Perioperative outcomes of laparoscopic and open distal pancreatectomy: our institution's 5-year experience.

BACKGROUND: Application of minimally invasive techniques in the surgical management of distal pancreatic lesions is increasing. Despite this, numbers of laparoscopic distal pancreatectomy remain low and limited to treatment of benign and premalignant lesions. METHODS: Retrospective analysis of 31 patients who underwent distal pancreatectomy from 2005 to 2010. Patients were grouped according to mode of surgical access: open (ODP) or laparoscopic (LDP). Perioperative parameters were compared. RESULTS: Twenty-one (67.7%) patients underwent ODP and 10 (32.3%) LDP (median age 61; 80.0% females in LDP group, p = 0.030). Postoperative morbidity rate were comparable between the two groups. In the LDP group, there were significantly lower estimated blood loss (p < 0.001) and amount of blood transfusion (p = 0.001), smaller tumor size (p = 0.010) and fewer lymph nodes harvested (p = 0.020), shorter postoperative length of stay (p = 0.020), and shorter length of stay in surgical high dependency (p = 0.001). CONCLUSION: LDP is a safe, efficient technique for resection of benign and premalignant pancreatic lesions. Indices reflecting perioperative outcomes in this study are highly competitive with those in other major centers.

Laparoscopic exploration can salvage failed endoscopic bile duct stone extraction.

INTRODUCTION: Conventionally, patients who failed endoscopic removal of common bile duct stones (CBDS) by endoscopic retrograde cholangiopancreaticography (ERCP) would be treated with open cholecystectomy and common bile duct exploration. Laparoscopic common bile duct exploration (LCBDE) is an established option for treating CBDS. The aim of this paper was to look at the feasibility of LCBDE as a salvage procedure after failed endoscopic stone extraction (ESE). The secondary endpoint was to examine the short-term outcomes of our LCBDE series. METHODS: We retrospectively reviewed a prospective database to study the feasibility of LCBDE as a salvage procedure for failed ERCP. RESULTS: Since its inception in 2006, 43 patients had undergone LCBDE at our centre. This was achieved via a transcystic approach in 25 patients and laparoscopic choledochotomy in 15 patients. There were three conversions. Of these 43 patients, 21 had a pre-operative attempt at ESE, but only six patients had their ducts cleared endoscopically. The 15 patients who failed ESE underwent LCBDE, of which 14 achieved successful stone clearance and one required open conversion. One patient developed a bile leak, which resolved spontaneously. The median length of stay (LOS) for these 15 patients was three days, while the median LOS for the whole cohort was two days. CONCLUSION: LCBDE has been shown to be a safe and effective method for treating CBDS, with the added bonus of a short hospital stay. Where the expertise is available, LCBDE is a safe option as a salvage procedure for failed ESE.

Surgery for perforated small bowel malignancy: a single institution's experience over 4 years.

INTRODUCTION: Surgery for perforated small bowel malignancy is associated with dismal morbidity and mortality rates. The aim of the paper was to highlight our institution's surgical experience in the management of patients with malignant small bowel perforation. METHODS: A retrospective review of all patients who underwent operative intervention for malignant small bowel perforation from 2004 to 2007 was performed. The diagnosis was confirmed upon histological evaluation. RESULTS: Emergency surgery was performed in seven patients with perforated small bowel malignancy during the study period. All were above 55 years old, with the majority (6/7) having an ASA score of 3 and above. Pneumoperitoneum on chest radiograph was seen in only one patient while computed tomographic scans demonstrating the pathology were performed in the rest. All patients underwent exploratory laparotomy with resection of the diseased segments within 24 h of admission. Jejunum and the ileum were the sites of perforation in six and one patients, respectively. Three patients had synchronous small bowel tumours. Two patients had stoma created due to extensive peritoneal soilage and haemodynamic instability. Lymphoma was the aetiology in four patients. The other pathologies included leiomyosarcoma (n = 1) and metastatic lung tumours (n = 2). The 30-day peri-operative mortality rate was 42.9% (n = 3). One was discharged to a hospice while another two received chemotherapy upon discharge. These three patients passed away within a year from the surgery. The last patient defaulted follow up. CONCLUSION: In our small series, patients who were admitted for perforated small bowel malignancy have a high peri-operative mortality rates. For those who survived the initially operation, the long term outlook is still dismal.

