Hiatal Hernia Repair With Tension-Free Mesh or Crural Sutures Alone in Antireflux Surgery: A 13-Year Follow-Up of a Randomized Clinical Trial.

Importance: Antireflux surgery is an effective treatment of gastroesophageal reflux disease (GERD), but the durability of concomitant hiatal hernia repair remains challenging. Previous research reported that the use of a mesh-reinforced, tension-free technique was associated with more dysphagia for solid foods after 3 years without reducing hiatal hernia recurrence rates compared with crural sutures alone, but the long-term effects of this technique have not been assessed. Objective: To assess the long-term anatomical and functional outcomes of using a mesh for hiatal hernia repair in patients with GERD. Design, Setting, and Participants: A double-blind, randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from January 11, 2006, to December 1, 2010. A total of 159 patients were recruited and randomly assigned. Data for the current analysis were collected from September 1, 2021, to March 31, 2022. All analyses were conducted with the intention-to-treat population. Interventions: Closure of the diaphragmatic hiatus with crural sutures alone vs a tension-free technique using a nonabsorbable polytetrafluoroethylene mesh (Bard CruraSoft). Main Outcomes and Measures: The primary outcome was radiologically verified recurrent hiatal hernia after more than 10 years. Secondary outcomes were dysphagia scores (ranging from 1 to 4, with 1 indicating no episodes of dysphagia and 4 indicating more than 3 episodes of dysphagia per day) for solid and liquid foods, generic 36-Item Short Form Health Survey and disease-specific Gastrointestinal Symptom Rating Scale symptom assessment scores, proton pump inhibitor consumption, and reoperation rates. Intergroup comparisons of parametric data were performed using t tests; for nonparametric data, Mann-Whitney U, χ2, or Fisher exact tests were used. For intragroup comparisons vs the baseline at follow-up times, the Friedman test was used, and post hoc analysis was performed using Wilcoxon matched pairs. Results: Of 145 available patients, follow-up data were obtained from 103 (response rate 71%; mean [SD] age at follow-up, 65 [11.3] years; 55 [53%] female), with 53 initially randomly assigned to mesh reinforcement, and 50 to crural suture alone. The mean (SD) follow-up time was 13 (1.1) years. The verified radiologic hiatal hernia recurrence rates were 11 of 29 (38%) in the mesh group vs 11 of 35 (31%) in the suture group (P = .61). However, 13 years postoperatively, mean (SD) dysphagia scores for solids remained significantly higher in the mesh group (mean [SD], 1.9 [0.7] vs 1.6 [0.9]; P = .01). Conclusions and Relevance: Findings from this long-term follow-up of a randomized clinical trial suggest that tension-free crural repair with nonabsorbable mesh does not reduce the incidence of hiatal hernia recurrence 13 years postoperatively. This finding combined with maintained higher dysphagia scores does not support the routine use of tension-free polytetrafluoroethylene mesh closure in laparoscopic hiatal hernia repair for treatment of GERD. Trial Registration: ClinicalTrials.gov Identifier: NCT05069493.

Total versus partial posterior fundoplication in the surgical repair of para-oesophageal hernias: randomized clinical trial.

