Bile duct injuries following laparoscopic cholecystectomy.

INTRODUCTION: Bile duct injuries occur rarely but are among the most dreadful complications following cholecystectomies. METHODS: Prospective registration of bile duct injuries occurring in the period 1992-2013 at a tertiary referral hospital. RESULTS: In total, 67 patients (47 women and 20 men) with a median age of 55 (range 14-86) years had a leak or a lesion of the bile ducts during the study period. Total incidence of postoperative bile leaks or bile duct injuries was 0.9% and for bile duct injuries separately, 0.4%. Median delay from injury to repair was 5 days (range 0-68 days). In 12 patients (18%), the injury was discovered intraoperatively. Bile leak was the major symptom in 59%, and 52% had a leak from the cystic duct or from assumed aberrant ducts in the liver bed of the gall bladder. Following the Clavien-Dindo classification, 39% and 45% were classified as IIIa and IIIb, respectively, 10% as IV, and 6% as V. In all, 31 patients had injuries to the common bile duct or hepatic ducts, and in these patients, 71% were treated with a hepaticojejunostomy. Of patients treated with a hepaticojejunostomy, 56% had an uncomplicated event, whereas 14% later on developed a stricture. Out of 36 patients with injuries to the cystic duct/aberrant ducts, 30 could be treated with stents or sphincterotomies and percutaneous drainage. CONCLUSION: Half of injuries following cholecystectomies are related to the cystic duct, and most of these can be treated with endoscopic or percutaneous procedures. A considerable number of patients following hepaticojejunostomy will later on develop a stricture.

Improving survival following surgery for pancreatic ductal adenocarcinoma--a ten-year experience.

OBJECTIVE: Report results following pancreatic surgery at a tertiary referral hospital in Norway, and our experience with the effects of preoperative use of common bile duct stents, the prophylactic efficacy of octreotide, and explore significant survival factors. MATERIAL AND METHODS: Prospective observational study of 275 patients during the years 1999-2009. RESULTS: Ninety-two ductal adenocarcinomas were operated, and 183 cases were inoperable. Pylorus preserving pancreatico-duodenectomy (PPPD) was performed in 42 cases, a classic Whipple procedure (WP) in 38, distal resection in 6 and total pancreatectomy in 6 patients. Median size of the tumours was 3 cm R(0) resection was obtained in 54 patients. Lymph node metastases were found in 64 patients. 20% experienced postoperative intra-abdominal complications, and 30 days postoperative mortality was 4%. A routine use of somatostatine analogues postoperatively did not reduce the frequency of leakage. Two years survival was 34.6% and 5 years 11.8%, respectively. CONCLUSIONS: Patients with ductal adenocarcinomas can be offered potential curative resections with acceptable rates of complication and mortality. Preoperative biliary stenting is still controversial and prophylactic octreotide should be used whenever the anastomosis is considered challenged and in cases of a soft pancreatic remnant. Five years all over survival has improved over the last decade from <5% to >11%.

Clinicopathological characteristics and non-adhesive organ culture of insulinomas.

BACKGROUND AND AIMS: Insulinoma is a very rare type of islet cell tumour, but nevertheless the most common endocrine tumour of the pancreas. We aimed at reviewing our clinical experience with this tumour type and to assess whether organ culture could be obtained from surgically resected insulinoma material. MATERIAL AND METHODS: All patients with insulinomas (6 men and 10 women) referred to Haukeland University Hospital between 1986 and 2006 were included in the study. Median age of onset was 53 years (range 21-74). Biochemical diagnosis was established during a 72 h fast test. Imaging and localization of the tumours were performed with intra-operative ultrasonography, endoscopic ultrasonography, CT-scan and/or transcutaneous ultrasonography. For six patients, organ cultures were set up from tumour tissue fragments. RESULTS: The annual incidence of insulinoma was 0.8 per million. The patients generally presented with non-specific, episodic symptoms, which often were mistaken for cardiovascular, neurological or diabetic disease and in some cases delayed the diagnosis with several years. Two patients had diabetes prior to the diagnosis of insulinoma. Patient weight gain was probably due to increased food intake, compensating for the hypoglycemia. Intra-operative ultrasonography detected all tumours correctly, whereas 73% were detected by endoscopic ultrasonography and 38% by CT scan. Five insulinomas were located in the head, eight in the body and three in the tail of the pancreas. All were removed by open-access surgery, eleven cases by resection and five by enucleation. One tumour was malignant with liver metastases and two patients had tumours defined as borderline. Insulinoma tissue fragments developed into spheroids during the first week of culturing and insulin secretion into the media was demonstrated. CONCLUSIONS: Insulinomas are rare and diagnostically challenging tumours. Intra-operative ultrasonography was superior to other imaging modalities to locate the lesion. In organ culture, insulinomas readily form spheroids which may be used to yield insight into beta-cell biology.

