Immediate surgery compared with short-course neoadjuvant gemcitabine plus capecitabine, FOLFIRINOX, or chemoradiotherapy in patients with borderline resectable pancreatic cancer (ESPAC5): a four-arm, multicentre, randomised, phase 2 trial.

BACKGROUND: Patients with borderline resectable pancreatic ductal adenocarcinoma have relatively low resection rates and poor survival despite the use of adjuvant chemotherapy. The aim of our study was to establish the feasibility and efficacy of three different types of short-course neoadjuvant therapy compared with immediate surgery. METHODS: ESPAC5 (formerly known as ESPAC-5f) was a multicentre, open label, randomised controlled trial done in 16 pancreatic centres in two countries (UK and Germany). Eligible patients were aged 18 years or older, with a WHO performance status of 0 or 1, biopsy proven pancreatic ductal adenocarcinoma in the pancreatic head, and were staged as having a borderline resectable tumour by contrast-enhanced CT criteria following central review. Participants were randomly assigned by means of minimisation to one of four groups: immediate surgery; neoadjuvant gemcitabine and capecitabine (gemcitabine 1000 mg/m2 on days 1, 8, and 15, and oral capecitabine 830 mg/m2 twice a day on days 1-21 of a 28-day cycle for two cycles); neoadjuvant FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, folinic acid given according to local practice, and fluorouracil 400 mg/m2 bolus injection on days 1 and 15 followed by 2400 mg/m2 46 h intravenous infusion given on days 1 and 15, repeated every 2 weeks for four cycles); or neoadjuvant capecitabine-based chemoradiation (total dose 50·4 Gy in 28 daily fractions over 5·5 weeks [1·8 Gy per fraction, Monday to Friday] with capecitabine 830 mg/m2 twice daily [Monday to Friday] throughout radiotherapy). Patients underwent restaging contrast-enhanced CT at 4-6 weeks after neoadjuvant therapy and underwent surgical exploration if the tumour was still at least borderline resectable. All patients who had their tumour resected received adjuvant therapy at the oncologist's discretion. Primary endpoints were recruitment rate and resection rate. Analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN, 89500674, and is complete. FINDINGS: Between Sept 3, 2014, and Dec 20, 2018, from 478 patients screened, 90 were randomly assigned to a group (33 to immediate surgery, 20 to gemcitabine plus capecitabine, 20 to FOLFIRINOX, and 17 to capecitabine-based chemoradiation); four patients were excluded from the intention-to-treat analysis (one in the capecitabine-based chemoradiotherapy withdrew consent before starting therapy and three [two in the immediate surgery group and one in the gemcitabine plus capecitabine group] were found to be ineligible after randomisation). 44 (80%) of 55 patients completed neoadjuvant therapy. The recruitment rate was 25·92 patients per year from 16 sites; 21 (68%) of 31 patients in the immediate surgery and 30 (55%) of 55 patients in the combined neoadjuvant therapy groups underwent resection (p=0·33). R0 resection was achieved in three (14%) of 21 patients in the immediate surgery group and seven (23%) of 30 in the neoadjuvant therapy groups combined (p=0·49). Surgical complications were observed in 29 (43%) of 68 patients who underwent surgery; no patients died within 30 days. 46 (84%) of 55 patients receiving neoadjuvant therapy were available for restaging. Six (13%) of 46 had a partial response. Median follow-up time was 12·2 months (95% CI 12·0-12·4). 1-year overall survival was 39% (95% CI 24-61) for immediate surgery, 78% (60-100) for gemcitabine plus capecitabine, 84% (70-100) for FOLFIRINOX, and 60% (37-97) for capecitabine-based chemoradiotherapy (p=0·0028). 1-year disease-free survival from surgery was 33% (95% CI 19-58) for immediate surgery and 59% (46-74) for the combined neoadjuvant therapies (hazard ratio 0·53 [95% CI 0·28-0·98], p=0·016). Three patients reported local disease recurrence (two in the immediate surgery group and one in the FOLFIRINOX group). 78 (91%) patients were included in the safety set and assessed for toxicity events. 19 (24%) of 78 patients reported a grade 3 or worse adverse event (two [7%] of 28 patients in the immediate surgery group and 17 [34%] of 50 patients in the neoadjuvant therapy groups combined), the most common of which were neutropenia, infection, and hyperglycaemia. INTERPRETATION: Recruitment was challenging. There was no significant difference in resection rates between patients who underwent immediate surgery and those who underwent neoadjuvant therapy. Short-course (8 week) neoadjuvant therapy had a significant survival benefit compared with immediate surgery. Neoadjuvant chemotherapy with either gemcitabine plus capecitabine or FOLFIRINOX had the best survival compared with immediate surgery. These findings support the use of short-course neoadjuvant chemotherapy in patients with borderline resectable pancreatic ductal adenocarcinoma. FUNDING: Cancer Research UK.

