Outcome after Surgical Treatment of Gastrointestinal Stromal Tumors in the Second Part of Duodenum: Is Localized Resection Appropriate?

BACKGROUND: The second part of the duodenum is the most common part to be involved with duodenal gastrointestinal tumors (D2-GISTs). Localized resection (LR) and pancreaticoduodenectomy (PD) are two viable options for curative resection. The aim of this study is to compare the middle-term outcomes in patients with D2-GIST after either LR or PD in a single institution. PATIENTS AND METHODS: Overall, 53 patients with non-metastatic D2-GIST were analyzed. Either LR or PD was executed depending on the involvement of the ampulla of Vater. The tumors were stratified in accordance with the Miettinen classification for tumor behavior. The patients were followed up for 3 years for recurrence and survival. RESULTS: Thirty-two of the patients were females (60%) and 21 males (40%), with a mean age of 55 ± 8 years. Bleeding was the most common presentation in 19 patients (36%). LR was performed in 41 patients (77%), whereas PD was performed in 12 patients (23%). Three-year survival and recurrence were comparable between the two groups. The disease-free survival at 3 years was 85% and 92% in LR and PD group, respectively. The PD group had a significantly longer operative time and a higher incidence of postoperative pancreatic fistula. Otherwise, no statistically significant difference was calculated. A significantly shorter survival was calculated in those with a mitotic index of >5 and also for tumors classified as high grade in accordance with the Miettinen classification. 71% of those with recurrence had high mitotic index > 5/hpf. CONCLUSIONS: LR for D2-GIST is an acceptable alternative to PD with satisfactory middle-term outcomes. For tumors involving the ampulla of Vater, PD is still indicated. Furthermore, tumor biology predicts the likelihood of survival and recurrence.

Endoscopic versus percutaneous biliary drainage for resectable pancreatic head cancer with hyperbilirubinemia and impact on pancreaticoduodenectomy: A randomized controlled study.

BACKGROUND: We hypothesized that percutaneous biliary drainage provides more short-term advantages over endoscopic stenting before pancreaticoduodenectomy. METHODS: Between January 2019 and December 2010, a prospective cohort study was conducted. Sixty patients with potentially resectable pancreatic head cancers and high bilirubin levels were stratified into two equal groups according to the method of biliary drainage: endoscopic stenting or percutaneous drainage. The primary outcome measures were operative difficulties and early postoperative morbidity, the secondary outcome was post-drainage complications. RESULTS: Both groups were comparable in age; gender; presenting symptoms, type of malignancy, post-drainage complications, and time intervals between drainage and surgery. Key preoperative significant differences were technically higher but clinical success rates was better in the PTD cohort. ERCP patients had significantly more difficult dissections, more blood loss, longer resection time, more postoperative bile leak, and longer hospital stay. CONCLUSION: From the operative perspective, patients who underwent PTD in the preoperative setting had fewer morbidities and shorter hospital stay. Large scale studies are required to support the validity of these findings in surgical practice.

Surgical protocol and outcome for sigmoidovesical fistula secondary to diverticular disease of the left colon: A retrospective cohort study.

BACKGROUND: Diverticular disease of sigmoid colon can rarely be complicated by a connective track to urinary bladder. Pneumaturia and fecaluria are the pathognomonic symptoms. Resection surgery is the preferred treatment to overcome the renal sequellae of the disease. The purpose of this study is to propose a guiding classification to help general surgeons during surgical management of diverticular disease complicated by sigmoidovesical fistula (SVF). PATIENTS AND METHODS: The data of 40 cases with colovesical fistula due to diverticular disease of sigmoid colon were retrospectively analyzed. Clinicopathological variables, imaging reports, types of treatment and patient outcome were evaluated. RESULTS: There were 36 men (90%) and four women (10%) in which the ages ranged from 32 to 79 with a mean of 58.1 years. Pneumaturia was the most common presenting symptom in 38 cases (95%) followed by urinary symptoms in 35 cases (87.5%) then fecaluria in 33 cases (82.5%). 37 patients underwent surgical resection while three patients were in poor general condition to withstand major resection. 16 patients underwent one stage resection and anastomosis, 16 patients were managed by two stage procedure and the remaining 5 patients were treated by three stages operation. CONCLUSIONS: Adequately performed CT followed by colonoscopy is the mainstay for diagnosis. Type 1 SVF should be treated in a single stage by complete resection and immediate anastomosis without a stoma. Type 2 cases are best managed in two stages while those with type 3 SVF are emergently managed by three stage procedure. Treatment of type 4 should be individualized.