Emergency surgery for jejunal diverticulosis: our experience and review of literature.

BACKGROUND: Jejunal diverticulosis is a rare entity and is often asymptomatic. However, some of its complications may require acute surgical intervention. This study was performed to evaluate the presentation and outcome of patients who underwent urgent surgery for complicated jejunal diverticulosis. METHODS: A retrospective review of all patients who underwent emergency surgery for complicated jejunal diverticulosis from November 2005 to December 2008 was performed. RESULTS: Six cases of complicated jejunal diverticulosis required urgent surgery during the study period. Three patients presented with acute abdomen from perforated jejunal diverticulum. Preoperative computed tomographic (CT) scans were useful in localizing the source of sepsis. One patient died from the subsequent complications. The other three patients presented with massive lower gastrointestinal haemorrhage for which CT angiography was able to localize the source of haemorrhage in two of them. Small bowel resection was then performed and all three were discharged well eventually. CONCLUSION: Though rare, jejunal diverticulosis can present with several life-threatening complications that mandates immediate surgery. While the surgical procedure may be technically simple, achieving the accurate preoperative diagnosis is often fraught with challenges. CT scan could prove invaluable in the management if the situation permits.

Is transurethral catheterisation the ideal method of bladder drainage? A survey of patient satisfaction with indwelling transurethral urinary catheters.

OBJECTIVE: Bladder catheterisation is a routine part of major abdominal surgery. Transurethral catheterisation is the most common method of bladder drainage but is also notorious for its discomfort and increased risk of urinary tract infection. The present study aimed to establish patient satisfaction with transurethral catheterisation and to assess the incidence of clinically significant urinary tract infections after transurethral catheterisation through survey. METHODS: All patients who underwent major open abdominal surgery between October 2006 and December 2008 and required standard transurethral bladder catheterisation, were asked to participate in the study. Fifty patients were recruited. RESULTS: Male patients were more dissatisfied than their female counterparts with transurethral catheterisation (satisfaction score: 4.18/10 vs. 2.75/10; p = 0.05). Male patients had more than double the score for pain at the urinary meatus with the catheter in situ (p =0.012) and during urine catheter removal (p = 0.013). Half the patients in the study also had symptoms of urinary tract infection after catheter removal. CONCLUSION: Our study emphasised the discomfort of transurethral urinary catheters, especially in male patients, and the high incidence of urinary tract infections in both sexes. Consideration should be given to the utilisation of alternative methods of bladder drainage, such as suprapubic catheterisation, which can be performed with ease during laparotomy.

Laparoscopic common bile duct exploration: our first 50 cases.

INTRODUCTION: Laparoscopic common bile duct exploration (CBDE) is becoming more popular in the management of choledocholithiasis due to improved laparoscopic expertise and advancement in endoscopic technology and equipment. This study aimed to evaluate the safety and short-term outcome of laparoscopic CBDE in a single institution over a 3-year period. MATERIALS AND METHODS: A retrospective review of the records of all patients who underwent laparoscopic CBDE in Tan Tock Seng Hospital between January 2006 and September 2008 was conducted. RESULTS: Fifty consecutive patients, with a median age of 60 years (range, 27 to 85) underwent laparoscopic CBDE for choledocholithiasis during the study period. About half of our patients presented as an emergency with acute cholangitis (32.0%) accounting for the majority. A total of 22 (44.0%) patients underwent laparoscopic CBDE as their primary procedure while the remaining 28 (56.0%) were subjected to preoperative ERCP initially. Of the latter group, documented stone clearance was only documented in 5 (17.9%) patients. Laparoscopic CBDE via the transcystic route was performed in 27 (54.0%) patients while another 18 patients (36.0%) had laparoscopic choledochotomy and 1 patient (2.0%) had laparoscopic choledocho-duodenostomy. There were 4 (8.0%) conversions in our series. The median operative time for laparoscopic CBDE via the transcystic route and the laparoscopic choledochotomy were 170 (75-465) and 250 (160-415) minutes, respectively. For the 18 patients who underwent a laparoscopic choledochotomy, T-tube was inserted in 8 (44.4%) patients while an internal biliary stent was placed in 4 (22.2%) with the remaining 6 patients (33.3%) undergoing primary closure of the choledochotomy. The median length of hospital stay was 2 days (range, 1 to 15) with no associated mortality. The main complications (n = 4, 8.0%) included retained CBD stones and biliary leakage. These were treated successfully with postoperative endoscopic retrograde cholangiopancreatography (ERCP) with/without percutaneous drainage with no further surgery required. CONCLUSION: Laparoscopic CBDE is a safe operation with good outcome in managing choledocholithasis. Its dividends include the numerous benefits of minimally invasive surgery. If possible, transcystic extraction is preferred to choledochotomy, as this obviates the need for biliary diversion. ERCP will still hold an important role in certain instances in the management of choledocholithiasis.

