Venous reconstruction thrombosis after pancreaticoduodenectomy with superior mesenteric/portal vein resection due to pancreatic cancer: an 8 years single institution experience.

BACKGROUND: Superior mesenteric/portal vein reconstruction (SMPVR) thrombosis remains a challenging complication following pancreaticoduodenectomy concomitant with venous resection. In this context, we aimed to present our SMPVR experiences and identify potential clinicopathological factors that increased SMPVR thrombosis. METHODS: A total of 33 patients who underwent SMPVR during pancreaticoduodenectomy were analyzed. Of these, 26 patients who experienced pancreatic head ductal adenocarcinoma met our inclusion criteria. Patients' data were compared as classified by SMPVR type and the development of SMPVR thrombosis. All interposition grafts were Dacron in this cohort. RESULTS: Types of SMPVR included: tangential resection with primary repair (n = 12); segmental resection with splenic vein preservation and either primary anastomosis (n = 8) or 14 mm tubular Dacron grafting (n = 1); segmental resection with splenic vein division either 14 mm tubular Dacron grafting (n = 2) or 14/7 mm 'Y'-shaped Dacron grafting (n = 3). A total of four patients having 14/7 mm 'Y'-shaped (n = 3) and 14 mm tubular Dacron (n = 1) developed SMPVR thrombosis (p = .001). Dacron grafting (p = .001) and splenic vein division (p = .010) were associated with SMPVR thrombosis. The median time to detection of SMPVR thrombosis was 4.3 months (2.5-21.0 months). The median follow-up time was 12.2 months (3.0-45 months). CONCLUSIONS: During pancreaticoduodenectomy for pancreatic head ductal carcinoma, extended venous resection requiring SMPVR with 'Y'-shaped and use of Dacron interposition grafts appeared to be associated with the development of SMPVR thrombosis. This result warrants further investigations.

Serum amylase on postoperative day one is a strong predictor of pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort.

Background/aim: Early identification of patients at risk for developing postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) may facilitate drain management. In this context, it was aimed to examine the efficiency of the serum amylase (SA) value on postoperative day (PoD) 1 in predicting the occurrence of POPF. Materials and methods: A total of 132 patients who underwent PD were studied. Occurrences of POPF were classified according to the International Study Group on Pancreatic Fistula classification as a biochemical leak (BL) or clinically relevant grade b/c POPF (CR-POPF). Receiver operating characteristic analysis identified a threshold value of SA on PoD 1 associated with POPF formation. Results: Overall, 66 (50%) patients had POPF, including 51 (38.7%) with BL and 15 with CR-POPF (11.3%). The threshold value of SA associated with the development of POPF was 120 IU/L (odds ratio [OR]: 3.20; p = 0.002). In the multivariate analysis, independent POPF risk factors were SA ≥120 IU/L, soft pancreatic texture, and high-risk pathology (i.e., duodenal, biliary, ampullary, islet cell, and benign tumors); SA ≥120 IU/L outperformed soft pancreatic texture and high-risk pathology in predicting POPF, respectively (OR: 2.22; p = 0.004 vs. OR: 1.37; p = 0.012 vs. OR: 1.35; p = 0.018). In a subset analysis according to gland texture (soft vs. hard), patients with soft pancreatic texture exhibited a significantly higher incidence of POPF (63.4% vs. 34.4%) and SA ≥120 IU/L (52.1% vs. 27.9%); SA <120 IU/L had a negative predictive value of 82.5% for developing POPF in patients with hard pancreatic texture (OR: 4.28, p = 0.028). Conclusion: A SA value ≥120 IU/L on the day after PD, which is the strongest predictor for POPF, can be used as a biomarker of the occurrence of POPF. The advantage of SA measurement is that it can contribute to identifying suitable patients for early drain removal.

Isolated Roux loop versus conventional pancreaticojejunostomy following pancreaticoduodenectomy.