Cholecystectomy improves long-term success after endoscopic treatment of CBD stones.

BACKGROUND/AIMS: The aim was to study prospectively primary endoscopic treatment of CBD stones and further the long-term need for renewed gallstone disease interventions, defined as short- and long-term outcome. METHODOLOGY: Seven years prospective follow-up of 101 consecutive patients with CBD stones who underwent endoscopic treatment with the intent of primarily achieving duct clearance. RESULTS: Many patients underwent several endoscopy sessions before stone clearance was completed in 83%. Eleven patients were treated surgically, 2 patients received a permanent stent, and the remaining 3 became stone free with other means. Complications occurred in 47 patients. During follow-up, 31 patients were readmitted for gallstone disease and 15 of these had recurrent CBD stones. Ten percent (8/78) of patients with the gallbladder in situ had acute cholecystitis during follow-up and late cholecystectomy was carried out in 22%. Risk factors for new gallstone disease were an in situ gallbladder containing stones and previous episodes of CBD stones. CONCLUSIONS: A goal of complete CBD stone clearance with ERC and ES proved to be relatively resource consuming. Subsequent cholecystectomy after duct clearance for CBD should be advised when the gallbladder lodges gallstones, especially in younger patients. Recurrent CBD stones were not influenced by cholecystectomy.

Acute pancreatitis in Bergen, Norway. A study on incidence, etiology and severity.

BACKGROUND: Studies on the incidence and etiology of acute pancreatitis show large regional differences. This study was performed to establish incidence, etiology and severity of acute pancreatitis in the population of Bergen, Norway. METHODS: A study of all patients with acute pancreatitis admitted to Haukeland University Hospital over a 10-year period was performed. Information was obtained about the number of patients with acute pancreatitis admitted to the Deaconess Hospital in Bergen. RESULTS: A total of 978 admissions of acute pancreatitis were recorded in these two hospitals giving an incidence of 30.6 per 100,000. Haukeland University Hospital had 757 admissions of acute pancreatitis in 487 patients. Pancreatitis was severe in 20% (96/487) of patients, more often in males (25%) than in females (14%). Mortality due to acute pancreatitis was 3% (16/487). Gallstones were found to be an etiological factor in 48.5% and alcohol consumption in 19% of patients. The risk of recurrent pancreatitis was 47% in alcohol induced and 17% in gallstone induced pancreatitis. The last five years of the study period, endoscopic sphincterotomy of patients with gallstone pancreatitis, resulted in drop in relapse rate from 33% to 1.6%. CONCLUSION: The incidence of acute pancreatitis was found to be 30.6 per 100,000 with 48.5% associated with gallstones and 17% alcohol induced. Incidence of first attack was 20/100,000. Pancreatitis was classified as severe in 20% of cases with a mortality of 3%.

Endoscopic sphincterotomy in acute gallstone pancreatitis: a prospective study of the late outcome.

OBJECTIVE: To describe the outcome after acute biliary pancreatitis in patients treated during the acute attack by endoscopic sphincterotomy without cholecystectomy. DESIGN: Prospective observational study. SETTING: University hospital, Norway. SUBJECTS: 130 patients with gallstones and acute pancreatitis. In 62 patients with common bile duct stones the bile duct was cleared by sphincterotomy and stone extraction. The remaining 68 patients had prophylactic sphincterotomy. Cholecystectomy was not planned later. MAIN OUTCOME MEASURES: Incidence of recurrent acute pancreatitis and need for cholecystectomy. RESULTS: 21 patients were dead or not available for the follow-up. Consequently 109 patients were followed-up for a median of 39 months (range 23-62). One patient had recurrent pancreatitis. 20 patients had a cholecystectomy later for symptoms related to gallstone disease. Of the rest, 25 patients had moderate or mild gallstone-related symptoms. There was no difference in gallstone-related symptoms between those who had had stones in the bile duct and those who had not. 63 patients had no symptoms related to gallstones. CONCLUSION: Endoscopic sphincterotomy during or immediately after acute gallstone pancreatitis resulted in half the patients being free of symptoms during the next three years.