Outcome of a strategy to reduce surgical site infection in a tertiary-care hospital.

BACKGROUND: Surgical site infection (SSI) is a preventable complication. Achieving a zero SSI rate for all clean operations should be the goal of all surgeons. AIM: We aimed to reduce our SSI rate by 50% for patients undergoing elective gastrointestinal and hernia operations. METHODS: The study was conducted in a tertiary-care hospital department of surgery from January 2006 to December 2007 for all clean and clean-contaminated elective gastrointestinal and hernia operations. Four interventions targeted at reducing SSI were implemented in January 2006: Use of clippers instead of shavers for surgical site hair removal; standardized prophylactic antibiotic regimen and antibiotic administration within 30 min before incision; standardized glucose monitoring for diabetics; and maintenance of postoperative normothermia. Prospective data were collected and compared with historical data from January to December 2005. RESULTS: A total of 2,408 patients underwent elective gastrointestinal and hernia operations from January 2006 to December 2007. After implementation, we were able to achieve 91%, 87%, 89%, and 76% overall compliance with the respective interventions, but postoperative normothermia was achieved in only 44% of our patients. With the bundle of interventions, our overall SSI rate was reduced from 3.1% to 0.5% (p < 0.001), an 84% reduction within two years. The incidence of SSI was 1.7% in colorectal operations, 1.2% in upper gastrointestinal operations, 0.3% in hepatopancreaticobiliary operations, and zero in inguinal and ventral hernia operations. The estimated cost saving for both the patients and the hospital was S$208,562 (US$147,967). CONCLUSIONS: Surgical site infections could be reduced with the bundle of interventions. With these encouraging results, the good practices should be sustained and promulgated. Such a SSI prevention program must be embedded in the work processes for all surgical disciplines.

New hope for an old cure: a pilot animal study on selective venesection in attenuating the systemic effects of ischaemic-reperfusion injury.

INTRODUCTION: Reperfusion of acutely ischaemic tissue may, paradoxically, lead to systemic complications. This phenomenon is believed to be initiated by humoral factors that have accumulated in the ischaemic tissue. The ancient art of venesection may reduce the load of these mediators at the point of reperfusion. The aim of this study is to test if selective venesection, by removing the initial venous return from the ischaemic tissue, can attenuate the systemic effects of the ischaemic-reperfusion injury using a porcine model of acute limb ischaemia. MATERIALS AND METHODS: The right femoral arteries of anaesthetised female pigs were clamped. Twelve pigs were divided into 2 groups (n = 6 per group). In the treatment group, 5% of blood volume was venesected from the ipsilateral femoral vein upon reperfusion; the other arm served as control. The animals were sacrifi ced after 4 days for histological examination. A pathologist, blinded to the experimental groups, graded the degree of microscopic injury. RESULTS: For the control group, the kidneys showed glomeruli and tubular damage. The livers demonstrated architectural distortion with cellular oedema. There was pulmonary oedema as well as extensive capillary congestion and neutrophil infiltration. Such findings were absent or reduced in the venesected animals. Consequently, the injury scores for the kidney, lung, liver and heart were significantly less for the venesected animals. CONCLUSION: Selective venesection reduces the remote organ injuries of the ischaemic-reperfusion phenomenon.

Emergency colorectal resections in Asian octogenarians: factors impacting surgical outcome.

