Impact of portal vein infiltration and type of venous reconstruction in surgery for borderline resectable pancreatic cancer.

BACKGROUND: The International Study Group of Pancreatic Surgery (ISGPS) recommends operative exploration and resection of pancreatic cancers in the presence of reconstructable mesentericoportal axis involvement. However, there is no consensus on the ideal method of vascular reconstruction. The effect of depth of tumour invasion of the vessel wall on outcome is also unknown. METHODS: This was a retrospective cohort study of pancreaticoduodenectomy with vein resection for T3 adenocarcinoma of the head of the pancreas across nine centres. Outcome measures were overall survival based on the impact of the depth of tumour infiltration of the vessel wall, and morbidity, in-hospital mortality and overall survival between types of venous reconstruction: primary closure, end-to-end anastomosis and interposition graft. RESULTS: A total of 229 patients underwent portal vein resection; 129 (56·3 per cent) underwent primary closure, 64 (27·9 per cent) had an end-to-end anastomosis and 36 (15·7 per cent) an interposition graft. There was no difference in overall morbidity (26 (20·2 per cent), 14 (22 per cent) and 9 (25 per cent) respectively; P = 0·817) or in-hospital mortality (6 (4·7 per cent), 2 (3 per cent) and 2 (6 per cent); P = 0·826) between the three groups. One hundred and six patients (47·5 per cent) had histological evidence of vein involvement; 59 (26·5 per cent) had superficial invasion (tunica adventitia) and 47 (21·1 per cent) had deep invasion (tunica media or intima). Median survival was 18·8 months for patients who had primary closure, 27·6 months for those with an end-to-end anastomosis and 13·0 months among patients with an interposition graft. There was no significant difference in median survival between patients with superficial, deep or no histological vein involvement (20·8, 21·3 and 13·3 months respectively; P = 0·111). Venous tumour infiltration was not associated with decreased overall survival on multivariable analysis. CONCLUSION: In this study, there was no difference in morbidity between the three modes of venous reconstruction, and overall survival was similar regardless of tumour infiltration of the vein.

Outcome after pancreaticoduodenectomy for T3 adenocarcinoma: A multivariable analysis from the UK Vascular Resection for Pancreatic Cancer Study Group.

BACKGROUND: Most resectable pancreatic cancers are classified as T3, including those involving the porto-mesenteric vein. Survival and perioperative morbidity for venous resection have been found to be comparable to standard resection. We investigate factors associated with short and long term outcomes in pancreaticoduodenectomy with (PDVR) and without (PD) venous resection exclusively for T3 adenocarcinoma of the head of the pancreas. METHODS: This is a UK multicenter retrospective cohort study assessing outcomes in patients undergoing PD and PDVR. All consecutive patients with T3 only adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. Multivariable logistic and proportional hazards regression analyses were performed to determine the association between the surgical groups and in-hospital mortality (IHM) and overall survival (OS). RESULTS: 1070 patients were included of whom 840 (78.5%) had PD and 230 (21.5%) had PDVR. Factors independently associated with IHM were a high creatinine (aHR 1.14, p = 0.02), post-operative bleeding (aHR 2.86, p = 0.04) and a re-laparotomy (aHR 8.42, p = 0.0001). For OS, multivariable analyses identified R1 resection margin status (aHR 1.22, p = 0.01), N1 nodal status (aHR 1.92, p = 0.0001), perineural invasion (aHR 1.37, p = 0.002), tumour size >20mm (aHR 0.63, p = 0.0001) and a relaparotomy (aHR 1.84, p = 0.0001) to be independently associated with overall mortality. CONCLUSION: This study on T3 adenocarcinoma of the head of the pancreas suggests that IHM is strongly associated with perioperative complications whilst OS is affected by histological parameters. Detailed pre-operative disease evaluation and advances in oncological treatment have the potential to improve OS.

Chicken or the leg: Sigmoid colon perforation by ingested poultry fibula proximal to an occult malignancy.

INTRODUCTION: Colonic perforation by ingested foreign bodies is exceedingly rare, with the diagnosis made more challenging by patients infrequently recalling any inadvertent ingestion and the poor sensitivity of plain radiography. PRESENTATION OF CASE: The presented case demonstrates that bony perforation of the large bowel might occur immediately proximal to an otherwise occult colonic malignancy. DISCUSSION: Ingestion of foreign bodies is common and rarely results in colonic perforation. However, bony ingestion is not usually remembered and can be missed even with cross-sectional imaging. If present, consideration should be given to the presence of an adjacent concealed colon cancer. CONCLUSION: The co-existence of separate pathology should be carefully assessed in these patients, since this has important implications for relevant investigations and appropriate surgical management.

Basic surgical training in the era of the European Working Time Directive: what are the problems and solutions?

