Total compared with partial pancreatectomy for pancreatic adenocarcinoma: assessment of resection margin, readmission rate, and survival from the U.S. National Cancer Database.

Introduction: Total pancreatectomy for pancreatic ductal adenocarcinoma has historically been associated with substantial patient morbidity and mortality. Given advancements in perioperative and postoperative care, evaluation of the surgical treatment options for pancreatic adenocarcinoma should consider patient outcomes and long-term survival for total pancreatectomy compared with partial pancreatectomy. Methods: The U.S. National Cancer Database was queried for patients undergoing total pancreatectomy or partial pancreatectomy for pancreatic adenocarcinoma during 1998-2006. Demographics, tumour characteristics, operative outcomes, 30-day mortality, 30-day readmission, additional treatment, and Kaplan-Meier survival curves were compared. Results: The database query returned 807 patients who underwent total pancreatectomy and 5840 who underwent partial pancreatectomy. More patients who underwent total pancreatectomy than a partial pancreatectomy had a margin-negative resection (p < 0.0001). Mortality and readmission rates were similar in the two groups, as was long-term survival on Kaplan-Meier curves (p = 0.377). A statistically significant difference in the rate of surgery only (without additional treatment) was observed for patients in the total pancreatectomy group (p = 0.0003). Conclusions: Although total compared with partial pancreatectomy was associated with a higher rate of margin-negative resection, median survival was not significantly different for patients undergoing either procedure. Patients who underwent total pancreatectomy were significantly less likely to receive adjuvant therapy.

Single-stage resection and microwave ablation for bilobar colorectal liver metastases.

BACKGROUND: Patients undergoing liver resection combined with microwave ablation (MWA) for bilobar colorectal metastasis may have similar overall survival to patients who undergo two-stage hepatectomy, but with less morbidity. METHODS: This was a multi-institutional evaluation of patients who underwent MWA between 2003 and 2012. Morbidity (90-day) and mortality were compared between patients who had MWA alone and those who underwent combined resection and MWA (CRA). Mortality and overall survival after CRA were compared with published data on two-stage resections. RESULTS: Some 201 patients with bilobar colorectal liver metastasis treated with MWA from four high-volume institutions were evaluated (100 MWA alone, 101 CRA). Patients who had MWA alone were older, but the groups were otherwise well matched demographically. The tumour burden was higher in the CRA group (mean number of lesions 3·9 versus 2·2; P = 0·003). Overall (31·7 versus 15·0 per cent; P = 0·006) and high-grade (13·9 versus 5·0 per cent; P = 0·030) complication rates were higher in the CRA group. Median overall survival was slightly shorter in the CRA group (38·4 versus 42·2 months; P = 0·132) but disease-free survival was similar (10·1 versus 9·3 months; P = 0·525). The morbidity and mortality of CRA compared favourably with rates in the existing literature on two-stage resection, and survival data were similar. CONCLUSION: Single-stage hepatectomy and MWA resulted in survival similar to that following two-stage hepatectomy, with less overall morbidity.

Robotic pancreaticoduodenectomy: comparison of complications and cost to the open approach.

BACKGROUND: Robotic pancreaticoduodenectomy (RP) has shown some advantages over open pancreaticoduodenectomy (OP) but no data has been published providing a cost comparison. METHODS: Retrospective analysis of all pancreaticoduodenectomies at a single quaternary cancer referral center was performed. Patient demographics, comorbidities, operative characteristics, complications, and charge data were recorded, and then compared using standard statistical methods. RESULTS: 71 pancreaticoduodenectomies were performed: 22 RP and 49 OP. Patients undergoing OP had similar demographics, comorbidities, pathology, and oncologic characteristics as patients undergoing RP. While operative charges were higher for RP, once inpatient stay associated costs and follow-up costs were included, there was no difference in total costs between RP and OP. CONCLUSIONS: Patients undergoing RP have equivalent rates of R0 resection as OP, and benefit from decreased number of complications, surgical site infections, and length of stay in the intensive care unit. Once cost of complications and follow-up are incorporated, no significant difference between procedures exists. Copyright © 2015 John Wiley & Sons, Ltd.

Laparoscopic microwave ablation for the management of hemorrhage from ruptured hepatocellular carcinoma.

BACKGROUND: Treatment of ruptured hepatocellular carcinoma (HCC) focuses on hemorrhage control and utilizes tumor vascular anatomy to palliate or temporize selected patients with hepatic artery embolization (HAE). Radiofrequency ablation (RFA) and microwave ablation (MWA) are feasible alternatives or adjunct modalities to resection of HCC; the method of energy delivery in MWA allows uniform coagulative necrosis in shorter time compared with RFA. CASE DESCRIPTION: We present the case of an 82-year-old man who presented with a ruptured liver tumor with active intraperitoneal bleeding on angiography. The patient remained hemodynamically stable with evidence of ongoing bleeding following HAE. Tumor destruction and definitive hemostasis were obtained with minimally invasive MWA. CONCLUSION: Tumor rupture remains a negative prognostic factor in the course of HCC. In select patients, MWA allows definitive hemorrhage control with minimal surgical morbidity.  Hippokratia 2016, 20(2): 169-171.