BACKGROUND: Fundoplication is an essential step in para-oesophageal hernia (POH) repair, but which type minimizes postoperative mechanical complications is controversial. METHODS: This was a randomized, double-blind clinical trial conducted between May 2009 and October 2018. Patients with symptomatic POH were allocated to either a total (Nissen) or a posterior partial (Toupet) fundoplication after hernia reduction and crural repair. The primary outcome was dysphagia (Ogilvie dysphagia scores) at 6 months postoperatively. Secondary outcomes were peri- and postoperative complications, swallowing difficulties assessed by the Dakkak dysphagia score, gastro-oesophageal reflux, quality of life (QoL), and radiologically confirmed hernia recurrence. RESULTS: A total of 70 patients were randomized to a Nissen (n = 32) or a Toupet (n = 38) fundoplication. Compared with baseline, Ogilvie dysphagia scores were stable at the 3- and 6-month follow-up in the Nissen group (P = 0.075 and 0.084 respectively) but significantly improved in the Toupet group (from baseline mean (s.d.): 1.4 (1.1) to 0.5 ( 0.8) at 3 months, and 0.5 (0.6) at 6 months; P = 0.003 and P = 0.001 respectively). At 6 months, Dakkak dysphagia scores were significantly higher in the Nissen group than in the Toupet group (mean (s.d.): 10.4 (7.9) versus 5.1 (7.2); P = 0.003). QoL scores improved throughout the follow-up. However, at 3 and 6 months postoperatively, the absolute median improvement (⍙) from preoperative values in the mental component scores of the Short Form-36 QoL questionnaire was significantly higher in the Toupet group (median (i.q.r.): 7.1 (-0.6 to 15.2) versus 1.0 (-5.4 to 3.3) at 3 months, and 11.2 (1.4 to 18.3) versus 0.4 (-9.4 to 7.5) at 6 months; (P = 0.010 and 0.003 respectively)). At 6 months, radiologically confirmed POH recurrence occurred in 11 of 24 patients (46 per cent) of the Nissen group and in 15 of 32 patients (47 per cent) of the Toupet group (P = 1.001). CONCLUSIONS: A partial posterior wrap (Toupet fundoplication) showed reduced obstructive complications and improved QoL compared with a total (Nissen) fundoplication following POH repair.Registration number: NCT04436159 (http://www.clinicaltrials.gov).

Clinical Outcomes of a Laparoscopic Total vs a 270° Posterior Partial Fundoplication in Chronic Gastroesophageal Reflux Disease: A Randomized Clinical Trial.

Importance: The efficacy of fundoplication operations in the management of gastroesophageal reflux disease (GERD) has been documented. However, few prospective, controlled series report long-term (>10 years) efficacy and postfundoplication concerns, particularly when comparing various types of fundoplication. Objective: To compare long-term (>15 years) results regarding mechanical complications, reflux control, and quality of life between patients undergoing posterior partial fundoplication (PF) or total fundoplication (TF) (270° vs 360°) in surgical treatment for GERD. Design, Setting, and Participants: A double-blind randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from November 19, 2001, to January 24, 2006. A total of 456 patients were recruited and randomized. Data for this analysis were collected from August 1, 2019, to January 31, 2021. Interventions: Laparoscopic 270° posterior PF vs 360° TF. Main Outcomes and Measures: The main outcome was dysphagia scores for solid and liquid food items after more than 15 years. Generic (36-Item Short-Form Health Survey) and disease-specific (Gastrointestinal Symptom Rating Scale) quality of life and proton pump inhibitor consumption were also assessed. Results: Among 407 available patients, relevant data were obtained from 310 (response rate, 76%; mean [SD] age, 66 [11.2] years; 184 [59%] men). A total of 159 were allocated to a PF and 151 to a TF. The mean (SD) follow-up time was 16 (1.3) years. At 15 years after surgery, mean (SD) dysphagia scores were low for both liquids (PF, 1.2 [0.5]; TF, 1.2 [0.5]; P = .58) and solids (PF, 1.3 [0.6]; TF, 1.3 [0.5]; P = .97), without statistically significant differences between the groups. Reflux symptoms were equally well controlled by the 2 types of fundoplications as were the improvements of quality-of-life scores. Conclusions and Relevance: The long-term findings of this randomized clinical trial indicate that PF and TF are equally effective for controlling GERD and quality of life in the long term. Although PF was superior in the first years after surgery in terms of less dysphagia recorded, this difference did not prevail when assessed a decade later. Trial Registration: ClinicalTrials.gov Identifier: NCT04182178.

Association of Mesh and Fixation Options with Reoperation Risk after Laparoscopic Groin Hernia Surgery: A Swedish Hernia Registry Study of 25,190 Totally Extraperitoneal and Transabdominal Preperitoneal Repairs.