Impact of SARS-CoV-2 pandemic on pancreatic cancer services and treatment pathways: United Kingdom experience.

INTRODUCTION: The SARS-CoV-2 pandemic presented healthcare providers with an extreme challenge to provide cancer services. The impact upon the diagnostic and treatment capacity to treat pancreatic cancer is unclear. This study aimed to identify national variation in treatment pathways during the pandemic. METHODS: A survey was distributed to all United Kingdom pancreatic specialist centres, to assess diagnostic, therapeutic and interventional services availability, and alterations in treatment pathways. A repeating methodology enabled assessment over time as the pandemic evolved. RESULTS: Responses were received from all 29 centres. Over the first six weeks of the pandemic, less than a quarter of centres had normal availability of diagnostic pathways and a fifth of centres had no capacity whatsoever to undertake surgery. As the pandemic progressed services have gradually improved though most centres remain constrained to some degree. One third of centres changed their standard resectable pathway from surgery-first to neoadjuvant chemotherapy. Elderly patients, and those with COPD were less likely to be offered treatment during the pandemic. CONCLUSION: The COVID-19 pandemic has affected the capacity of the NHS to provide diagnostic and staging investigations for pancreatic cancer. The impact of revised treatment pathways has yet to be realised.

A training tool to assess laparoscopic image navigation task performance in novice camera assistants.

BACKGROUND: A number of tools for assessing task performance of the laparoscopic camera assistant have been described, but few focus on the acquisition and assessment of the attainment of proficiency in novice laparoscopic camera assistants. Our aim was to develop a simulated objective assessment tool for a novice camera assistant. MATERIALS AND METHODS: A 10-cycle image navigation task tool was developed. This involved a series of 360° clockwise and anticlockwise rotation maneuvers of a 30° laparoscope along its shaft, focusing on a predefined geometric target on a 45° fixed slope in a laparoscopic box trainer. The tasks were to simultaneously maintain neutral horizon, optimum distance, and centering. Task accuracy and time to completion were assessed objectively at 3-s intervals on an unedited video recording. RESULTS: Twenty-nine novice medical students were assessed. Novices improved mean total error and task completion time (first versus fifth cycle, mean errors 15.4 versus 8.4, P = 0.048; mean task time 158.1 versus 92.9 s, P = 0.04). This improvement continued until the task cycle was completed (sixth versus 10th cycles, 7.9 versus 6.2, P = 0.01; 91.9 versus 76.6 s, P < 0.0001). There was a significant decrease in centering errors (5.2 versus 2.4, P = 0.001) and horizon (4.8 versus 2.3, P = 0.004), when comparing the first versus fifth task cycle. It took six cycles for optimum distance to achieve significance (5.4 versus 3.3, P = 0.023). CONCLUSIONS: Using our assessment tool, novices achieved an objective proficiency-gain curve for laparoscopic camera navigation tasks. There was improvement in errors related to maintaining horizon, optimum distance, and centering. Mean task completion time also decreased. This tool could be used as an additional mean of assessment and training in novice surgical trainees.

Ureterorenoscopy training on cadavers embalmed by Thiel's method: simulation or a further step towards reality? Initial report.

INTRODUCTION: The technique of ureterorenoscopy has a significant learning curve. Cadavers embalmed by the Thiel method have been successfully used for simulation training in a number of surgical specialties. Here we present our experience of the first use of Thiel cadavers in a formal ureteroscopy training course. MATERIAL AND METHODS: The inaugural 'Masterclass in Flexible Ureterorenoscopy' was run with participants performing ureterorenoscopy on three Thiel cadavers under expert supervision. A qualitative questionnaire was delivered to the participants and faculty. Assessed domains were tissue characteristics of the cadaveric urinary tract, anatomical features and procedural aspects. A five-point Likert score was used to assess responses. Data regarding participant experience in endourology were also collected. RESULTS: 8 questionnaires were collected. All participants completed cadaveric ureterorenoscopy. Three-quarters reported the overall quality of tissue in the cadaveric bladder, ureters and pelvicalyceal system as high or excellent. Half reported the cadaveric bladder as being softer than in a live patient, whilst five out of eight thought that the cadaveric ureter was softer and more prone to trauma. Seven out of eight were satisfied with the overall quality of the cadaveric model. The quality of vision and irrigation in the upper urinary tracts was reported as high. CONCLUSIONS: Thiel cadavers have been shown to have excellent tissue characteristics, as well as being durable and reusable. We have described the first use of Thiel cadavers in a designated ureterorenoscopy course, with high levels of delegate satisfaction. Further work is required to develop the role of Thiel cadavers as part of an integrated, modular urology training.