BACKGROUND AND AIMS: Imposed reductions in working hours will impact significantly on the ability of surgical trainees to achieve competency. The objective of this study was to obtain the opinions of Scottish surgical trainees concerning the training they receive, in order to inform and guide the development of future, high-standard training programmes. METHODS: An anonymous questionnaire was sent to basic surgical trainees on the Edinburgh, Aberdeen and Dundee Basic Surgical Rotations commencing after August 2002. RESULTS: Thirty six questionnaire responses were analysed. Very few of the returned comments were complimentary to the existing training structure; indeed, most comments demonstrated significant trainee disappointment. Despite "regular" exposure to operative sessions, training tutorials and named consultant trainers, the most common concern was a perceived lack of high-quality, structured, operative exposure and responsibility. Textbooks and journals remain the most frequently utilised learning tools, with high-tech systems such as teleconferencing, videos, CD-ROMS, and DVDs being poorly exploited. CONCLUSIONS: Current surgical training is not meeting the expectation of the majority of its trainees. To solve this problem will require extensive revision of attitudes and current educational format. A greater emphasis on the integration of 21st century learning tools in the training programme may help bridge this gap.

Paraileostomy recontouring by collagen sealant injection: a novel approach to one aspect of ileostomy morbidity. Report of a case.

INTRODUCTION: Poorly fitting stoma appliances, resulting in stomal leakage and subsequent skin excoriation, remain a significant cause of ileostomy-related morbidity. One cause of ill-fitting stoma bags is the presence of parastomal dermal contour defects/irregularities. These may occur after surgical complications or change in patient weight and body habitus. METHODS: We report the case of a 29-year-old man who, after panproctocolectomy and formation of ileostomy for ulcerative colitis, experienced significant problems with stoma bag application because of dermal contour defects. As a result, he suffered from significant stomal leakage and skin excoriation. After a single treatment of cutaneous parastomal infiltration of porcine collagen (Permacol Injection), applied stoma bags achieved a watertight seal, and the patient experienced complete and sustained resolution of his symptoms. CONCLUSIONS: Porcine collagen is a safe, versatile, and relatively easy method of restoring irregular skin defects surrounding abdominal stomas, thus resolving the significant patient morbidity associated with ill-fitting stomal appliances. Such a technique avoids the need for surgical stoma refashioning, which may be associated with significant morbidity and unsatisfactory outcomes.

Results of decompression surgery for pain in chronic pancreatitis.

INTRODUCTION: A vast majority of patients with chronic pancreatitis require regular opiate/opioid analgesia and recurrent hospital admission for pain. However, the role and timing of operative strategies for pain in chronic pancreatitis is controversial. This study hypothesized that pancreatic decompression surgery reduces analgesia requirement and hospital readmission for pain in selected patients. PATIENTS AND METHODS: This was a retrospective review of patients undergoing longitudinal pancreatico-jejunostomy (LPJ), with or without coring of the pancreatic head (Frey's procedure), between 1995 and 2007 in a single UK centre. Surgery was performed for chronic pain with clinical/radiological evidence of chronic pancreatitis amenable to decompression/head coring. RESULTS: Fifty patients were identified. Thirty-six were male with a median age of 46 years and median follow-up of 30 months. Twenty-eight underwent LPJ and 22 underwent Frey's procedure. No significant difference in reduction of analgesia requirement (71% vs 64%, p=0.761) or hospital readmission for pain (21% vs 23%, p=1.000) was observed when comparing LPJ and Frey's procedure. Patients were significantly more likely to be pain-free following surgery if they required non-opiate rather than opiate analgesia preoperatively (75% vs 19%, p=0.0002). Fewer patients required subsequent hospital readmission for pain if taking non-opiate rather than opiate analgesia preoperatively (12.5% vs 31%, p=0.175). CONCLUSIONS: In selected patients, LPJ and Frey's procedure have equivalent benefit in short-term pain reduction. Patients should be selected for surgery before the commencement of opiate analgesia.

Gastric adenocarcinoma missed at endoscopy.

BACKGROUND AND PURPOSE: The diagnosis of gastric cancer is based on histological confirmation at endoscopy with the emphasis on early detection to improve prognosis. The aims of this study were to identify the proportion of patients with gastric adenocarcinoma in whom the diagnosis was missed at first endoscopy and the subsequent delay which occurred before the histological diagnosis was established. METHODS: Retrospective review of 137 consecutive patients with biopsy-proven gastric adenocarcinoma presenting to one surgical unit over a five-year period. RESULTS: Two patients with a biopsy diagnosis at laparotomy and 6 patients in whom case notes could not be traced were excluded from the study. Of the remaining 129 patients, the diagnosis of gastric adenocarcinoma was missed at first endoscopy in 18 (14%). The median delay to histological diagnosis in this subgroup of patients was 13 weeks (range 3-102). CONCLUSION: Delays in establishing the diagnosis of gastric adenocarcinoma following initial endoscopy occur in a number of patients. Greater suspicion and a more rigorous protocol for repeat endoscopy and biopsy must be implemented in order to reduce the number of missed diagnoses after initial endoscopy.