Laparoscopic partial splenectomy in distal pancreatectomy may preserve splenic function.

INTRODUCTION: Splenectomy is known to carry a risk of infection with encapsulated organisms and associated sepsis. Current Australian guidelines recommend intensive vaccination schedules and long-term antibiotic therapy. We postulate that in some clinical scenarios where distal pancreatectomy (DP) and splenectomy is being performed, a partial splenectomy is feasible. This may preserve splenic function and help retain immunocompetence. METHODS: Five patients underwent laparoscopic distal pancreatectomy with partial splenectomy (LDPPS). The DP is performed with proximal division and resection of the splenic artery and vein. The inferior portion of the spleen is removed en bloc with the distal pancreas with ligasure and linear cutting staplers. The line of demarcation on the spleen after the division of the splenic artery identifies the portion supplied by the short gastric vessels. Temporary clamping of the short gastrics during splenic parenchymal transection reduces blood loss. All operations were completed laparoscopically and within 4 h. RESULTS: The pathology of resected lesions includes a serous cystadenoma, a pseudocyst, an IPMN and two small medial pancreatic ductal adenocarcinomas. The benign lesions involved splenic vessels at the hilum, making Kimura or Warshaw procedures untenable. No patient required blood transfusion. One patient suffered a postoperative collection consistent with postoperative pancreatic fistula requiring a drain for 10 days. Follow-up ranged from 6 to 24 months. Following surgery, all patients had a perfused splenic remnant on imaging and benign blood films, which suggests retained splenic function. CONCLUSION: Preserving some spleen when performing distal pancreatectomy may provide long-term benefits for patients.

Investigating the impact of 'dark nudges' on drinking intentions: A between groups, randomized and online experimental study.

OBJECTIVES: This study explored how 'dark nudges' (tactics used in alcohol industry-funded responsible drinking campaigns) affect drinking intentions, perceived source credibility and whether individual differences in perceptions of prototypical drinkers moderated these effects. DESIGN: Two 2 × 2 between-groups online experimental studies. METHODS: Study 1 (N = 164) presented three alcohol health messages per condition, comprising social norm (healthy/unhealthy ("dark nudge")) by frame (loss/gain). Study 2 (N = 229) presented one message per condition, comprising cancer causality (single cause/multiple causes (dark nudge)) by funding disclosure (disclosure/non-disclosure (dark nudge)). Outcomes were drinking intentions and perceived source credibility. Exploratory analyses considered prototype perceptions as a between-subjects moderator. RESULTS: No significant effects of message frame, social norm, fundi or multiple cancer causality arguments on drinking intentions were found. In Study 2, in the dark nudge multiple cancer causality conditions, perceived source credibility was high when funding was undisclosed, but significantly lower when it was disclosed. Exploratory analyses suggested effects were moderated by prototype similarity. In Study 1, higher perceived similarity to a heavy drinker and lower perceived similarity to a responsible drinker were associated with higher drinking intentions in the unhealthy norm/gain frame condition, but lower drinking intentions in the other conditions. CONCLUSIONS: Framing, social norm, funding disclosure and multiple causality manipulations as tested in this study did not exert a dark nudge effect on drinking intentions. However, the exploratory analyses suggest it could be hypothesised that the types of messages used in alcohol industry-funded responsible drinking campaigns may result in greater drinking intentions among those who identify more as heavy drinkers and less as responsible drinkers. Perceived prototype similarity may be an important moderator of the impact of alcohol health messages that warrants further research. Study 2 suggests disclosure of industry funding guides judgements of the credibility of sources of misleading messages about alcohol and cancer.

Brunner's gland adenoma: a robotic approach.

This report describes an unusual case of a symptomatic Brunner's gland adenoma arising in a man in his 40s that underwent robotic transduodenal resection. Initial investigations revealed a polypoidal, submucosal lesion that was found in the first part of the duodenum. Microscopically, there was neither dysplasia nor evidence of adenocarcinoma, suggesting differentials of gastrointestinal stroma tumour and duodenal adenoma. Given the size of the lesion, he underwent a surgical resection. Symptomatic Brunner's gland adenoma is uncommon and should be considered as a differential diagnosis in patients presenting with obstructive symptoms.

Am I a responsible drinker? The impact of message frame and drinker prototypes on perceptions of alcohol product information labels.

BACKGROUND: Current alcohol product labelling tends to include ambiguous messages such as 'drink responsibly'. Consumers who identify as responsible drinkers may not pay heed to health warning messages, believing that they are not the intended target. AIMS: We aimed to determine how responses to responsible drinking labels would differ from responses to positively and negatively framed health messages. We also explored if prototype perceptions would moderate the message impact. METHODS: A between groups, three arm (ambiguous, positive or negative messages) experiment recruited 465 participants. Outcomes were drinking intentions and label acceptability (novelty, believability, personal relevance, and potential to change behaviour). Measures of heavy and responsible drinker prototype perceptions were included for exploratory moderation analyses. RESULTS: Positive and negative messages were rated significantly more likely to change behaviour than ambiguous messages. There was also a moderation effect: participants with stronger favourability and similarity to the responsible drinker prototype intended to drink more alcohol in the future after exposure to negatively framed labels, but not after exposure to ambiguous or positively framed labels. DISCUSSION: Drink responsibly' messages are unlikely to lead to behaviour change. Incorporating theoretical moderators may have value in developing our understanding of the impact of alcohol product labelling.