Development and Validation of a Novel and Cost-Effective Animal Tissue Model for Training Transurethral Resection of the Prostate.

OBJECTIVES: To develop and validate a new and cost-effective animal tissue training model for practicing resection skills of transurethral resection of the prostate (TURP). METHODS AND MATERIALS: A porcine kidney was prepared and restructured to simulate the relevant anatomy of the human prostate. The restructured prostate was connected to an artificial urethra and bladder. Face, content, and construct validity of the model was carried out using a 5-point Likert scale questionnaire, and comparison in task performance between participants and experts was made using observational clinical human reliability analysis. RESULTS: A total of 24 participants and 11 experts who practiced TURP skills on this model from October 2014 to December 2015 were recruited. The mean score on specific feature of the anatomy and color, sensation of texture and feeling of resection, conductibility of current, and efficacy and safety of the model were 4.34 ± 0.37, 4.51 ± 0.63, 4.13 ± 0.53, and 4.35 ± 0.71, respectively, by participants whereas they were 4.22 ± 0.23, 4.30 ± 0.48, 4.11 ± 0.62, and 4.56 ± 0.77, respectively, by the experts on a scale of 1 (unrealistic) to 5 (very realistic). Participants committed more technical errors than the experts (11 vs 7, p < 0.001), produced more movements of the instruments (51 vs 33, p < 0.001), and required longer operating time (11.4 vs 6.2min, p < 0.001). CONCLUSIONS: A newly developed restructured animal tissue model for training TURP was reported. Validation study on the model demonstrates that this is a very realistic and effective model for skills training of TURP. Trainees committed more technical errors, more unproductive movements, and required longer operating time.

Vascular resection in pancreaticoduodenectomy for periampullary cancers. A 10 year retrospective cohort study.

BACKGROUND: Pancreaticoduodenectomy (PD) is the only chance of cure for periampullary cancers. This study aims to evaluate survival and complication rates for PD with additional vascular resection performed for local vascular involvement and compare to standard PD. MATERIALS AND METHODS: A retrospective cohort analysis of a departmental hepato-pancreatobiliary database from 2004 to 2014 was performed. All patients (n = 92) who underwent PD without vascular resection (n = 72), with venous resection (n = 16), with both arterial and venous resection (n = 4) were included in the study. Patients who received palliative double bypass (n = 6) were also included for survival analysis. Survival and post-operative complications were assessed. RESULTS: Median survival for standard PD and PD with venous resection was 21 months and 18 months respectively (P = 0.588). Patients who received PD with venous and arterial resection had a median survival of 7 months, significantly less than standard PD (P = 0.044). Median survival in the palliative bypass group was 4 months, comparable to PD with venous and arterial resection (P = 0.191). There was a significant survival advantage in patients who received an R0 resection (median survival 24 months) compared to those who received an R1 resection (median survival 18 months) (P < 0.02). Patients with a lymph node ratio <0.2 had a median survival of 25 months, which was significantly higher than that of patients who had a lymph node ratio ≥0.2 (9 months) (P < 0.005). CONCLUSION: PD with venous resection has similar survival to standard PD with no increased risk of procedure specific post-operative complications. On the other hand, PD with venous resection and additional arterial resection has no survival benefit and may be a step too far in our experience.

The effect of a simple intraprocedural checklist on the task performance of laparoscopic novices.

BACKGROUND: Surgical checklists are used for error reduction. Checklists are infrequently applied during procedures and have been limited to lists of procedural steps as aid memoires. We aimed to study the effect of a self-administered checklist on the laparoscopic task performance of novices during a standardized task. METHODS: Twenty novices were randomized into 2 equal groups, those receiving paper feedback (control group) and those receiving paper feedback and the checklist (checklist group). Subjects performed laparoscopic double knots, repeated over 5 separate stages. Human reliability assessment technique was used for error analysis. RESULTS: 2,341 errors were detected during the 5 stages. During the first stage, the errors were not significantly different between the 2 groups. The checklist group committed significantly fewer errors as compared with the control group during all the later 4 stages (P < .01). CONCLUSIONS: The simple intraprocedural checklist significantly improved the laparoscopic task performance and the learning curve of laparoscopic novices.