Predictors of success of treatment of distal two thirds common bile duct strictures: A retrospective Cohort study over two years.

BACKGROUND: Distal biliary stricture is a challenging clinical condition that requires a co-ordinated multidisciplinary approach. THE AIM OF THIS WORK: was to evaluate the predictors of success of different treatment modalities of distal two thirds CBD strictures. PATIENTS AND METHODS: Data were retrieved retrospectively from the medical records of the patients with distal biliary strictures treated in the Main Alexandria University Hospital from June 2013 to June 2015. Patients were classified into three groups according to the intervention performed: (endoscopic, open surgical, and percutaneous). In addition to the forth group that was followed up without intervention. RESULTS: The study included 282 patients. The mean age was 61.1 ± 10.8 years (25-78) years. The most frequent presenting symptom was jaundice. Pancreatic adenocarcinoma was the most common cause followed by fibrotic stricture secondary to stones. CONCLUSION: In univariate analysis, the success of treatment was significantly associated with the pathology of the stricture of the distal two thirds CBD. In the multivariate analysis, only two factors were affecting the success of the treatment; the stricture length and site.

Management of intrahepatic stones: the role of subcutaneous hepaticojejunal access loop. A prospective cohort study.

BACKGROUND: Patients with intrahepatic stones usually present with recurrent cholangitis, biliary sepsis and intrahepatic abscesses, may develop liver atrophy and may progress to cholangiocarcinoma. Treatment of intrahepatic stones is difficult and the disease progresses in most patients even after adequate treatment. Surgical removal of stones has been the standard management but residual stones and stone recurrence occur frequently whatever the technique. Because of the need for repeated biliary instrumentation, long-term access routes involving percutaneous transhepatic cholangioscopic lithotripsy (PTCSL), hepaticocutaneousjejunostomy (HCJ) and subparietal hepaticojejunal access loop to permit stone retrieval or stricture dilatation have been developed. PURPOSE: The aim of this work was to evaluate the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones. PATIENTS AND METHODS: Between January 2009 and January 2013, 42 patients with intrahepatic stones underwent surgical treatment at the Gastrointestinal Surgery Unit, Main Alexandria University Hospital. Demographic data, details of operative findings, follow up details, and treatment of recurrent stones were analyzed. After approval of local ethics committee, all patients included in the study were informed well about the procedure and an informed written consent was obtained from every patient before carrying the procedure. RESULTS: Forty-two patients (17 males and 25 females) with intrahepatic stones underwent surgery with construction of a subcutaneous hepaticojejunal access loop. Stones were confined to the left lobe in 25 patients, the right lobe in 3 patients and bilobar in 14 patients. Associated extrahepatic stones were found in 33 patients. Twenty-two patients had associated intrahepatic duct strictures. Five patients with atrophy of segments II and III underwent hepatic resection at the time of access loop formation. The mean operation time was 4.9 h and mean blood loss was 440 mL. Mean postoperative hospital stay was 10 days. Wound infection was the commonest complication, occurring in 5 (12%) patients. There were no specific complications attributable to the construction of the access loop. The subcutaneous access loop was used to gain access to the biliary tree in 28 patients with residual or recurrent stones. A total of 55 procedures (range 1-5) were attempted with successful access achieved in all cases and successful stone clearance in 21 of the 28 patients, and all of them were symptom free for at least 12 months after the last procedure. Partial stone clearance was achieved in the remaining seven patients. These seven patients had different degrees of biliary strictures. CONCLUSION: The subcutaneous access loop offers the advantage of permanent access for the successful management of retained or re-formed intrahepatic stones with minimal morbidity since it permitted easy access to intrahepatic ducts using the conventional forward-viewing endoscope or the choledochoscope, without the additional morbidity of a biliary-cutaneous fistula or transhepatic access.