Blueprint for safe transition from a low- to high-volume pancreatic surgery center.

We describe a straightforward model to implement a high volume specialty surgery program at a community hospital. Using pancreatic surgery as an example, we employed published processes in three arenas. First, mandatory multidisciplinary tumor board presentations captured all the patients considered for surgery. Then, perioperative protocols using tools such as enhanced recovery and teamwork in the perioperative arena created a reproducible and safe environment for complex surgery. We critically reviewed all complications using the Clavien-Dindo methodology, and confirmed our favorable outcomes via the targeted NSQIP program. These standard steps can be used for implementation of a new complex surgical procedure.

Prevention and Early Detection of Pancreatic Cancer.

Preventing cancer has much to offer. Aside from plummeting health care costs, we might enjoy a healthier life free of cancer and chronic disease. Prevention requires the adoption of healthier choices and a moderate amount of exercise. The supporting evidence is observational, clinical, and partly common sense. Further investigations reveal several substances in a whole-food plant-based diet that have protective effects and an inhibitory effect on tumor development. For pancreatic cancer, the basis of cure remains a century old operation that rarely cures. With little to lose, prevention deserves center stage and additional studies.

A Tale of 2 Techniques: Preoperative Biliary Drainage and Routine Surgical Drainage with Pancreaticoduodenectomy.

Preoperative drainage of an obstructed biliary tree before pancreaticoduodenal resection (PDR) and placement of intraabdominal drains following pancreatic resection have been suggested to be both unnecessary and associated with a higher complication rate. The evidence for and against that practice is presented and analyzed to highlight its risks and benefits. A selective approach on an individual basis for preoperative biliary decompression is advocated, based on multiple factors. Additionally, the evidence for routine use of surgical drains after PDR is critically reviewed and the rationale for routine drainage is made.

Cancer of the Pancreas-Actual 5, 10, and 20+Year Survival: The Lucky and Fortunate Few.

Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malignancy. This article updates an earlier experience of actual long-term survival of CaP in patients treated between 1991 to 2000, and reviews the literature. Survival is expressed as actual, not projected, survival.

Rare, Uncommon, and Unusual Complications After Pancreaticoduodenal Resection.

Complications after pancreaticoduodenal resection occur in at least 30% of patients. Most are a direct result of an intraoperative event, dissection, or anastomoses which account for the most serious morbidities, sepsis, pseudoaneurysms, and hemorrhage. Rarely, complications are due to the systemic impact of the procedure even if the procedure itself was unremarkable. Rare systemic complications after PDR (Transfusion transmitted Babesiosis, pituitary apoplexy, and TRALI) and a number of uncommon and unusual other complications are discussed. Pancreaticoduodenal resection is a significant operation with serious consequences. Decisions on selection of candidates and safe operations should be thoughtful and always in surgeons' minds.

Laparoscopic Repair of an Intrapericardial Diaphragmatic Hernia After Convergent Maze Procedure.

The convergent maze procedure (CMP) is a new minimally invasive technique for the surgical treatment of atrial fibrillation (AF). Recently, multiple groups have published excellent results and few adverse events with CMP. However, we now report the second case of an intrapericardial diaphragmatic hernia with small bowel obstruction that resulted from CMP. This adverse event was managed successfully by laparoscopic repair of the hernia and the use of a polytetrafluoroethylene mesh closure with hepatic buttress, achieving an excellent result. With the expanding use of CMP for the treatment of AF, awareness of this adverse event and its appropriate management are increasingly important.

What is the incidence of biliary carcinoma in choledochal cysts, when do they develop, and how should it affect management?

The incidence of cancer in choledochal cysts (CCs) in adults was calculated to determine the timing and need for surgery. In 78 publications (1996-2010), 434 of 5780 reported CCs patients had cancer. Cholangiocarcinoma (70.4 %) and gallbladder cancer (23.5 %) were the most common malignancies. Only nine malignancies were reported before age 18 (0.42 %). In contrast, the incidence of malignancy in adults was 11.4 %. The median age for diagnosis of cancer was 42 years, and the incidence increased with each decade.

Three synchronous, sporadic and separate periampullary and pancreatic tumors: more than a coincidence?

Three sporadic, synchronous, and separate lesions in the ampulla of Vater and the head of the pancreas presented in an 81-year-old male. One was symptomatic and two were incidental. One was detected preoperatively (the ampullary lesion) and two by examination of the resected specimen (the neuroendocrine and pancreatic carcinomas). The case is summarized and the literature and the issue of commonality are reviewed.

Familial pancreatic cancer: the case for prophylactic pancreatectomy in lieu of serial screening and shared decision making.

At-risk family members with familial pancreatic cancer (FCaP) face uncertainty regarding the individual risk of developing pancreatic cancer (CaP) and whether to choose serial screening or prophylactic pancreatectomy to avoid CaP. We treated 2 at-risk siblings with a history of FCaP, congenital hepatic fibrosis (CHF), and jaundice secondary to a bile duct stricture. In one, a pancreaticoduodenal resection was done and in the second a total pancreatectomy. Malignancy was not present, but extensive pancreatic intraepithelial neoplasia (PanIn) 2 was present throughout both pancreata. The clinical course and literature review are presented along with the previously unreported association of CHF and CaP.

Biliary pain, no gallstones--remove the gallbladder, anyway?

As these 2 cases show, cholecystectomy may be helpful for such patients, even those with a high ejection fraction.

Laparoscopic repair of an intrapericardial diaphragmatic hernia.

An isolated intrapericardial diaphragmatic hernia is very rare. Only 15 cases have been reported, 2 of which are in adults. The defect in the anterior diaphragm allows abdominal contents to enter the pericardial cavity. We report the 16th case--the third in an adult--and its laparoscopic repair.

Robotic pancreatic surgery is no substitute for experience and clinical judgment: an initial experience and literature review.

Robotic pancreatic surgery offers technical advantages, and has been applied across many surgical specialties. We report an initial experience of 12 distal pancreatic resections for benign tumors from an established pancreatic center with previous general and biliary laparoscopic experience. Of a total of 12 patients, 7 were women; the mean age was 55.5 years, and the lesions included 8 distal intraductal papillary mucinous tumors, 1 insulinoma and in 3 a non-functioning neuroendocrine tumor. All operations were performed in between 90 and 180 minutes, and blood loss and hospital stay were minimal.

Hepatic actinomycosis mimicking an isolated tumor recurrence.

Actinomyces species has been described as an opportunistic pathogen, particularly in the oral cavity; however, in rare cases these bacteria can cause actinomycosis which is characterized by formation of abscesses in the mouth, lungs, or gastrointestinal tract. Actinomycosis was commonly present in the pre-antibiotic era; however, it has a low prevalence now days. It has been recognized since 150 years ago, but because of its variable clinical presentation and indolent course, its recognition is difficult and patients are often misdiagnosed. Here we present a case of primary hepatic actinomycosis presenting as a metastatic liver tumor.