Outcomes of a prospective multi-center trial of a second-generation composite mesh for open ventral hernia repair.

PURPOSE: Composite mesh prostheses incorporate properties of multiple materials for use in open ventral hernia repair (OVHR). This study examines clinical outcomes in patients who underwent OVHR with a polypropylene/expanded polytetrafluoroethylene (ePTFE) composite graft containing a novel polydioxanone (PDO) absorbable ring to facilitate placement and graft positioning. METHODS: Data were prospectively collected on consecutive patients undergoing OVHR using a synthetic composite mesh. Seven centers enrolled patients during the study period. All patients underwent a standardized surgical procedure consisting of OVHR with sublay intraperitoneal placement of mesh. Mesh fixation was accomplished with peripheral tacks and transfascial sutures. RESULTS: One hundred and nineteen patients underwent OVHR with the composite mesh. Average age was 55.8 years; there were 71 (59.7 %) females and 48 (40.3 %) males with mean BMI of 33.5 ± 7.1 kg/m(2). One hundred and two (85.7 %) patients presented with primary ventral hernias. Mean defect size was 13.6 cm(2), and mean mesh size was 113.6 cm(2). Most patients (67 %) were discharged the day of surgery. Twelve patients (10.1 %) experienced complications in the perioperative time period primarily consisting of seroma (4.2 %) and ileus (1.7 %). Two patients required reoperation and mesh removal in the early postoperative period for infection and herniorrhaphy site pain, respectively. There was a decline in pain and movement limitation scores between baseline and 1-year follow-up. Six-month (n = 109) and twelve-month (n = 99) follow-up revealed no hernia recurrences (95 % CI 0-3 %, and 0-4 %, respectively). CONCLUSIONS: The use of this second-generation composite mesh was associated with no hernia recurrences and a low complication rate after open ventral hernia repair.

Hemostatic Agents in Hepatobiliary and Pancreas Surgery: A Review of the Literature and Critical Evaluation of a Novel Carrier-Bound Fibrin Sealant (TachoSil).

Background. Despite progress in surgical techniques applied during hepatobiliary and pancreas (HPB) surgery, bleeding and bile leak remain significant contributors to postoperative mortality and morbidity. Topical hemostatics have been developed and utilized across surgical specialties, but data regarding effectiveness remains inconsistent and sparse in HPB surgery. Methods. A comprehensive search for studies and reviews on hemostatics in HPB surgery was performed via an October 2011 query of Medline, EMBASE, and Cochrane Library. In-depth evaluation of a novel carrier-bound fibrin sealant (TachoSil) was also performed. Results. The literature review illustrates multiple attempts have been made at developing different topical hemostatics and sealants to aid in surgical procedures. In HPB surgery, efforts have been directed at decreasing bleeding, biliary leakage, and pancreatic fistula. Conflicting scientific evidence exists regarding the effectiveness of these agents. Critical evaluation of the literature demonstrates TachoSil is a valuable tool in achieving hemostasis, and possibly biliostasis and pancreatic fistula prevention. Conclusion. While progress has been made in topical hemostatics for HPB surgery, an ideal agent has not yet been identified. TachoSil is promising, but larger randomized, controlled clinical trials are required to more fully evaluate its efficacy in reducing bleeding, biliary leakage, and pancreatic fistulas in HPB surgery.

Evaluation of absorbable and permanent mesh fixation devices: adhesion formation and mechanical strength.

PURPOSE: Laparoscopic ventral hernia repair is commonly performed with mesh prostheses; however, there is no standard for fixation devices used to secure mesh to the abdominal wall. This study is a functional comparison of novel, screw-type absorbable and permanent fixation devices with a traditional titanium fixation device. METHODS: Fifteen pigs each underwent the laparoscopic placement of two 11 × 14-cm mesh prostheses and were randomized for mesh fixation with either titanium spiral tacks (TS), absorbable screw-type fasteners (SF), or permanent screw-type fasteners (PF) (n = 10 mesh prostheses for each fixation group). Adhesions were assessed laparoscopically at 4 weeks. The fixation devices were also embedded in porcine abdominal rectus muscle for ex vivo mechanical testing along with partial thickness polypropylene suture (PR) as a control group (n = 40 for each group). Maximum pull-off forces were measured. All statistical tests were two-tailed, and a P-value < 0.05 was considered to be significant. RESULTS: The mean tenacity adhesion scores were 1.40 ± 0.52 (PF), 1.7 ± 0.82 (SF), and 2.6 ± 1.07 (TS). Adhesions in the PF group were significantly less tenacious compared with the TS group (P = 0.01). Quantitative adhesion scores were not significantly different among groups. The maximum pull-off forces, measured in Newtons, were 28.61 N ± 4.89 N (TS), 22.71 N ± 7.86 N (SF), 16.98 N ± 7.59 N (PF), and 20.83 N ± 6.25 N (PR). The pull-off force in the TS group was higher than all of the other groups (P < 0.001). The SF group also had a higher pull-off force compared with the PF group (P < 0.001). CONCLUSIONS: The screw-type absorbable and permanent fixation devices provided adequate fixation and were associated with decreased adhesions in this porcine model.

