underwent surgery for primary cutaneous malignant melanoma at St. Elisabeth Cancer Institute in Bratislava. The indication for SLNB and the procedure was made according to international guidelines. In this retrospective study, a cohort of 78 patients was analyzed (35 women and 43 men). Inclusion criteria comprised patients with cutaneous melanoma with no evidence of distant metastases or clinical lymphadenopathy. SLNB comprised a dual labelling method (Tc-99m Nanocolloid / blue dye) in a one-day protocol. Median follow-up was 657 days. The primary composite outcome was the time to the first disease-related event (death, reintervention, worsening of symptoms). Primary outcome measures were overall (disease-specific) and disease-free survival. The overall identification rate of SLN in melanoma patients by dual labelling method was 98.5%. All patients with positive SLNB on frozen section underwent complete regional lymphadenectomy. Using multivariable analysis Breslow thickness of the lesion (p=0.00004, HR 4.03 on logarithmic scale) was identified as the strongest independent predictor of the disease-free survival (DFS) and male gender was significant predictor of DFS. An increase in tumor thickness was associated with significantly higher risk of an event. Neither SLN positivity nor initial S-100 level proved to be significant predictors of the event at the 0.05 level of probability. Multidisciplinary approach represents the gold standard of care for melanoma patients and surgery remains the best option for most localized cases. Although the usefulness of SLNB procedure has been questioned, it provides an excellent staging method, moreover, it can identify high-risk patients. The routine use of completion lymphadenectomy after a positive SLNB is still controversial. It is not clear whether CLND following a positive SLN biopsy improves survival but it could provide regional disease control.

Surgical management of breast cancer liver metastases.

We analyzed the treatment results in patients who underwent hepatic resection for breast cancer liver metastases(BCLM).Between 1/2003 and 12/2012, 15 patients underwent hepatic resection for BCLM. All primary breast tumors were diagnosed as invasive breast cancer. Synchronous BCLM ocurred in 2 patients and 13 patients presented with metachronous BCLM. Median age of patients at the time of BCLM diagnosis was 51 years(range from 31 to 73 years). All resections were considered as R0. From among 15 resections we performed 10 major hepatic resections according to Couinaud classification(≥3 segments) and the rest were minor ones. There was no postoperative mortality within 60 days . All postoperative complications were managed conservatively. Median hospital stay was 10,5 days, ranging from 7-14 days.Standard therapy for patients with BCLM remains systemic chemo- and hormonal therapy. Hepatic resection as a part of multimodal treatment in tertiary HPB centers can offer in a selected group of patients a safe option for improved survival.

Surgical management of breast cancer liver metastases.

We analyzed the treatment results in patients who underwent hepatic resection for breast cancer liver metastases(BCLM).Between 1/2003 and 12/2012, 15 patients underwent hepatic resection for BCLM. All primary breast tumors were diagnosed as invasive breast cancer. Synchronous BCLM ocurred in 2 patients and 13 patients presented with metachronous BCLM. Median age of patients at the time of BCLM diagnosis was 51 years(range from 31 to 73 years). All resections were considered as R0. From among 15 resections we performed 10 major hepatic resections according to Couinaud classification(≥3 segments) and the rest were minor ones. There was no postoperative mortality within 60 days . All postoperative complications were managed conservatively. Median hospital stay was 10,5 days, ranging from 7-14 days.Standard therapy for patients with BCLM remains systemic chemo- and hormonal therapy. Hepatic resection as a part of multimodal treatment in tertiary HPB centers can offer in a selected group of patients a safe option for improved survival. Keywords: breast cancer, liver metastases, hepatic resection.

[Ductal carcinoma in situ (DCIS) and biopsy of the sentinel lymph node]. / DCIS a biopsia sentinelovej uzliny.

INTRODUCTION: Ductal carcinoma in situ (DCIS) is the disease with increasing incidence. Nowadays, approximately 80% DCIS are diagnosed via mammography and represent more than 20% of all types of breast cancer. The acceptance of surgical procedures with this type of breast carcinoma is controversial as primary diagnosis of non-invasive carcinoma is often underestimated and in the end, histopathological examination reveals invasive carcinoma with biological potential to metastasize. In cases of "risk" patient groups with DCIS, several studies report lymph node metastases. The aim of the study has been to assess the incidence of sentinel lymph node metastatic involvement in high-risk patient group with DCIS and in ductal carcinoma in situ with microinvasion (DCISMI), to note the incidence of invasive carcinoma in definitive histopathology in patients with pre-operative diagnosis of DCIS and to analyze some predictors of invasivity. STUDY TYPE AND PATIENT GROUP: In retrospective analysis, we evaluated the setting of 119 patients who have been operated on at our Clinic from January, 1st 2008 until December, 31th 2010 for the diagnosis of DCIS. Prospectively, we have created the setting of 44 patients with high-risk DCIS with sentinel lymph node biopsy (SLNB) performed. METHODS AND RESULTS. Metastatic involvement of sentinel lymph node in high-risk DCIS has been found in 4 cases (9.0%)--in 1 patient (2.2%) with correct diagnosis of DCIS and in 3 patients (6.8%) with invasive carcinoma according to final histopathology. In the patient with DCIS, a micrometastasis of 0.4 mm was found in one sentinel lymph node. After complete axillary dissection, non-sentinel axillary lymph nodes metastatic involvement was not demonstrated (14/0). In 6 cases (5.0%), we identified DCISMI and did not find metastasis in sentinel lymph node. In the high-risk DCIS group, in 4 patients (9.0%) DCISMI and in 12 patients (27.2%) invasive carcinoma was found after definitive histopathologic examination. In this group, the overall ratio of invasive lesions was 36.2%. As for predictors of invasivity, high-grade carcinoma (OR 4.2; 95% CI 1,40-12,58) has more than 4-fold higher influence and lesion size

[Significance of the sentinel lymph node biopsy in early breast carcinomas]. / Význam biopsie sentinelovej uzliny pri vcasnom karcinóme prsníka.

We present our experience regarding sentinel lymph node biopsy (SLNB) at St. Elizabeth Institute of Oncology during 48 months. From January 1st, 2006 until December 31st, 2009, we had performed SLNB in 269 patients. Primary tumour size was 0.3-3.5cm including non-invasive breast carcinoma (i.e. TIS, T1 and T2 of TNM classification). Invasive carcinoma accounted for 255 (94.8%) cases, while non-invasive carcinoma for 14 (5.2%) cases. From total of 269 patients with invasive carcinoma, we used validation method in 157 (72.7%). In 255 patients with invasive carcinoma, sentinel node was not identified in 4 (1.6%) cases--in 1 patient with T1 invasive carcinoma and in 3 patients with T2 tumours. False negativity of sentinel node in T1 tumours was 4.3%. The incidence of macrometastases in sentinel nodes was confirmed using standard histopathologic examination with hematoxylin-eosin stain. In negative instances, the examination was then completed with serial sections and immunohistochemistry using cytoskeletal antibodies for confirmation of presence of micrometastases. In 6 (2.4%) cases, we found micrometastase in originally negative sentinel lymph node. Subsequent axillary dissection has not confirmed non-sentinel nodes involvement.