BACKGROUND: International guidelines concerning mesh and mesh fixation options in laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) groin hernia repair are based on studies focusing on either mesh or fixation. We hypothesized that the value of such recommendations is limited by lacking knowledge on how mesh and fixation interact. The current registry-based nationwide cohort study compared different mesh/fixation combinations for relative risks for reoperation after TEP and TAPP groin hernia repair. STUDY DESIGN: All TEP and TAPP registered in the Swedish Hernia Registry 2005 to 2017 with standard polypropylene (StdPPM) or lightweight (LWM) flat mesh, having tack, fibrin glue, or no fixation, were included. The endpoint was reoperation due to recurrence as of December 31, 2018. Multivariable Cox regression rendered relative risk differences between the exposures, expressed as hazard ratios (HR) with 95% CIs. RESULTS: Of 25,190 repairs, 924 (3.7%) were later reoperated for recurrence. The lowest, mutually equivalent, reoperation risks were associated with StdPPM without fixation (HR 1), StdPPM with metal tacks (HR 0.8, CI 0.4 to 1.4), StdPPM with fibrin glue (HR 1.1, CI 0.7 to 1.6), and LWM with fibrin glue (HR 1.2, CI 0.97 to 1.6). Except for with fibrin glue, LWM correlated with increased risk, whether affixed with metal (HR 1.7, CI 1.1 to 2.7), or absorbable tacks (HR 2.4, CI 1.8 to 3.1), or deployed without fixation (HR 2.0, CI 1.6 to 2.6). CONCLUSIONS: With StdPPM, neither mechanical nor glue fixation seemed to improve outcomes. Thus, for this mesh category, we recommend nonfixation. With LWM, we recommend fibrin glue fixation, which was the only LWM alternative on par with nonaffixed StdPPM.

Using alteplase nephrostomy tube installation for thrombolysis of ureter tract clot obstruction.

In literature, few cases have been reported regarding the use of alteplase installation in a nephrostomy as anticoagulant treatment of blood clots in the upper urinary tract. Our case -report provides a unique case of alteplase installation in the nephrostomy tube for thrombolysis of a blood clot formation in the upper ureter. The blood clot formation emerged as acute obstruction following a planned endoscopic lithotripsy. A new protocol for alteplase installation for percutaneous nephrostomy is presented in this article.

Major intraoperative bleeding during pancreatoduodenectomy - preoperative biliary drainage is the only modifiable risk factor.

BACKGROUND: Pancreatoduodenectomy is associated with a high risk of complications. The aim was to identify preoperative risk factors for major intraoperative bleeding. METHODS: Patients registered for pancreatoduodenectomy in the Swedish National Pancreatic and Periampullary Cancer Registry, 2011 to 2016, were included. Major intraoperative bleeding was defined as ≥1000 ml. Univariable and multivariable analysis of preoperative parameters were performed. RESULTS: In total, 1864 patients were included. The median blood loss was 600 ml, and 502 patients (27%) had registered bleeding of ≥1000 ml. Preoperative independent risk factors associated with major bleeding were male sex (p < 0.001), body mass index (BMI) ≥25 kg/m2 (p < 0.001), preoperative biliary drainage (PBD) (p < 0.001), C-reactive protein (CRP) ≥12 mg/L (p = 0.006) and neo-adjuvant chemotherapy treatment (NAT) (p = 0.002). Postoperative intensive care (p < 0.001), reoperation (p = 0.035), surgical infections (p = 0.036), and bile leakage (p = 0.045) were more common in the group with major bleeding, and the 30-day mortality was higher (4.9% vs 1.6%; p < 0.001). CONCLUSION: Most predictive parameters for major intraoperative bleeding are not modifiable. PBD is an independent predictor for major intraoperative bleeding and to reduce the risk, patients with resectable periampullary tumors should, if possible, be subject to surgery without preoperative biliary drainage.

Preoperative biliary drainage by plastic or self-expandable metal stents in patients with periampullary tumors: results of a randomized clinical study.

BACKGROUND AND STUDY AIMS: Preoperative biliary drainage in patients with periampullary tumors and jaundice has been popularized to improve the quality of life and minimize the risks associated with subsequent radical surgery. The aim of this study was to investigate the possible superiority of self-expandable metal stents (SEMS) over plastic stents, by comparing the amount of bacteria in intraoperatively collected bile and using this variable as a proxy for the efficacy of the respective biliary drainage modalities. PATIENTS AND METHODS: In this randomized clinical trial, 92 patients with obstructive jaundice were enrolled; 45 were allocated to the plastic stent group and 47 to the SEMS group. The primary outcome was the extent and magnitude of biliary bacterial growth at the time of surgical exploration. Secondary outcomes were: macroscopic grading of inflammation of the stented bile ducts, occurrence of adverse events after stenting, stent dysfunction, recognized surgical complexities, and incidence of postoperative complications. RESULTS: The patients were well matched regarding clinical and disease-specific characteristics. At surgery, there were no group differences in the bacterial amount and composition of the bile cultures or the perceived difficulty of surgical dissection. During the preoperative biliary drainage period, more instances of stent dysfunction requiring stent replacement were recorded in the plastic stent group (19 % vs. 0 %; P  = 0.03). Postoperative complications in patients who underwent curative surgery were more common in patients with plastic stents (72 % vs. 52 %), among which clinically significant leakage from the pancreatic anastomoses seemed to predominate (12 % vs. 3.7 %); however, none of these differences in postoperative adverse events reached statistical significance. CONCLUSION: This randomized clinical study was unable to demonstrate any superiority of SEMS in the efficacy of preoperative bile drainage, as assessed by the amount of bacteria in the intraoperatively collected bile. However, some data in favor of SEMS were observed among the clinical secondary outcomes variables (preoperative stent exchange rates) without increases in local inflammatory reactions.