Spot urinary 5-hydroxyindoleacetic acid is not an ideal diagnostic test for acute appendicitis.

BACKGROUND AND PURPOSE OF THE STUDY: There is growing evidence to suggest the use of urinary 5-hydroxyindoleacetic acid (5-HIAA) test to help with the diagnosis of appendicitis. The aim of our study was to establish whether urinary 5-HIAA could be used as an effective diagnostic test for acute appendicitis. DESIGN AND METHODS: A prospective double-blinded study was carried out from December 2014 to October 2015. Patients admitted to the emergency surgical ward of a teaching hospital with suspected appendicitis were included in the study. The diagnostic accuracy of the test was measured by receiver operating characteristic curve. RESULTS: Ninety-seven patients were divided into 2 groups: acute appendicitis (n=38) and other diagnosis (n=59). The median value of urinary 5-HIAA was 24.19µmol/L (range, 5.39-138.27) for acute appendicitis vs 18.87µmol/L (range, 2.27-120.59) for other diagnosis group (P=.038). The sensitivity and specificity of urinary 5-HIAA at a cutoff value of 19µmol/L were 71% and 50%, respectively. Receiver operating characteristic analysis showed that the area under curve was 0.64 (confidence interval [CI], 0.513-0.737) for urinary 5-HIAA, which was lower than white blood cell count (0.69; CI, 0.574-0.797), neutrophil count (0.68; CI, 0.565-0.792), and C-reactive protein (0.76; CI, 0.657-0.857). There was no significant difference in the median values of 5-HIAA between different grades of severity of appendicitis (P=.704). CONCLUSION: Urinary 5-HIAA is not an ideal test for the diagnosis of acute appendicitis.

Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis.

BACKGROUND: With advances in laparoscopic instrumentation and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) is technically feasible and increasingly practiced by surgeons worldwide. Traditional practice of suturing the dochotomy with T-tube drainage may be associated with T-tube-related complications. Primary duct closure (PDC) without a T-tube has been proposed as an alternative to T-tube placement (TTD) after LCBDE. The aim of this meta-analysis was to evaluate the safety and effectiveness of PDC when compared to TTD after LCBDE for choledocholithiasis. METHODS: A systematic literature search was performed using PubMed, EMBASE, MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases for studies comparing primary duct closure and T-tube drainage. Studies were reviewed for the primary outcome measures: overall postoperative complications, postoperative biliary-specific complications, re-interventions, and postoperative hospital stay. Secondary outcomes assessed were: operating time, median hospital expenses, and general complications. RESULTS: Sixteen studies comparing PDC and TTD qualified for inclusion in our meta-analysis, with a total of 1770 patients. PDC showed significantly better results when compared to TTD in terms of postoperative biliary peritonitis (OR 0.22, 95% CI 0.06-0.76, P = 0.02), operating time (WMD, -22.27, 95% CI -33.26 to -11.28, P < 0.00001), postoperative hospital stay (WMD, -3.22; 95% CI -4.52 to -1.92, P < 0.00001), and median hospital expenses (SMD, -1.37, 95% CI -1.96 to -0.77, P < 0.00001). Postoperative hospital stay was significantly decreased in the primary duct closure with internal biliary drainage (PDC + BD) group when compared to TTD group (WMD, -2.68; 95% CI -3.23 to -2.13, P < 0.00001). CONCLUSIONS: This comprehensive meta-analysis demonstrates that PDC after LCBDE is feasible and associated with fewer complications than TTD. Based on these results, primary duct closure may be considered as the optimal procedure for dochotomy closure after LCBDE.

Liver retraction system by C3-muco-adhesive polymer films for laparoscopic surgery.