An algorithm for managing patients who have Composix Kugel ventral hernia mesh.

Composix Kugel (CK) mesh is a prosthetic available since 2000 for ventral hernia repair. A recent voluntary, class I recall of CK has caused concern regarding implantable medical devices and has caused many patients to seek medical attention and advice related to their hernia repair. Surgeons are required to answer many patient inquiries and address their concerns. Although the Food and Drug Administration (FDA) warnings can help guide surgeons in dealing with events such as this recall, detailed information and algorithms are lacking. We present information regarding the composite mesh recall and propose an algorithm for the management of patients who have had this mesh implanted.

Strength of tissue attachment to mesh after ventral hernia repair with synthetic composite mesh in a porcine model.

BACKGROUND: A prospective animal study involving 12 female swine aimed to measure the strength of tissue attachment to composite mesh at various time points after laparoscopic ventral hernia repair in a porcine model. METHODS: Each animal had two 10 x 16-cm sheets of polypropylene/expanded polytetrafluoroethylene (ePTFE) composite mesh laparoscopically affixed to the abdominal wall with a helical tacking device. No transfascial sutures were used. The animals were euthanized 2, 4, 6, and 12 weeks after surgery, and abdominal walls were resected en bloc with the patches. Each patch was cut into 2 x 7-cm strips, and each strip was independently analyzed. The strength of the tissue attachment to the mesh was measured using a servohydraulic tensile testing frame. The abdominal wall was peeled from the mesh, and the transverse, or "lap-shear" force was recorded. Data are reported as mean force in pounds. RESULTS: The mean lap-shear force was 0.83 +/- 0.06 lbs at 2 weeks, 1.06 +/- 0.07 lbs at 4 weeks, 0.88 +/- 0.08 lbs at 6 weeks, and 1.13 +/- 0.07 lbs at 12 weeks. The mean force was higher at 12 weeks than at 2 weeks (p < 0.05). No other periods were significantly different from any other. CONCLUSIONS: The findings demonstrate that the majority of tissue ingrowth and strength has occurred by 2 weeks after laparoscopic placement of a composite hernia prosthesis. Strength very gradually increases until 12 weeks after surgery. This has clinical implications for human ventral hernia repair. Further study is needed to evaluate the necessity of transfascial sutures for securing polypropylene-based prostheses to the abdominal wall during ventral hernia repair.

Laparoscopic repair of the leaking percutaneous endoscopic gastrostomy.

Peritonitis is an infrequent yet major complication of a percutaneous endoscopic gastrostomy (PEG). Traditionally, patients with peritonitis from leaking PEG tubes underwent open abdominal exploration with repair of the gastrostomy site. We report successful laparoscopic treatment of this significant complication. Surgical techniques and technical aspects of the procedure are discussed.

Minimally invasive management of hepatic metastases.

The introduction of laparoscopy for diagnosis of abdominal tumors has also allowed for the destruction of hepatic metastases by cryotherapy and radiofrequency ablation. The advantage of laparoscopically based therapy over the percutaneous treatment is the benefit of finding additional lesions that preoperative studies may not have detected. The results from available data in patients with metastatic colorectal carcinoma suggest an improvement in survival. Tumor ablation in patients offers an 18- to 36-month median survival and the possibility of 50% and 24% survival rates at 2 and 5 years, respectively. Patients with metastases from melanoma, breast, esophagus, lung, stomach, pancreas, and gynecologic malignancies have historically not demonstrated improved survival after hepatic resection. The value of hepatic tumor ablation for metastases from these lesions remains undetermined.

Primary nonampullary/periampullary adenocarcinoma of the duodenum.