A case report of a rare and challenging gangrenous splenic flexure volvulus in a pregnant patient.

INTRODUCTION: Splenic flexure volvulus is a rare cause of intestinal obstruction and is uncommonly encountered in young patients from developed countries. PRESENTATION OF CASE: This report details a challenging case of a gangrenous large bowel volvulus in a 25 year old woman 20 weeks pregnant, highlighting the diagnostic and operative challenges that this rare clinical situation presents. After urgent MRI confirming a splenic flexure volvulus, an emergency open left hemicolectomy and end colostomy was performed. Following uneventful recovery and successful delivery of her baby at full term, she was reversed 6 months later. DISCUSSION: Splenic flexure volvulus is a rare cause of large bowel obstruction, and as such can result in a delay in diagnosis, particularly in the setting of pregnancy. In this case, the patient was not diagnosed until day 3 of her admission when she decompensated with a rising white cell count. CONCLUSION: Splenic flexure volvulus is a rare occurrence. This case report of a young pregnant woman presenting with a large bowel obstruction due to splenic flexure volvulus highlights the importance of considering and investigating for this diagnosis.

Total 5-mm port approach: a feasible technique for both elective and emergency laparoscopic cholecystectomy.

BACKGROUND: The laparoscopic approach is considered the standard of care for cholecystectomy. Attempts to minimize incisions with single site and natural orifice approaches have shown promise but also have limitations. Technological advances have facilitated decreased port size, which may have a variety of benefits. The aim of this study was to determine the feasibility of an all 5-mm port approach for patients undergoing both elective and emergency laparoscopic cholecystectomy. METHODS: A consecutive series of laparoscopic cholecystectomies at three different hospitals using all 5-mm ports was prospectively evaluated. Recorded outcomes included operative findings, procedural difficulties, the need to extend the umbilical incision during extraction, operative time, length of stay and post-operative complications. RESULTS: A total of 101 patients were included and all had a successful cholecystectomy without the need for additional ports. The umbilical incision was extended for gallbladder extraction in 29 (29%) patients. Eight (8%) patients experienced minor post-operative complications and there were no major complications. Cholangiography was performed in 98% of cases and three patients underwent successful common bile duct exploration without requiring additional ports. In a small number of cases, there was difficulty with the quality of the view through the 5-mm laparoscope but this was rectified by removing old or damaged laparoscopes from the circulating stock. CONCLUSION: This study demonstrates that laparoscopic cholecystectomy using all 5-mm ports is both feasible and safe, and is comparable to published outcomes after conventional laparoscopic cholecystectomy. Further work is needed to determine whether this approach can also improve short- and long-term outcomes.

Synchronous colorectal liver metastases in pregnancy and post-partum.

BACKGROUND: Metastatic colorectal cancer (mCRC) in pregnancy and post-partum is rare, but represents significant diagnostic and therapeutic challenges for clinicians. A multidisciplinary team (MDT) approach is essential. This study reports the first series in the Australasian literature, describing our experience with and management of pregnant and post-partum patients diagnosed with synchronous colorectal liver metastases (sCRLM). METHOD: A retrospective review of prospectively collected data for patients with sCRLM diagnosed during pregnancy or post-partum, presenting to a tertiary referral hospital between 2009 and 2014, was performed. Data regarding patient presentation, imaging, management, histopathology and survival were analysed. Patient characteristics and outcomes were reviewed, including age, presenting complaint and median survival. RESULTS: Five patients were identified with sCRLM: three patients were diagnosed antepartum and two post-partum. Median age was 31 years (range 26-34). All patients were diagnosed with colorectal primary and synchronous liver lesions. All patients received folinic acid, fluorouracil, oxaliplatin chemotherapy, two intrapartum. One patient had both the primary lesion and liver metastases excised early post-partum. Second-line chemotherapy with folinic acid, fluorouracil, irinotecan and other biological agents was used in some cases post-partum. One patient suffered a fetal loss, while the other four had uncomplicated live births. Median survival was 7.6 months, with two patients dying shortly after delivery. CONCLUSION: The diagnosis of mCRC in pregnancy is challenging and survival is poor. A MDT approach to management is essential. Chemotherapy remains the mainstay of treatment from the second trimester. Rapid confirmation of diagnosis and early chemotherapy, followed by post-partum colorectal and liver resection may improve survival.