BACKGROUND: Conventional laparoscopic instruments used for retraction may cause trauma at the retraction site. Alternative retraction/lifting especially of heavy solid organs such as the liver may be obtained by other means. The present study was designed to explore the use of C3-muco-adhesive polymers (C3-MAPs), which exhibit strong binding to the liver shortly after application to the organ and which retain strong adhesion for sufficient time, to enable sustained retraction during laparoscopic operations. METHODS AND MATERIALS: C3-muco-adhesive polymers were produced specifically for the study. In an ex vivo experimental set-up, discs of C3-MAPs were placed on the surface of porcine livers for adhesion and retraction studies involving objective measurements by tensiometry. RESULTS: Experiments were carried out on 14 porcine livers. The force required to detach the C3-MAPs from the liver exceeded 2.0 N 30 s after application. The adhesion force by C3-MAPs files was sufficient to enable sustained retraction force necessary for exposure of the gall bladder, which was achieved by a mean retraction force of 4.85 N (SD = 0.63). This was sustained for a mean of 130 min (range 17.0-240.0). In the adhesion studies, the forces at 30 s required to detach the polymer discs from the liver exceeded 20 N (upper limit of the load cells of the Instron). The duration of the adhesion enabled sustained optimal gall bladder exposure for periods ranging from 17 to 240 min, with a mean of 130 ± 91 min. CONCLUSIONS: The results of the present study demonstrate that the adhesion and retraction properties of the engineered C3-MAP films are sufficient to enable complete exposure of the gall bladder for a period exceeding 1 h, confirming their potential for atraumatic retraction in laparoscopic and other minimal-access surgical approaches.

The effect of divided attention on novices and experts in laparoscopic task performance.

BACKGROUND: Attention is important for the skilful execution of surgery. The surgeon's attention during surgery is divided between surgery and outside distractions. The effect of this divided attention has not been well studied previously. We aimed to compare the effect of dividing attention of novices and experts on a laparoscopic task performance. METHODS: Following ethical approval, 25 novices and 9 expert surgeons performed a standardised peg transfer task in a laboratory setup under three randomly assigned conditions: silent as control condition and two standardised auditory distracting tasks requiring response (easy and difficult) as study conditions. Human reliability assessment was used for surgical task analysis. Primary outcome measures were correct auditory responses, task time, number of surgical errors and instrument movements. Secondary outcome measures included error rate, error probability and hand specific differences. Non-parametric statistics were used for data analysis. RESULTS: 21109 movements and 9036 total errors were analysed. Novices had increased mean task completion time (seconds) (171 ± 44SD vs. 149 ± 34, p < 0.05), number of total movements (227 ± 27 vs. 213 ± 26, p < 0.05) and number of errors (127 ± 51 vs. 96 ± 28, p < 0.05) during difficult study conditions compared to control. The correct responses to auditory stimuli were less frequent in experts (68 %) compared to novices (80 %). There was a positive correlation between error rate and error probability in novices (r (2) = 0.533, p < 0.05) but not in experts (r (2) = 0.346, p > 0.05). CONCLUSION: Divided attention conditions in theatre environment require careful consideration during surgical training as the junior surgeons are less able to focus their attention during these conditions.

Pancreatic glucagonoma metastasising to the right ovary five years after initial surgery: a case report.

CONTEXT: Glucagonomas of the pancreas are neuroendocrine tumours (NETs) that arise from well-differentiated neuroendocrine cells within the pancreatic islets. They are considered to be aggressive NETs and often have metastases at initial presentation. In contrast localised glucagonoma without metastatic spread may have prolonged disease free survival with radical resectional surgery. CASE REPORT: The authors present a case of a glucagonoma that initially presented with classical necrolytic migratory erythema and a large solitary mass in the body and tail of the pancreas that was surgically resected. Five years after surgery the patient presented with increased serum glucagon levels and a mass in the right ovary. Pathology of the resected ovary after oophorectomy identified this as an isolated metastatic glucagonoma. CONCLUSION: Glucagonoma is a rare pancreatic NET that has significant malignant potential. This is the first case of a pancreatic glucagonoma metastasising to the ovary 5 years after radical distal pancreatosplenectomy.

Centralization of services and reduction of adverse events in pancreatic cancer surgery.

BACKGROUND: The perioperative period is critical in the outcome for patients with pancreatic cancer. The aim of the present analysis was to examine adverse events in patients dying under surgical care in relation to changes in the organization of pancreatic cancer surgery. METHODS: From 1996 to 2005, 1,033 patients with pancreatic cancer, mean age of 71 years (range 21-97 years) died under surgical care. The incidence, mortality, and number of operations for pancreatic cancer remained stable across the time period, but the proportion of patients undergoing surgery in the five specialist cancer centers increased from 50 to 80 % (p < 0.001). Prior to death 260 (25 %) patients underwent operation and 96 (9 %) had endoscopic retrograde cholangiopancreatography (ERCP). There was a significant rise in ERCP (p = 0.03) and a decrease in non-resectional operations (p = 0.001). RESULTS: Since 1996, 52 (15 %) patients in whom 90 adverse events were recorded died following surgical intervention: 28 adverse events related to the perioperative period with 15 due to direct procedure complications such as bleeding or anastomotic leak; 13 were attributed to decision making around the choice or timing of the procedure. The postoperative mortality after curative pancreatic resection reduced from 3.5 to 1.8 %. Identified adverse events fell significantly in patients who died relating to the operative period (median of 3 per annum [1994-2000] to 1 per annum [2001-2005]) (p = 0.014) and medical care (3-0) (p = 0.003). CONCLUSIONS: Continuous peer review audit has demonstrated a reduction in the number of adverse events in patients dying with pancreatic cancer under surgical care as increased numbers of patients treated in specialist cancer centers.