Primary duodenal adenocarcinoma not involving the ampullary region is rare. Our aim was to review the outcome of these patients and determine the factors that affect survival. We performed a retrospective review of all patients with primary, nonampullary duodenal adenocarcinoma at the Cleveland Clinic Foundation from January 1986 through December 1996. Twenty-six patients with primary, nonampullary duodenal malignancies were identified. There were 16 adenocarcinomas, 3 gastrinomas, 3 stromal tumors, 3 leiomyosarcomas, and 1 carcinoid tumor. Patients with adenocarcinoma had symptoms present an average of 6.1 months. Tumors were identified by upper gastrointestinal contrast study and esophagogastroduodenoscopy in 90 per cent and 87 per cent of patients, respectively. Twelve of 13 (93%) cancers found in the third or fourth portion of the duodenum were adenocarcinomas. Seven of the 16 adenocarcinomas were resectable on exploration. Those that were contained within the serosa have not recurred (mean, 6 years); one of the two patients with locally invasive adenocarcinoma remains disease free. The average survival for patients with unresectable disease was 6.7 months. The 5-year survival rates were: all adenocarcinoma, 38 per cent; resectable, 86 per cent; and unresectable, 0 per cent. All patients presenting with weight loss or obstructive symptoms died of disease; those with melena survived long term. Patients with tumors other than adenocarcinoma had a 90 per cent 5-year survival. We conclude that patients typically present with a long history of symptoms. Distal duodenal malignancies are most frequently adenocarcinomas. Upper gastrointestinal contrast study or endoscopy is often diagnostic. Patients with weight loss and/or obstructive symptoms had invasive disease and a morbid prognosis. Aggressive surgery is warranted, and most with resectable disease (86%) had long-term survival.

Ventral duct pancreaticolithiasis in pancreas divisum.

Pancreas divisum, partial or nonfusion of the dorsal and ventral pancreatic ductal systems, affects up to 10 per cent of the population. Approximately 25 per cent of patients with pancreas divisum will develop complications such as recurrent pancreatitis as a consequence of stenosis of the minor papilla with altered dorsal duct drainage. Surgical and endoscopic therapy usually include minor papilla sphincterotomy or sphincteroplasty to facilitate drainage of the dorsal ductal system. The following case represents an unusual complication of pancreas divisum with primarily ventral duct disease and pancreaticolithiasis.

The role of laparoscopy in the management of pancreatic cancer.

Video laparoscopy has undergone significant advancements in the past several years. This technology can be applied to the management of patients with pancreatic carcinoma. Laparoscopy can be used to achieve the following goals when treating patients with pancreatic cancer: (1) to accurately stage the disease including diagnosis of intraperitoneal and extrapancreatic disease, (2) to evaluate resectability, (3) in resectional therapy and, (4) in palliation of unresectable disease. This chapter reviews in detail these four applications of the laparoscopic surgical approach in the management of patients with pancreatic carcinoma.

Laparoscopic cryoablation of hepatic metastases.

Cryosurgery for liver metastases may improve survival for unresectable hepatic metastases. The laparoscopic approach to managing these tumors is a novel method fostered by increasing surgeon and patient interest in minimally invasive surgical techniques and the development of laparoscopic ultrasound and cryoprobes. A retrospective review of our patients who underwent laparoscopic cryoablation of hepatic tumors from April 1996 to December 1997 was conducted. We report on this experience and comment on the feasibility and safety of the procedure based on this early trial.

Laparoscopic cryoablation of hepatic metastases.

OBJECTIVE: To evaluate the feasibility of laparoscopic cryoablation for the management of hepatic metastases. DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: Nine patients were evaluated by laparoscopy for planned laparoscopic cryoablation of hepatic metastases at The Cleveland Clinic Foundation, Cleveland, Ohio, from April 1996 to May 1997. RESULTS: Laparoscopic exploration revealed diffuse extrahepatic disease not identified by preoperative studies in 2 patients. The remaining 7 patients underwent 9 cryotherapy sessions. During 4 of the cryotherapy sessions, ultrasonography demonstrated unrecognized additional treatable hepatic lesions. An average of 3 lesions (range, 2-5) were treated. Operative time averaged 3.5 hours with a mean intraoperative blood loss of 235 mL. One patient had significant intraoperative hemorrhage requiring conversion to open hepatic resection for bleeding control. Eight of the 9 patients tolerated normal diets and ambulated independently on the first postoperative day. Following cryotherapy, 4 of the patients developed fever without an infectious source. One patient developed a postoperative bile leak requiring percutaneous biliary stenting. Postoperative hospital stay averaged 4.5 days (median, 4 days; range, 2-14 days). At a mean follow-up of 9 months, 4 of the 7 patients treated are alive without evidence of disease, 2 are alive with disease, and 1 patient with a pancreatic primary tumor has died of disease. CONCLUSIONS: Laparoscopy with laparoscopic ultrasonography is a useful tool in evaluating patients with hepatic metastases. Laparoscopic cryoablation is feasible and may result in lower postoperative morbidity in patients receiving aggressive treatment for inoperable hepatic metastases.