Survival Analysis and Risk for Progression of Intraductal Papillary Mucinous Neoplasia of the Pancreas (IPMN) Under Surveillance: A Single-Institution Experience.

PURPOSE: While surveillance of the majority of patients with IPMN is considered best practice, consensus regarding the duration of follow-up is lacking. This study assessed the survival rate and risk for progression of IPMN under surveillance. METHODS: All patients diagnosed with and surveyed for IPMN between January 2008 and December 2013 were identified and assigned to two groups: patients without indication for surgery (Group 1), and patients whose IPMN required surgery but were inoperable for general reasons (Group 2). Disease progression and survival data were compared between both groups. RESULTS: In total 503 patients were identified, of whom 444 (88.3%) were followed up. Group 1 included 395 patients, and Group 2 had 49. In Group 1, IPMN-specific 1-, 5-, and 10-year survival rates were 100, 100, and 94.2%, respectively. Four patients died of associated or concomitant pancreatic cancer, and 230 patients (58.2%) experienced disease progression. The 1-, 4-, 10-year cumulative risk for progression and for surgery was 11.2, 70.6, 97.5, and 2.9, 26.2, 72.1%, respectively. In Group 2, the 1-, 5-, 10-year IPMN-specific survival rate was 90.7, 74.8, and 74.8%, respectively. CONCLUSIONS: This study confirmed the safety of surveillance for patients with IPMN who do not require surgery. However, the risk for disease progression and for surgery increases significantly over time. The study results support International and European guidelines not to discontinue IPMN surveillance and validate the European recommendation to intensify follow-up after 5 years. The fairly good prognosis of patients whose IPMN requires surgery but cannot undergo resection suggests a relatively indolent disease biology.

Cattell-Braasch maneuver combined with local hypothermia during superior mesenteric artery resection in pancreatectomy.

BACKGROUND: The recent development of new neo-adjuvant treatment regimens associated with a higher success rate of down-staging has increased the interest of pancreatic surgeons on the role of extended surgery for patients affected by locally advanced pancreatic cancer. Pancreatectomy together with resection of the portal/superior mesenteric vein is considered nowadays standard of care for patients affected by pancreatic cancer. However, the resection of major abdominal arteries is still debatable. In particular, the short- and long-term results after resection of the superior mesenteric artery (SMA) remain controversial and only few cases have been described in literature. The present paper describes a new, quick, and easy technique for resection of the SMA. CLINICAL CASE: A 71-year-old patient affected by IPMN cancer with infiltration of the SMA received FOLFIRINOX-based neo-adjuvant treatment. After 4 months of treatment, the patient underwent total pancreatectomy with en bloc resection of the SMA and direct end-to-end anastomosis. The vascular resection was performed combining a complete Cattell-Braasch maneuver with local bowel hypothermia in an attempt to avoid graft interposition by facilitating an end-to-end anastomosis and to reduce the warm ischemia time. The post-operative course was uneventful and the patient was discharged 8 days post-operatively.

Delayed Gastric Emptying after Pancreatic Surgery: Analysis of Factors Determinant for the Short-term Outcome.