The role of interventional radiology in the management of surgical complications after pancreatoduodenectomy.

OBJECTIVES: This study evaluates the role of interventional radiology (IR) in the management of postoperative complications after pancreatoduodenectomy (PD). METHODS: A total of 120 consecutive patients were reviewed to identify IR procedures performed for early complications after PD. RESULTS: Findings showed that 24 patients (20.0%) required urgent radiological or surgical re-intervention for early complications, including 11 instances of post-pancreatectomy haemorrhage (PPH), six intra-abdominal abscesses, two bile leaks, one pancreatic fistula and one bowel ischaemia. Three of 24 complications were managed by surgery and 21 were managed by IR. Two of 11 PPHs involved intraluminal haemorrhage (ILH) and nine involved intra-abdominal haemorrhage (IAH). One ILH was managed conservatively and one required surgical intervention. In eight of nine patients with IAH, the bleeding site was identified on computed tomography angiography, and endovascular stenting or coil embolization were performed. No patient required a re-look laparotomy following IR for haemorrhage or intra-abdominal abscess. Overall, three of 120 patients required an urgent re-look laparotomy for early complications. CONCLUSIONS: Rates of major morbidity after PD remain high. However, many significant complications (PPH, pancreatic fistula, intra-abdominal abscess) can be managed by IR, reducing the need for reoperation. Re-look surgery is still required in a small percentage (2.5%) of patients.

Totally laparoscopic strategies for the management of colorectal cancer with synchronous liver metastasis.

INTRODUCTION: Laparoscopy is an accepted treatment for colorectal cancer and liver metastases, but there is no consensus for its use in the management of synchronous liver metastases (SCRLM). The purpose of this study was to evaluate totally laparoscopic strategies in the management of colorectal cancer with synchronous liver metastases. METHODS: Patients presenting to Ninewells Hospital between July 2007 and August 2010, with adenocarcinoma of the colon and rectum with synchronous liver metastases were considered. Patients underwent simultaneous laparoscopic liver and colon cancer resection, a staged laparoscopic resection of SCRLM and colon cancer, or simultaneous colon resection and radiofrequency ablation (RFA) of SCRLM. Primary endpoints were in-hospital morbidity and mortality, total hospital stay, intraoperative blood loss, duration of surgery, and resection margin status. RESULTS: Twenty-eight patients presented with synchronous colorectal liver metastases. Thirteen patients underwent a simultaneous laparoscopic liver and colon resection (median operating time, 370 (range, 190-540) min; median hospital stay, 7 (range, 3-54) days), seven patients had a staged laparoscopic resection of SCRLM and primary colon cancer (median operating time, 530 (range, 360-980) min; median hospital stay 14, (range, 6-51) days), and eight patients underwent laparoscopic colon resection and RFA of SCRLM (median operating time, 310 (range, 240-425) min; median hospital stay, 8 (range, 6-13) days). There were no conversions to an open procedure. Overall in-hospital morbidity and mortality was 28 and 0 % respectively. An R0 resection margin was achieved in 91 % of the resection group. At a median follow-up of 26 (range, 18-55) months, 19 (90 %) patients remain disease-free. CONCLUSIONS: Totally laparoscopic strategies for the radical treatment of stage IV colorectal cancer are feasible with low morbidity and favorable outcomes. A laparoscopic approach for the simultaneous management of SCRLM and primary colon cancer is associated with reduced surgical access trauma, postoperative morbidity, and hospital stay with no compromise in short-term oncological outcome.

Preoperative serum C-reactive protein levels and post-operative lymph node ratio are important predictors of survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.