AIM: This study aimed to examine the effects of isolated Roux loop (IP) versus conventional pancreaticojejunostomy (CP) techniques on the rate of postoperative pancreatic fistula and its severity. MATERIAL AND METHODS: This study included retrospectively collected data from 132 patients who underwent pancreaticoduodenectomy in a single institute. Collected data were compared between IP and CP groups. Postoperative pancreatic fistula and its grades were defined according to International Study Group on Pancreatic Fistula (ISGPF) definition. RESULTS: A total of 58 patients had IP and 74 patients had CP. Biochemical leak (IP 20.6% versus CP 14.9%, p=0.38) and grade B/C pancreatic fistula (IP 20.6% versus CP 32.4%, p=0.13) rates of both groups were similar. Durations of hospital stay and intensive care unit stay and 30-day mortality rates of the two groups were similar. CONCLUSION: Isolated Roux loop reconstruction following pancreaticoduodenectomy is not associated with a lower rate of pancreatic fistula but may contribute to reducing the severity of pancreatic fistula. KEY WORDS: Anastomotic leak, Pancreatic fistula, Pancreaticoduodenectomy, Roux en y anastomosis.

Effect of Modified Blumgart Anastomosis on Surgical Outcomes After Pancreaticoduodenectomy.

BACKGROUND: Surgeons continue to be concerned about complications after pancreaticoduodenectomy, especially postoperative pancreatic fistula. Among the factors that cause postoperative pancreatic fistula, the pancreaticojejunostomy technique has stood out in recent studies. In this study, we aimed to compare the surgical outcomes, especially POPF, of the modified Blumgart and the traditional anastomosis techniques in patients who underwent pancreaticoduodenectomy. METHODS: A total of 144 patients who underwent pancreaticoduodenectomy were divided into 2 groups according to the performed pancreaticojejunostomy technique (modified Blumgart anastomosis, n = 91 and traditional anastomosis, n = 53). Preoperative clinicodemographic data, perioperative findings, and postoperative results were compared between the groups. Additionally, factors associated with clinically relevant postoperative pancreatic fistula were analyzed. RESULTS: The modified Blumgart anastomosis group had lower clinically relevant postoperative pancreatic fistula rate than traditional anastomosis group (n = 8 (8.8%) versus n = 14 (26.4%), P = .005). On the contrary, the biochemical leakage rate was higher in the modified Blumgart anastomosis group (n = 30 (33%) versus n = 9 (17%), P = .037). While postoperative pancreatic fistula-related reoperation rate was lower (n = 2 (2.2%) versus n = 7 (13.2%), P = .013), the length of hospital stay was also shorter (11 days (5-47 days) versus 21 days (6-46 days), P < .001) in the modified Blumgart anastomosis group. Univariate and multivariate analyses revealed that modified Blumgart anastomosis was an independent and negative predictive factor for clinically relevant postoperative pancreatic fistula (odds ratio = 0.274, 95% confidence interval = 0.103-0.728, P = .009). CONCLUSION: Compared to the traditional anastomosis, modified Blumgart anastomosis decreases the rate of transition from biochemical leakage to clinically relevant postoperative pancreatic fistula and postoperative pancreatic fistula-related reoperation and also shortens the length of hospital stay. In addition, modified Blumgart anastomosis is an independent and negative predictive factor for the development of clinically relevant postoperative pancreatic fistula.

Is Prognostic Nutritional Index an Indicator for Postoperative 90-Day Mortality in Laparoscopic Gastric Cancer Surgery?

Gastic cancer is a life-threatening malignancy in the world. The aim of this study was to investigate the clinical significance of the prognostic nutritional index (PNI) as a guiding marker for gastric cancer patients with laparoscopic gastrectomy. We retrospectively examined the medical records of 138 gastric cancer patients who had adenocarcinoma pathological diagnosis and operated laparoscopically. Patients were divided into two groups (survived and death) and these groups were compared with clinical and laboratory parameters results. The PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3). Logistic regression analyses were performed to identify the risk factors of 90-day mortality. The median age of the study cohort was 62.5 (19-91) years, 98 (71%) were males, and 9 (6.5%) patients died during the 90-day after laparoscopic gastrectomy. The PNI levels were significantly lower in death group compared with survived group 37.5 (25-47.1) to 46.9 (22.8-64.9). The PNI (Odds Ratio = 0.81, 95% Confidence Interval 0.70-0.92, p = 0.003) was found as an independent factor for 90-day mortality in multivariate analysis. Receiver operating characteristic (ROC) curve analysis showed that 45.15 is the best-cutoff value for 90-day mortality after laparoscopic gastrectomy. 90-day mortality rate of PNI > 45.15 was 2.2% and PNI ≤ 45.15 was 13.6% found. Lower PNI is associated with increased 90-day mortality in laparoscopic gastrectomy for gastric cancer. The PNI may be a useful marker for predicting the 90-day mortality of gastric cancer patients after laparoscopic gastrectomy.