BACKGROUND: Delayed gastric emptying (DGE) frequently complicates pancreatoduodenectomy (PD). Mainly DGE develops as consequence of postoperative intra-abdominal complications (secondary), while the incidence of primary DGE (i.e., not related to surgical complications) has rarely been studied. Moreover, the pathogenesis of DGE is complex and needs to be further elucidated. The present study aimed at highlighting potential mechanisms behind primary and above all secondary DGE by studying a variety of different pancreatic surgical procedures. PATIENTS AND METHODS: During the time period 2008-2011, 327 patients underwent pancreatic resective procedures at Karolinska University Hospital. Of these, 242 were PD and 56 tail resections, 17 had a duodenal preserving pancreatectomy for chronic pancreatitis, and 15 patients with familial duodenal polyposis had a pancreas preserving duodenectomy. All postoperative courses were assessed and scored according to Clavien-Dindo. The presence of DGE was evaluated and recorded according to the definition launched by the International Study Group for Pancreatic Surgery (ISGPS). Crude associations were studied in a univariate model, followed by a multivariate analysis of the respective factors. The associations were presented as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: In total DGE emerged during the postoperative course in about 40% of the PD cases. About half of those (n = 47) were scored as being primary. The majority of the primary DGEs were classified as A (n = 26) and only four as grade C, whereas among the secondary cases significantly more patients were scored as grade C (p < 0.01). In those submitted to a pancreatic body and tail resection 25% reported DGE. The distribution of the different grades of DGE in patients with a tail resection followed the same pattern with a predominance of Grade A cases with an equal distribution between those being scored as primary and secondary. Duodenal preservation, as well as keeping the pancreas intact following duodenectomy, was not followed by primary DGE. Multivariate risk factor analyses for the development of primary GE revealed no specific risk profile except for high age. CONCLUSION: DGE is frequently seen after different surgical procedures directed toward the pancreatic gland. DGE is most commonly seen after PD, and half of these cases are scored as primary DGE. Primary and secondary DGE are seen in one-quarter of the cases even after pancreatic tail resection emphasizing the complex nature of the pathogenesis. Resection of the duodenum as an important mechanism behind DGE is not supported by the present results.

Are There Indications for Total Pancreatectomy in 2016?

An elective total pancreatectomy (TP) was first performed by Eugene Rockey of Portland, Oregon, in 1942. In the 1960s and 1970s, TP was the routine resection for pancreatic cancer in many centers because of fear of a leaking pancreatojejunostomy and multicentricity of the disease but the result used to be dreadful (in today's perspective). However, more recently, postoperative mortality and morbidity after pancreatic resections have improved due to better anastomotic technique and pre-, peri- and postoperative care. Today, TP - despite being a more extensive operation - can be offered with about the same operation risk as that of a Whipple procedure. Also, major improvements in the control of diabetes have been seen and there is actually an ongoing discussion on the actual severity of the diabetic state after TP. Also, the development of modern pancreatic enzyme preparations with sufficient control of endocrine and exocrine pancreatic insufficiency provides options for overcoming the postoperative problems following TP. Due to the improved results, there are today different - and more specific - indications than before for TP: malignant tumors growing from the pancreatic head into the left pancreas, pancreatic head cancer where it is not possible to secure a tumor-free resection margin with extended resection or with dubious changes in the pancreatic main duct at frozen section, recurrent malignancy in the pancreatic remnant, at cancer surgery with resection of the celiac trunk, rescue pancreatectomy after a leaking pancreatojejunostomy with sepsis or bleeding after a Whipple-type first resection, multifocal intraductal papillary mucinous neoplasm with potentially malignant foci present in all parts of the gland, multiple metastases of renal cell carcinoma and melanoma without any residual tumor outside the pancreatic gland (possibly also other specified but uncommon metastatic tumors with a potential for cure by pancreatectomy), multifocal neuroendocrine tumors including multiple endocrine neoplasia and hereditary pancreatic cancer with a high grade of cancer penetration risk for the bearers.

Cattell-Braasch Maneuver Combined with Artery-First Approach for Superior Mesenteric-Portal Vein Resection During Pancreatectomy.