CONTEXT: There is paucity of data on the prognostic value of pre-operative inflammatory response and post-operative lymph node ratio on patient survival after pancreatic-head resection for pancreatic ductal adenocarcinoma. OBJECTIVES: To evaluate the role of the preoperative inflammatory response and postoperative pathology criteria to identify predictive and/or prognostic variables for pancreatic ductal adenocarcinoma. DESIGN: All patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma between 2002 and 2008 were reviewed retrospectively. The following impacts on patient survival were assessed: i) preoperative serum CRP levels, white cell count, neutrophil count, neutrophil/lymphocyte ratio, lymphocyte count, platelet/lymphocyte ratio; and ii) post-operative pathology criteria including lymph node status and lymph node ratio. RESULTS: Fifty-one patients underwent potentially curative resection for pancreatic ductal adenocarcinoma during the study period. An elevated preoperative CRP level (greater than 3 mg/L) was found to be a significant adverse prognostic factor (P=0.015) predicting a poor survival, whereas white cell count (P=0.278), neutrophil count (P=0.850), neutrophil/lymphocyte ratio (P=0.272), platelet/lymphocyte ratio (P=0.532) and lymphocyte count (P=0.721) were not significant prognosticators at univariate analysis. Presence of metastatic lymph nodes did not adversely affect survival (P=0.050), however a raised lymph node ratio predicted poor survival at univariate analysis (P<0.001). The preoperative serum CRP level retained significance at multivariate analysis (P=0.011), together with lymph node ratio (P<0.001) and tumour size (greater than 2 cm; P=0.008). CONCLUSION: A pre-operative elevated serum CRP level and raised post-operative lymph node ratio represent significant independent prognostic factors that predict poor prognosis in patients undergoing curative resection for pancreatic ductal adenocarcinoma. There is potential for future neo-adjuvant and adjuvant treatment strategies in pancreatic cancer to be tailored based on preoperative and postoperative factors that predict a poor survival.

Development and use of a restructured animal tissue model for training in laparoscopic salpingostomy and salpingectomy.

Ectopic pregnancy is commonly managed via either laparoscopic salpingostomy or salpingectomy. However, there is a proficiency gain curve in mastering these 2 surgical procedures, and an effective simulated model is essential for training students of gynecology. The objective of this study was to develop and evaluate a restructured animal tissue model that can be used in the surgical training of gynecologists in laparoscopic salpingostomy and salpingectomy. Since 2005, a hands-on laparoscopic training course for gynecologic students has been developed and conducted at the Cushieri Skills Centre, University of Dundee. A restructured animal tissue model of ectopic pregnancy was developed and used for practicing laparoscopic salpingostomy and salpingectomy. At the end of each course, data were collected using a standardized anonymous questionnaire using a Likert scale (1= strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; and 5 = strongly agree). Feedback on the ectopic pregnancy model from course participants was obtained insofar as the realism of the anatomical condition of the model, quality of the tissue and organ color, quality of organ consistency, and operative tactile properties during dissection. Over the last 6 years, from June 2005 to September 2010, 96 gynecologic trainees have practiced using this phantom. The mean (SD) overall satisfaction rate for the training phantom for laparoscopic salpingostomy and salpingectomy was 4.9 (0.1) on a scale of 1(unrealistic/poor) to 5 (very realistic/useful). Compared with real operating conditions, quality assessment of the model for anatomical condition was 4.9 (0.2), for quality of tissue and organ color was 4.9 (0.4), for organ consistency was 4.8 (0.3), and for operative tactility was 4.8 (0.6). It was concluded that the restructured animal tissue model of laparoscopic salpingostomy and salpingectomy in ectopic pregnancy is realistic, cost-effective, and simple enough to be produced for use in laboratory-based surgical training courses.

Impact of methicillin-resistant Staphylococcus Aureus (MRSA) infection on patient outcome after pancreatoduodenectomy (PD)--a cause for concern?

OBJECTIVES: This study evaluated the impact of methicillin-resistant Staphylococcus aureus (MRSA) hospital-acquired infection on postoperative complications and patient outcome after pancreatoduodenectomy (PD). METHODS: Seventy-nine patients who underwent PD were monitored for hospital-acquired MRSA. The patients were grouped as (1) no MRSA infection, (2) skin colonization with MRSA, and (3) systemic MRSA infection. RESULTS: Forty (51%) of the 79 patients were MRSA positive during hospital admission. Fourteen of the 40 patients swabbed for MRSA were found positive (skin colonization), and 26 patients (33%) developed systemic MRSA infection after PD. The sites of MRSA infection included (1) abdominal drain fluid (16/26; 42%), (2) sputum (4/26; 15%), (3) blood cultures (2/26; 8%), and (4) combination of sites (9/26; 35%). The patients with systemic MRSA infection had a longer postoperative stay (31 vs 22 days; P = 0.005) and increased incidence of chest infections compared with MRSA-negative patients (14 vs 4; P = 0.02). Four of the 16 patients with MRSA-positive drain fluid had a postpancreatectomy hemorrhage compared with 3 of the 63 patients with no MRSA infection in drain fluid (P = 0.02). CONCLUSION: Of the 79 patients admitted for PD, 51% became colonized with MRSA infection. Systemic hospital-acquired MRSA infection in 33% was associated with prolonged postoperative stay, increased wound and chest infections, and increased risk of postoperative hemorrhage.