Surgical Site Infections after Laparoscopic Bariatric Surgery: Is Routine Antibiotic Prophylaxis Required?

Background: It is a challenging question, especially in bariatric surgery (BS), whether antibiotic prophylaxis is necessary in all cases; considering the serious consequences of surgical site infection (SSI) on the one hand and irrational use of antibiotics on the other. The aim of this study was to determine the need/rationale for antibiotic prophylaxis in patients undergoing laparoscopic bariatric surgery, especially low-risk patients. Methods: This retrospective analysis involved 313 morbidly obese patients (body Mass Index [BMI] ≥40) who underwent laparoscopic BS at three medical centers between September 2018 and June 2019. During the trial, no inducement was given to use antibiotics, and the centers had chosen whether to use prophylaxis. The U.S. Centers for Disease Control and Prevention (CDC)-2016 criteria were used for the diagnosis of SSI. Results: Antibiotic prophylaxis was given to 181 patients, and the SSI rate in the entire series was 4.5% (14/313). There was no significant difference in SSI between the group who received antibiotics and that who did not (2.8% versus 6.8%, respectively; p = 0.09). Post-operative intra-abdominal complications were the main independent determinant for SSIs (p < 0.001). Antibiotic prophylaxis did not have any significant effect on the rate of SSI caused by these complications (2.2% versus 3.8%, respectively; p = 0.50). The second independent factor was the rate of SSI in patients with super-obesity (BMI ≥60), particularly incisional SSIs (p < 0.001). Antibiotic prophylaxis did not produce any significant decrease in the rate of SSI in patients with a BMI < 60 (2.8% versus 5.5%, respectively; p = 0.24). When these two independent factors were excluded, there were no patients with SSI in the no-antibiotics group, and only one in the antibiotic prophylaxis group (0.5%) (p = 1.00). Conclusions: Routine antibiotic prophylaxis should be questioned in laparoscopic BS. Prophylaxis may reduce incisional SSI in patients with a BMI of ≥60. In other cases, antibiotic prophylaxis does not provide a decrease in SSI.

Mini-laparoscopic adrenalectomy with transgastric specimen extraction.

We aimed to describe the initial experience of mini-laparoscopic adrenalectomy combined with transgastric specimen extraction and to assess its safety and feasibility. We used only 5-mm trocars, three ports for left adrenalectomy and four for right. Intraoperative gastroscopy was performed for specimen extraction through the mouth via an endoscopic snare. The gastrotomy was closed intracorporeally. Demographic, perioperative and pathological data were analyzed. There were 16 patients (12 females) with the mean age of 46.5 ± 11.3 years and half of them had previous abdominal surgeries. The median operative time was 150 (45-432) min with a median blood loss of 88 (0-350) ml. The median oral intake time was 2 (1-4) days and the median length of hospital stay was 2 (2-5) days. There was no mortality and extraction-related complication. Histopathological median tumor length, width and depth were 3 cm, 2.15 cm, and 1.9 cm, respectively. The median specimen length, width and depth were 6.25 cm, 4 cm, and 2.2 cm, respectively. Mini-laparoscopic adrenalectomy combined with transgastric specimen extraction is a safe and feasible surgical technique. It provides a less invasive surgery and may also have some benefits on wound-related complications and cosmesis.

Should there be a specific length of the colon-rectum segment to be resected for an adequate number of lymph nodes in cases of colorectal cancers? A retrospective multi-center study.