Pancreatectomy associated with superior mesenteric-portal vein (SMPV) resection is currently considered the standard of care for patients with pancreatic tumors involving the major peripancreatic veins. However, a standard approach for resection and reconstruction is not defined yet. The aim of this study is to analyze the feasibility and short-term results of an original Cattell-Braasch artery-first approach (CBAF) for the resection of SMPV during pancreatectomy. Of 144 pancreatectomies with vascular resection undertaken from 2008 to 2013 at Karolinska University Hospital, 45 (31.2 %) were performed combining a Cattell-Braasch maneuver with an artery-first approach (from 2011 to 2013). The mean patient age was 65.2 years. Thirty-seven (82.2 %) patients underwent pancreatoduodenectomy and 8 (17.8 %) total pancreatectomy. Histology showed pancreatic ductal adenocarcinoma in 42 patients (93.3 %). The median length of the resected SMPV segment was 4.6 cm (range 3-7). In all patients, a direct end-to-end anastomosis was performed without graft interposition. In nine cases (20 %), an arterial resection was also performed. There was no mortality in this series, and the morbidity rate was 35.5 %. Combined CBAF for the resection of SMPV during pancreatectomy seems to be safe and effective. The reconstruction of the resected vessels is possible in many cases without graft interposition, even if the resected vein segment is of considerable length.

Pancreas-preserving duodenectomy is a safe alternative to high-risk pancreatoduodenectomy for premalignant duodenal lesions.

BACKGROUND: Pancreas-preserving duodenectomy (PPD) can be considered a technical alternative to pancreaticoduodenectomy for the treatment of premalignant/low-grade malignant lesions of the duodenum. However, no many data are available comparing surgical results and costs of these two procedures. METHODS: Prospectively collected data from the Karolinska University Hospital's electronic database was analyzed retrospectively for patients who underwent PD and PPD between January 2006 and December 2011. The demographics, length of stay (LOS), postoperative morbidity and mortality, and hospital costs were analyzed. RESULTS: Twenty patients operated with PPD and 369 with PD were identified. Of the PDs, 81 were classified as HR-PDs, based on the intraoperative assessment of the gland. PPD patients were younger than those with HR-PD (50 vs 62 years; p = 0.0003), and with slight prevalence of overweight, BMI ≥25 (60 vs 45.7 %; p = 0.2). No differences were found in overall morbidity (55 vs 68 %; p = 0.3), in severe postoperative complications-Dindo-Clavien grade ≥3b (20 vs 30 %; p = 0.3), in delayed gastric emptying (10 vs 12 %, ns), and postpancreatectomy hemorrhage (10 vs 7.4 %, ns) between PPD and HR-PDs. However, the incidence of POPF was marginally lower in the PPD group (15 vs 37 %; p = 0.06) and was treated conservatively, while ten patients in the HR-PD group were reoperated and with POPF-associated mortality of 40 %. Also, shorter ICU stay (5 vs 12.%, ns), lower reoperation rate (10 vs 21 %, ns), lower mortality (0 vs 6.2 %), and shorter LOS (16.9 vs 24.6 days) were observed with PPD compared to HR-PD, but the numbers did not reach statistical significance. PPD was performed with shorter operative time (319 vs 418 min; p < 0.0001) and less intra-operative blood loss than HR-PD (521 vs 1027 ml; p = 0.003). The hospital costs for PPD were significantly lower than for HR-PD (29,170 vs 53,080 Euro, p = 0.03) CONCLUSIONS: PPD for resection of premalignant and low-grade malignant duodenal lesions in this small series shows to be an equivalent alternative to HR-PD, as it can be performed with shorter operative time, less intraoperative blood loss, and comparable, even slightly better, postoperative outcome and with lower costs.

The use of LigaSure™ Does not Affect Histologic Margin Assessment in Pancreatoduodenectomy (PD) specimens.

CONTEXT: LigaSure™ is considered safe in performing pancreaticoduodenectomy (PD). However, no data are available regarding the possible damage of tissues at the resection margins and the impact thereof on histologic margin assessment. OBJECTIVE: This study compares the degree of histologic damage to the resection margins when using LigaSure™ (Group 1) or traditional ligature (Group 2). METHODS: Both groups included 8 consecutive patients who underwent PD at Karolinska Institute in December 2013 (Group 1) or earlier (Group 2) by the same surgeon (M.D.C.). The quality of tissues at the circumferential margins was compared between both groups by scoring for three different kinds of damage: tissue fragmentation, hemorrhage, and cell damage. RESULTS: The mean score for fragmentation was 1.3 (Group 1) versus 1.7 (Group 2; P=0.1). For hemorrhage the mean score was 0.8 (Group 1) versus 1.5 (Group 2; P=0.04). The mean score for cell damage was 1.4 (Group 1) compared to 1.2 (Group 2; P=0.1). CONCLUSIONS: LigaSure™ does not cause tissue damage that could affect histologic margin assessment in PD specimens.