PURPOSE: The population in developing countries is aging and the number of octogenarians is expected to increase in the future at an alarmingly fast rate. This paper evaluates the surgical outcomes of emergency colorectal resections among Asian octogenarians. METHODS: We conducted a retrospective review of all octogenarians and older, who had an emergency colorectal resection performed between February 1996 to December 2001. RESULTS: Fifty-eight emergency colorectal resections were performed in patients with a median age of 83 years. The indications for surgery were colorectal cancer (74%) and complicated diverticular disease (12%). The most common presentation was an intestinal obstruction (72%). Fifty-one (88%) of the patients had comorbidities. Forty-five percent of patients had an American Society of Anesthesiologists (ASA) score of I and II, while 55% had a score of III and IV. Consultants performed 53% of the procedures. The mean surgical time was 156 min. Hartmann's procedure was the most common procedure performed (43%). There were 16 (28%) mortalities. The postoperative morbidity was 81%. The only factor impacting outcome was a high ASA score of III and IV. The median length of stay was 17.5 (range 3-108) days. CONCLUSIONS: The mortality and morbidity of emergency colorectal resections among Asian octogenarians are high and can be predicted by their ASA status.

Novel approach to laparoscopic resection of tumours of the distal pancreas.

BACKGROUND: Laparoscopic resection for small lesions of the pancreas has recently gained popularity. We report our initial experience with a new approach to laparoscopic spleen-preserving distal pancreatectomy so that the maximum amount of normal pancreas can be preserved while ensuring adequate resection margins and preservation of the spleen and splenic vessels. METHODS: Three patients underwent laparoscopic distal pancreatectomy with spleen and splenic vessel preservation over a 2-month period. Surgical techniques and patient outcomes were examined. RESULTS: All three patients were females, with ages ranging from 31 to 47 years. Two patients underwent resection using the conventional medial-to-lateral dissection as the lesion was close to the body or proximal tail of the pancreas. The third patient had a lesion in the distal tail of the pancreas and surgery was carried out in a lateral-to-medial manner. This new approach minimized excessive sacrifice of normal pancreatic tissue for such distally located lesions. The splenic artery and vein were preserved in all cases and there was no significant difference in clinical outcome, operative time or intraoperative blood loss. CONCLUSION: Laparoscopic distal pancreatectomy with preservation of the spleen and splenic vessels is a feasible surgical technique with acceptable outcome. We have shown that a tailored approach to dissection and pancreatic transection based on the location of the lesion allows the maximum amount of normal pancreatic tissue to be preserved without additional morbidity. Although the conventional 'medial-to-lateral' approach is recommended for more proximal tumours of the pancreas, distal lesions can be safely addressed using the 'lateral-to-medial' approach.

Pancreatic tuberculosis mimicking pancreatic carcinoma: series of three cases.

Tuberculosis (TB) is a worldwide pandemic, and is seeing a resurgence because of the AIDS epidemic. Pancreatic involvement is rare in the world, and when it is isolated around the pancreas, it is often mistaken for pancreatic carcinoma. We report three cases of pancreatic TB that masqueraded as malignancy in a 50-year-old female, a 34-year-old male and a 39-year-old male with a previous history of abdominal TB. All had computed tomographic scans suspicious of possible pancreatic malignancy. Endoscopic ultrasound was performed in two patients. Two patients underwent laparotomy but did not undergo the intended pancreaticoduodenectomy, whereas the third patient was diagnosed after computed tomographic-guided percutaneous biopsy of the pancreatic mass. In conclusion, pancreatic TB should always be considered as a differential diagnosis to pancreatic malignancy.

An audit of ambulatory laparoscopic cholecystectomy in a Singapore institution: are we ready for day-case laparoscopic cholecystectomy?

