Surgical Management of Pancreatic Neuroendocrine Tumors.

Pancreatic neuroendocrine tumors (pancNETs) are rare neoplasms that comprise 2% to 4% of all clinically detected pancreatic tumors. They are usually indolent, and their malignant potential is often underestimated. The management of this disease poses a challenge because of the heterogeneous clinical presentation and varying degree of aggressiveness. Treatment decisions for this clinical entity are still patient- and/or physician-specific. Optimal clinical management of pancNETs requires a multidisciplinary approach. The only potentially curative treatment option, especially in the early stage disease, remains surgical resection; however, as many as 75% of patients present with advanced disease (nodal and/or distant metastases).

The value of continuous wound infusion systems for postoperative pain control following laparoscopic Roux-en-Y gastric bypass: an analysis of outcomes and cost.

BACKGROUND: Current health-care reform is focusing on improving patient outcomes while cutting health-care costs, and as such, surgeons should consider that postoperative pain management techniques can contribute to the overall value of care delivered to patients. The current study aims to evaluate the value of continuous wound infusion systems (CWIS) in patients following laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: Records of all consecutive patients who underwent elective LRYGB by a single surgeon from January 2008 until June 2010 were reviewed. The presence of CWIS, patient pain scores, postanesthesia care unit (PACU) times, postoperative narcotic and antiemetic requirements, postoperative complications, and hospital length of stay (LOS) were recorded. Clinical data were subsequently linked and correlated with hospital financial data to determine overall hospital costs. RESULTS: Forty-four LRYGB patients were reviewed; 24 (54.5 %) received CWIS for postoperative pain control. There was no significant difference in PACU times, postoperative LOS, or postoperative complications. Patients with CWIS required significantly less narcotics (36.7 vs. 55.5 mg IV morphine equivalents for total LOS; p = 0.03) and antiemetics (5.0 vs. 12.4 mg ondansetron for total LOS; p = 0.02); however, patients with CWIS did not report better pain control and had slightly higher hospital costs ($13,627.00 vs. $13,395.05, p = 0.68). CONCLUSIONS: Data from the current study suggest that the value of CWIS for postoperative pain control following LRYGB is limited. As the environment for hospital reimbursement is changing to be one which is value driven, surgeons should consider analyses such as this when making decisions on which treatments to offer their patients.

Iatrogenic combined bile duct and right hepatic artery injury during single incision laparoscopic cholecystectomy.

BACKGROUND: Numerous recent reports describe the performance of laparoscopic procedures through a single incision. Although the feasibility of this approach for a variety of procedures is currently being established, little data are available regarding safety. CASE REPORT: A 65-year-old female patient who was transferred from an outside institution had undergone a single incision laparoscopic cholecystectomy that resulted in biliary tract and vascular injuries. METHODS: The patient was transferred with a known bile duct injury on the first postoperative day following single incision laparoscopic cholecystectomy. Review of her magnetic resonance imaging and percutaneous transhepatic cholangiogram studies showed a Bismuth type 3 bile duct injury. Hepatic angiogram demonstrated an occlusion of the right hepatic artery with collateralization from the left hepatic artery. She was initially managed conservatively with a right-sided external biliary drain, followed 6 weeks later by a Hepp-Couinaud procedure to reconstruct the biliary tract. CONCLUSION: As new techniques evolve, it is imperative that safety, or potential side effects, or both safety and side effects, be monitored, because no learning curve is established for these new techniques. In these initial stages, surgeons should have a low threshold to add additional ports when necessary to ensure that procedures are completed safely.