Correlation between preoperative imaging and intraoperative risk assessment in the prediction of postoperative pancreatic fistula following pancreatoduodenectomy.

BACKGROUND: Prediction of postoperative pancreatic fistula (POPF) can be carried out with the intraoperative assessment of pancreatic consistency (PC) and via pancreatic duct width (iPDW). Preoperative computed tomography (CT) calculated pancreatic remnant volume (PRV) and duct width (rPDW) have also been shown to offer useful information about the risk of POPF. OBJECTIVE: The objective of this study was to determine the predictive value of the preoperative radiological features as compared with the intraoperative risk estimation for the subsequent development of POPF. METHOD: All patients undergoing pancreatoduodenectomy between September 2007 and March 2012 at the Karolinska University Hospital Stockholm were included. PRV and rPDW were determined on preoperative CT and in parallel, intraoperative PC and iPDW of the remnant pancreas were independently assessed. RESULTS: A total of 296 consecutive pancreatoduodenectomies were included. POPF occurred in 45 patients (15.2 %). Of those with a preoperatively calculated PRV < 23.0 cm(3), 2.8 % developed POPF compared with 25.7 % of those with a corresponding volume > 46.0 cm(3). In patients with an rPDW > 7.0 mm, 4.1 % had a POPF as compared with 38.7 % for those with rPDW < 2.0 mm. The POPF risk estimates based on PRV and rPDW and the intraoperative risk assessments were found to be identical (p < 0.001). In the receiver operating characteristic analysis, area under the curve was 0.80 (95 % confidence interval [CI] 0.72-0.87) and 0.80 (95 % CI 0.72-0.88) for the CT-based and intraoperative risk prediction models, respectively. CONCLUSIONS: Preoperative CT-based and intraoperative gland risk assessments offer comparable predictive information on the risk of POPF after pancreatoduodenectomy. These results imply that accurate POPF risk estimation can be carried out in the preoperative setting to opt for improved patient selection into relevant research protocols and the availability of surgical expertise and techniques.

Comparison of preoperative conference-based diagnosis with histology of cystic tumors of the pancreas.

BACKGROUND: Diagnostic errors in the evaluation of cystic neoplasms of the pancreas (PCNs) are quite common. Few data are available regarding the impact of these errors on clinical management. The aim of this study was to determine the accuracy of a pancreatic multidisciplinary conference in diagnosing PCNs, to assess the potential risk of misdiagnosis, and to evaluate the clinical impact of these errors. METHODS: A retrospective consecutive series of patients undergoing surgery for PCNs at Karolinska University Hospital between 2004 and 2012 was analyzed. RESULTS: During the study period, a total of 141 patients had undergone pancreatic resection for PCN. The overall accuracy of the preoperative diagnosis was 60.9 %. The rate of concordance between preoperative diagnosis and histology was similar for asymptomatic and symptomatic lesions (62.8 vs. 59.1 %; p = NS). The rate of correct diagnosis increased over time (54.5 % in 2004-2006, 61.7 % in 2007-2012, 63.5 % in 2010-2012). Univariate analysis identified the location of the lesion (diffuse pancreatic involvement) and a mucinous nature of the lesion as factors conducive to a correct diagnosis. Reevaluation of the original indication for surgery in light of the exact diagnosis showed that a surgical procedure should not have been performed in 12 patients (8.5 %). CONCLUSIONS: This study confirms that diagnostic errors are fairly common in the preoperative assessment of PCNs, but the errors are clinically relevant in <10 % of patients.

Impact of body mass index for patients undergoing pancreaticoduodenectomy.