Other risk factors for pancreatic cancer: hormonal aspects.

Exocrine pancreatic cancer is significantly more common in younger men than in younger women. The male-to-female sex ratio is, in most countries, between 1.25 and 1.75 to 1, but decreases with increasing age. Moreover, prior oophorectomy appeared in one study to be significantly more common in women with pancreatic cancer than in controls. This has raised interest in sex hormones in the development in pancreatic cancer. It has been questioned if there are estrogen receptors in ductal pancreatic cancer, but there are no doubt estrogen receptors and estrogen-binding protein in human healthy pancreas. It is also well proven that it is possible to influence experimental pancreatic cancer with estrogens. However, in clinical studies tamoxifen has repeatedly been shown to be without significant effects. On the other hand, there are also androgen receptors in pancreatic cancer and testosterone has been shown to strongly promote growth in experimental pancreatic cancers. It is therefore of considerable interest that an antiandrogen recently was shown to significantly prolong life in patients with unresectable pancreatic carcinoma. However, in patients with advanced pancreatic carcinoma the S-testosterone is low, far lower than what could be expected due to weight-loss and malnourishment alone. Pancreatic cancer has etiologically been connected to diet, for example the intake of fat. Cholecystokinin receptors have been found on human pancreatic cancer, possible to stimulate in vitro by cholecystokinin (CCK). Studies with CCK-receptor binding, hybridization with radiolabeled complementary DNA (cDNA) probes, or reverse-transcription polymerase chain reaction have shown that CCK-A receptors also are present in rat pancreatic putative preneoplastic lesions and cancer tissue, rat pancreatic-cancer cell lines, pancreatic carcinomas in transgenic mice, hamster pancreatic cancer, and human pancreatic cancer cell lines and tumors. Also, CCK-B receptors have been found in some human pancreatic cancers. There are a vast number of experiments done on CCK-stimulation of pancreatic cancer. They indicate that CCK may have a promotional effect on exocrine pancreatic cancer, but it is not probable that hyperstimulation with CCK alone induce pancreatic cancer. At present, however, despite a lot of evidence for a hormone-dependence of pancreatic cancer there are no data confirming a role for estrogens, androgens, CCK or their antagonists in clinical treatment of exocrine pancreatic cancer.

Pain management of pancreatic cancer.

Quality of life is receiving increasing attention as a criterion for the assessment of treatment, not least for surgery, in pancreatic cancer. In exocrine pancreatic cancer there are three main symptoms that must be dealt with: pain, loss of weight and jaundice. All of them seriously impair quality of life, but most often pain is the most feared by the patients. Despite this, the intensity and the quality of the pain is all too often only scantly described. In 85 consecutive patients with newly diagnosed pancreatic cancer we have prospectively registered the quality and quantity of their pain and correlated it to tumor and patient characteristics. It was found that about one fourth of the patients were totally pain free and half of all suffered a pain described by two or less on a Visual Analogue Scale. Only one in ten had severe pain. Although more and more patients were treated with morphine, it was still about one third of all patients that had no or only little pain in the last part of their life. Pain had a strong correlation to survival. This may be due to secondary effects like depressing the mood of the patient and reducing the food intake, but is probably more often a reflection of that generalized cancer induces more pain. Analgesic drugs are the cornerstone of the pharmacologic management of pain due to pancreatic cancer. A significant part of the patients do well with only paracetamol and nonsteroidal antiinflammatory agents. Combining these agents with narcotic analgesics can enhance pain control while lessening the dose of narcotics. A wide range of narcotics are available as well as different modes for delivery: regular pills, slow release forms, injections, subcutaneous injections, epidural etc. Each patient's pain management should be individualized, based on the intensity of pain, the type of pain and the side effects. It is essential not only to describe the medication, but also to follow-up the development of the pain and the patient's total experience of the situation. As an alternative to narcotics, plexus celiac blocks have been used with somewhat different result; in the hands of the experts the percutaneous approach is usually sufficient, but in the hands of other also poor results are reported. During the last years thoracoscopic splanchnicectomy has been tried as a complement giving long-standing pain relief with little or no side effects in the majority of patients. With this approach the sympathetic fibers lead by the symphathetic chain and further by the nervus splanchnicus major, minor and minors are divided. The denervation is easily done and can be performed bilateraly in one seance. This method will probably be used more often as the technique is now well described.