OBJECTIVES: This study aimed to evaluate the question as to whether there should be a certain length of the colon-rectum segment to be resected for correct lymph node staging in cases with colorectal cancer. MATERIAL AND METHODS: The files and electronic datas of the patients had been undergone surgery for colorectal cancer between January 2011 and June 2016 were evaluated. The patients were divided into two groups; Group I= ≥ 12 lymph nodes, and Group II= lymph nodes less than 12 ( <12) lymph nodes. RESULTS: Mean age of the 327 participants in this study was 64.30 ± 12.20. Mean length of resected colon-rectum segment was 25.61 (± 14.07) cm; mean number of dissected lymph nodes was 20.63 ± 12.30. Median length of the resected colon was 24 cm (range: 145-6) in Group I and 20 cm (range: 52-9) in Group II; a significant difference was found between the groups (p= 0.002). Factors associated with adequate lymph node dissection included type of the operation (p= 0.001), tumor location (p= 0.005), tumor T stage (p= 0.001), condition of metastasis in the lymph node (p= 0.008) and stage of the disease (p= 0.031). Overall survival was 62.4 ± 1.31 months, and Group I and Group II survival was 61.4 ± 1.39 months and 66.7 ± 3.25 months, respectively (p= 0.449). CONCLUSION: Results of the study showed that ≥ 12 lymph nodes would likely be dissected when the length of the resected colon-rectum segment is > 21 cm. We conclude that the removed colonic size can be significant when performed with oncological surgical standardization.

Is it beneficial to use clinical scoring systems for acute appendicitis in adults?

BACKGROUND: Clinical scoring systems have been used to reduce negative appendectomy rate for several decades. However, the use of these systems has been questioned due to differences in their diagnostic accuracies. The aim of this prospective study was to develop a new clinical scoring system using a combination of all previously described variables for the diagnosis of acute appendicitis (AA). METHODS: Consecutive patients who underwent emergency appendectomy for AA between December 2016 and April 2017 were prospectively included in the study. During admission, a prepared questionnaire including variables obtained from the previously used clinical scoring systems was administered. Histopathological analysis was regarded as the main outcome. Patients with no histopathological evidence of AA were defined as negative appendectomy. All variables were analyzed separately to assess their association with AA. A receiver operating characteristic curve with area under curve analysis was performed to obtain the cut-off values for numerical variables. RESULTS: There were 200 patients with a mean age of 30.8±12.8 years with a negative appendectomy rate of 5.5%. There was no significant association between the variables and the detection of histologically proven AA except increased white blood cell count >11.05/mm3 and proportion of the polymorphonuclear leukocytes >71.2% (p=0.003 and p=0.015, respectively). CONCLUSION: The present study shows that the development and/or use of scoring systems does not significantly improve the diagnostic accuracy of AA.

Laparoscopic resection of choledochal cysts in adults: a series from Turkey.

OBJECTIVES: Choledochal cyst is a congenital disease in which surgical treatment is preliminary because of the potential for malignancy. In recent years, increase in technological developments and laparoscopic experience have popularised the use of laparoscopy in adult choledochal cyst surgery. This study aimed to present the results of eight adult patients undergoing laparoscopic choledochal excision surgery. MATERIAL AND METHODS: Patients who underwent laparoscopic choledochal cyst excision and hepatico-jejunostomy anastomoses between the years 2013 and 2018 were evaluated retrospectively. Demographic characteristics, preoperative and postoperative findings, pathological results and final condition of the patients were examined. RESULTS: Of the eight patients, three were males and five were females. Median age was 41.5 years (22-49). One of the patients had Type IVa and the rest had Type I choledochal cysts. Laparoscopic choledochal cyst excision, cholecystectomy, and hepatico-jejunostomy anastomoses were performed on all of the patients. One patient was converted to open surgery. Three patients had postoperative biliary leakage. Duration of the operations was determined as median 330 (240-480) minutes and blood loss was 50 (10-100) mL. Hospitalization of the patients was median 6 (4-23) days and follow-up time was median 20 (2-65) months. In the late period, cholangitis occured in a patient who was treated with medical therapy and there was no mortality in the follow-up period. CONCLUSION: We suggest that laparoscopic choledochal cyst excision in adults may be an alternative to open surgery due to the satisfactory results in the late period in spite of early problems like self-limiting bile leakage.