BACKGROUND: Day-Case laparoscopic cholecystectomy (LC) is practiced in many countries. However, this has yet to be widely accepted in Singapore. This study aims to determine the potential success rate of day-case LC in our institution. PATIENT AND METHODS: We retrospectively assessed the proportion of our Ambulatory Surgery 23 hour (AS23) LC patients that met discharge criteria. Our proposed same-day discharge criteria include minimal pain, ability to tolerate feeds, ambulate independently and void spontaneously after 6-8 hours of monitoring. RESULTS: From January 2005 to December 2006, of 405 patients listed for elective LC, 84% of patients were admitted to our AS23 ward. Patients with previous biliary sepsis or pancreatitis or who need laparoscopic common bile duct exploration (LCBDE) were included. The other 66 were admitted as inpatient. Forty-one of them were admitted due to conversion. A history of cholecystitis or cholangitis was a significant predictor of conversion to open surgery (OR=5.73 and 5.74 respectively, p<0.001). Of the 339 patients, 66% of them fulfilled all four criteria within eight hours of monitoring. Therefore, based on an intention-to-treat analysis, 51.2% fulfilled all four criteria and could potentially be discharged the same day. No predictor for failure was identified, including presence of co-morbidities, duration of operation, surgeon's grade and additional procedures like LCBDE. CONCLUSION: Using our current inclusion criteria, we projected a success rate of at least 50% with the implementation of day-case LC. With the attendant advantages of cost savings and reduced resource utilization, it is therefore worthwhile to start it in Singapore.

Perioperative and follow-up results after central pancreatic head resection (Berne technique) in a consecutive series of patients with chronic pancreatitis.

BACKGROUND: Many patients require surgery for chronic pancreatitis (CP). By combining the essences of the Beger and the Frey procedures, a hybrid procedure was developed: central pancreatic-head resection (CPHR) (Berne technique). METHODS: A prospective evaluation of 100 consecutive patients who underwent CPHR for CP between January 2002 and December 2006 was performed. Long-term follow-up, including quality-of-life (QOL) assessment, was carried out. RESULTS: The hospital mortality rate was 1%; the surgical morbidity rate was 16%; and the relaparotomy rate was 6%. Mean surgery time was 295 +/- 7 minutes; mean intraoperative blood loss was 763 +/- 75 mL; and the mean postsurgical hospital stay was 11.4 +/- .8 days. After a median follow-up of 41 months, pain was improved in 55% of patients; weight increase occurred in 67% of patients; and insulin-dependent diabetes mellitus developed in 22% of the patients. Comparison of QOL parameters with a German adult control population showed no statistically significant differences. CONCLUSIONS: CPHR is a safe surgical option to resolve CP-associated problems. Long-term follow-up QOL after CPHR shows results comparable with date published data after the Beger and the Frey procedures.

KAI1 inhibits anchorage-dependent and -independent pancreatic cancer cell growth.

Decreased expression of the tumor suppressor gene, KAI1, is associated with metastasis formation in pancreatic cancer. The aim of the present study was to investigate whether KAI1 influences pancreatic cancer cell growth and colony formation. A full-length KAI1 cDNA expression vector was stably transfected into Panc-1 and MiaPaCa-2 pancreatic cancer cell lines. Transfection was confirmed by Western blot analysis and immunohistochemistry. Tumor cell growth and cell cycle distribution were determined by MTT cell growth assays, colony formation assays, and flow cytometric analysis. KAI1-transfected, but not control-transfected pancreatic cancer cells displayed cytoplasmic KAI1 immunoreactivity. Cell proliferation decreased in the KAI1-transfected cells compared to parental and control cells together with a Go/G1-phase cell cycle arrest. Colony formation was reduced by 2.6- and 3.5-fold in the KAI1-transfected Panc-1 and MiaPaCa-2 pancreatic cancer cells, respectively, compared with parental cells. KAI1 blocks pancreatic cancer cell growth through cell cycle arrest and inhibits anchorage-independent cell growth. These findings support the premise that KAI1 functions as a tumor suppressor in this malignancy.

Complications of pancreatic surgery.

Pancreatic resection is the only treatment option that can lead to a meaningful prolonged survival in pancreatic cancer and, in some instances, perhaps a potential chance for cure. With the advent of organ and function preserving procedures, its use in the treatment of chronic pancreatitis and other less common benign diseases of the pancreas is increasing. Furthermore, over the past two decades, with technical advances and centralization of care, pancreatic surgery has evolved into a safe procedure with mortality rates of <5%. However, postoperative morbidity rates are still substantial. This article reviews the more common procedure-related complications, their prevention and their treatment.