AIM: To evaluate the impact of body mass index (BMI) on short and long term results after pancreaticoduodenectomies (PD). METHODS: A consecutive series of PDs performed at the Karolinska University Hospital from 2004 till 2010 were retrieved from our prospective database. The patients were divided by BMI into overweight/obese (O; BMI ≥ 25 kg/m(2)) and controls (C; BMI < 25 kg/m(2)). Demographics, peri-operative data, morbidity, mortality, pancreatic fistula (PF) rate, length of stay (LOS), hospital costs, histology, and survival were analyzed. An additional sub analysis of survival was performed in patients with a diagnosis of pancreatic ductal adenocarcinoma (PDAC) and divided in underweight, normal-weight, overweight and obese. RESULTS: A total of 367 PDs were included (O = 141/C = 226). No differences were found between O and C regarding demographics, peri-operative data, costs, morbidity or mortality. O was associated with higher intra-operative blood loss (1392 ± 115 mL vs 1121 ± 83 mL; P = 0.01), rate of PF (20% vs 9.5%; P = 0.006) and marginally longer LOS (18 ± 0.9 d vs 15 ± 1.1 d; P = 0.05). An increasing risk for PF was observed with increasing BMI. The 1, 3 and 5 years survival rate was similar in O and C in PDAC (68.7%, 26.4% and 8.8% vs 66.1%, 30.9% and 17.9% respectively; P = 0.9). When the survival was analyzed using 4 different categories of BMI (underweight, normal, overweight and obese), a trend was seen toward a difference in survival, with a worse prognosis for the underweight and obese patients compared to normal weight and overweight patients. CONCLUSION: Overweight increases the risk for intra-operative bleeding and PF, but do not otherwise alter short or long term outcome after PD for pancreatic cancer.

Portal venous system thrombosis after pancreatic resection.

BACKGROUND: Portal venous system thrombosis (PVST) is a rare, potentially fatal complication after pancreatic resection. The aim of this study was to assess the incidence, presenting symptoms, management, and treatment of PVST in a large cohort of patients. METHODS: Prospectively collected data on patients undergoing pancreatic resection between 1997 and 2009 were reviewed retrospectively. Preoperative and postoperative imaging were analyzed for the presence or absence of venous thrombi. All patients received standard thromboprophylaxis with low-molecular-weight heparin (LMWH). RESULTS: Of 516 pancreatic resections performed, 18 (3.5 %) were complicated by PVST. The most common clinical presentations were abdominal pain (n = 9) and ascites (n = 5) but never any alarm symptoms. Other symptoms were vague and nonspecific (e.g., weight loss, fatigue, fever). Total pancreatectomy was a risk factor compared to hemipancreatectomy (p < 0.01), whereas the underlying disease per se did not make any difference. The median interval between surgery and diagnosis of PVST was 105 days (range 1-1,440 days). PVST was at least a contributing factor in the postoperative deaths of two patients. LMWH therapy did not significantly affect survival. CONCLUSIONS: PVST remains a relatively infrequent complication after pancreatic resection. Because accurate diagnosis and timely intervention may reduce morbidity and mortality, the possibility of PVST should be considered in patients presenting with vague symptoms. Whether anticoagulant treatment is needed is still not clear; there were no obvious differences in outcome between treated and untreated patients.

[A 90-year-old woman with acute abdomen]. / En 90 år gammel kvinne med akutt abdomen.

Bowel strangulation is defined as mechanical obstruction associated with compromised blood circulation of the bowel wall. Delayed diagnosis and treatment are the main causes of the high mortality. A 90-year-old woman was admitted to our hospital with acute abdominal pain. Plain abdominal x-ray studies were inconclusive. However, bowel strangulation was suggested by computer tomography and the diagnosis was confirmed under the laparotomy. In the case of bowel strangulation, abdominal CT is a fast, reliable and useful diagnostic tool when imaging is considered necessary before a laparotomy.

[Scrotal pain and Henoch-Schönlein purpura]. / Skrotal smerte og Henoch-Schönleins purpura.

An acute scrotum is a potential urologic emergency and requires urgent evaluation in order to rule out conditions that need immediate surgical management. The most important condition to rule out is torsion of the testis. In cases of less emergency, a wide variety of differentials may be considered. Scrotal pain or swelling may occur in 10 to 15% of boys with Henoch-Schönlein purpura. We present the case of a 19-year-old boy who had intermittent scrotal pain of two weeks' duration with acute exacerbation prior to admission. The clinical examination gave no specific results. A regular and Doppler sonographic scan showed no evidence of testicular affection. The patient was observed in hospital. Two years earlier he had present with abdominal cramps, rectal bleeding, duodenitis, proteinuria and a purpuric rash, suggestive of Henoch-Schönlein purpura; IgA-nephritis was proven after a renal biopsy. As all other differentials had been ruled out, we concluded that Henoch-Schönlein syndrome was the cause of the recurrent scrotal pain in our patient.