Late post pancreatectomy haemorrhage. Risk factors and modern management.

CONTEXT: Current management of late post-pancreatectomy haemorrhage in a university hospital. OBJECTIVE: Haemorrhage after pancreaticoduodenectomy is a serious complication. We report on risk factors and outcome following management by radiological intervention. SETTING: Tertiary care centre in Scotland. SUBJECTS: Sixty-seven consecutive patients who underwent pancreaticoduodenectomy. METHODS: All pancreaticoduodenectomies over a 3-year period were reviewed. International Study Group on Pancreatic Surgery (ISGPS) definition of post-pancreatectomy haemorrhage was used. MAIN OUTCOME MEASURES: Endpoints were incidence of haemorrhage, pancreaticojejunal anastomosis leak, methicillin-resistant Staphylococcus aureus (MRSA) infection and mortality. RESULTS: Seven patients (10.4%) developed post-pancreatectomy haemorrhage out of 67 pancreaticoduodenectomies. Median age was 71 years. All post-pancreatectomy haemorrhage were late onset (median 23 days; range: 3-35 days), extraluminal and ISGPS grade C. Post-pancreatectomy haemorrhage arose from hepatic artery (n=4), superior mesenteric artery (n=1), jejunal artery (n=1), and splenic artery (n=1). Angiographic treatment was successful in all patients by embolisation (n=5) or stent grafting (n=2). Pancreatic fistula rate was similar in post-pancreatectomy haemorrhage and "no-haemorrhage" groups (57.1% vs. 40.0%; P=0.440); MRSA infection was significantly higher in post-pancreatectomy haemorrhage group (57.1% vs. 16.7%; P=0.030). Mortality from post-pancreatectomy haemorrhage despite successful haemostasis was 42.9%. Univariate and multivariate analysis identified MRSA infection as a risk factor for post-pancreatectomy haemorrhage. CONCLUSION: CT angiogram followed by conventional catheter angiography is effective for treatment of late extraluminal post-pancreatectomy haemorrhage. MRSA infection in the abdominal drain fluid increases its risk and therefore aggressive treatment of MRSA and high index of suspicion are indicated.

Management guidelines for gallstone pancreatitis. Are the targets achievable?

CONTEXT: Current management of gallstone pancreatitis in a university hospital. OBJECTIVE: Comparison of current management of gallstone pancreatitis with recommendations in national guidelines. SETTING: Tertiary care centre in Scotland. SUBJECTS: One-hundred consecutive patients admitted with gallstone pancreatitis. METHODS: All patients that presented with gallstone pancreatitis over a 4-year period were audited retrospectively. Data were collated for radiological diagnosis within 48 hours, ERCP within 72 hours, CT at 6-10 days, and use of high-dependency or intensive therapy units in severe gallstone pancreatitis, and definitive treatment of gallstone pancreatitis within 2 weeks as recommended in national guidelines. RESULTS: Forty-six patients had severe gallstone pancreatitis and 54 patients mild pancreatitis. Etiology was established within 48 hours in 92 patients. Six (13.0%) out of the patients with severe gallstone pancreatitis were managed in a high dependency unit. Fifteen (32.6%) patients with severe gallstone pancreatitis underwent CT within 6-10 days of admission. Four (8.7%) of the 46 patients with severe gallstone pancreatitis had urgent ERCP (less than 72 hours). Overall 22/100 patients unsuitable for surgery underwent endoscopic sphincterotomy as definitive treatment. Seventy-eight patients had surgery, with 40 (51.3%) of these patients undergoing an index admission cholecystectomy, and 38 (48.7%) patients were discharged for interval cholecystectomy. Overall 81 patients with gallstone pancreatitis had definitive therapy during the index to same admission (cholecystectomy or sphincterotomy). Two (5.3%) patients were readmitted whilst awaiting interval cholecystectomy: one with acute cholecystitis and one with acute pancreatitis. There were no mortalities in this cohort. CONCLUSION: This study has highlighted difficulties in implementation of national guidelines, as the use of critical care, timing of ERCP and CT, and definitive treatment prior to discharge did not concur with national targets for gallstone pancreatitis.