Laparoscopic adjustable gastric band revisional surgery: a single surgeon series.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is a safe and proven surgical option for morbid obesity; however, the need for revisional surgery is being increasingly reported. This study reports outcomes and incidence for a large cohort of patients requiring revisional LAGB surgery for various indications. METHODS: A retrospective review of prospectively collected data for 1524 primary LAGB placed between 2003 and 2013 by a single surgeon at a single institution was performed, analysing data for all patients in this cohort requiring revisional LAGB surgery. RESULTS: A total of 434 revisions were performed on 349 patients. A total of 278 patients had a single revision, with 71 patients having two or more revisions. Revisions amounting to 213 were band repositions, 68 were band removal only and 153 were band removal with conversion to another bariatric procedure, mostly Roux-en-Y gastric bypass (n = 143). A total of 47 (35.1%) 'band-to-band' revision patients were lost to follow-up. Patients undergoing 'band-to-band' revision for a slipped band, patient intolerance and mechanical band failure had mean excess weight loss (EWL) at 4 years of 49.9% (n = 35), 38.6% (n = 10) and 67.4% (n = 6), respectively. Port or tubing revisions were not included. Mean follow-up for 'band-to-band' revision patients was 33.4 months (standard deviation 26.4 months). 22.9% of patients required one or more band revision procedures by 2013, increased from 13% in 2008. CONCLUSION: Continued EWL is achieved with repositioning or replacement of a LAGB. However, a significant and increasing rate of re-operation over time exists.

Long-term survival in laparoscopic vs open resection for colorectal liver metastases: inverse probability of treatment weighting using propensity scores.

BACKGROUND: This study compares long-term outcomes between intention-to-treat laparoscopic and open approaches to colorectal liver metastases (CLM), using inverse probability of treatment weighting (IPTW) based on propensity scores to control for selection bias. METHOD: Patients undergoing liver resection for CLM by 5 surgeons at 3 institutions from 2000 to early 2014 were analysed. IPTW based on propensity scores were generated and used to assess the marginal treatment effect of the laparoscopic approach via a weighted Cox proportional hazards model. RESULTS: A total of 298 operations were performed in 256 patients. 7 patients with planned two-stage resections were excluded leaving 284 operations in 249 patients for analysis. After IPTW, the population was well balanced. With a median follow up of 36 months, 5-year overall survival (OS) and recurrence-free survival (RFS) for the cohort were 59% and 38%. 146 laparoscopic procedures were performed in 140 patients, with weighted 5-year OS and RFS of 54% and 36% respectively. In the open group, 138 procedures were performed in 122 patients, with a weighted 5-year OS and RFS of 63% and 38% respectively. There was no significant difference between the two groups in terms of OS or RFS. CONCLUSION: In the Brisbane experience, after accounting for bias in treatment assignment, long term survival after LLR for CLM is equivalent to outcomes in open surgery.

Laparoscopic approach to a planned two-stage hepatectomy for bilobar colorectal liver metastases.

BACKGROUND: This report describes the technical aspects and outcomes of a laparoscopic approach in planned two-stage liver resections for patients with bilobar colorectal cancer (CRC) liver-only metastases. METHODS: This is a retrospective review of our database examining consecutive patients who underwent an initial first-stage laparoscopic liver resection for CRC metastases, with a planned second-stage resection from 2007 to 2013. RESULTS: Seven patients underwent an initial laparoscopic first stage with concurrent right portal vein ligation (RPVL) in two patients. Median operating time was 100 (60-170) min with a median blood loss of 100 (50-400) mL. Median length of stay was 3 (2-5) days. The remaining five patients required post-operative right portal vein embolization (RPVE). All patients had significant hypertrophy of the future liver remnant (FLR) (future liver remnant volume (FLRV) >25%) and six patients subsequently had a successful open right hepatectomy with one attempted laparoscopically converted to open. Two patients had prolonged bile leaks after the second procedure. Three patients remained disease free, with median follow-up of 34 (13-80) months. One patient had disease progression following RPVE precluding performance of second stage. CONCLUSION: Laparoscopic first-stage resection of tumours in the left liver can be safely combined with RPVL/RPVE to achieve adequate hypertrophy of the FLR, allowing subsequent right hepatectomy.

Intercostal and transthoracic trocars enable easier laparoscopic resection of dome liver lesions.

BACKGROUND: Dome liver lesions (those in segments VII or VIII) pose a challenge to standard laparoscopic resection. The use of additional intercostal and transthoracic trocars (ITTs) potentially facilitates resection over standard subcostal laparoscopic (SSL) techniques. METHODS: A retrospective review of a prospectively collected liver resection database was performed, selecting all minor resections of segments VII and VIII using the ITT and SSL approaches. The techniques of intercostal transdiaphragmatic access are described and the surgical outcomes of the two groups compared. RESULTS: A total of 19 patients were analysed. The ITT group included 8 patients and the SSL group included 11. The groups were comparable in median lesion size (20 mm in the ITT group and 26 mm in the SSL group). Blood loss, operative times, morbidity and conversion rates were similar. There was no lung injury or postoperative clinical pneumothorax in any patient undergoing transdiaphragmatic access. Median hospital stay was significantly shorter in the ITT group (2 days) than in the SSL group (6 days) (P = 0.032). CONCLUSIONS: The ITT approach is safe, effective and complementary to standard laparoscopic techniques for the resection of small tumours in segments VII and VIII.