Para-aortic lymph node sampling in pancreatic head adenocarcinoma.

BACKGROUND: The significance of positive para-aortic nodes in patients with resectable pancreatic carcinoma is unclear. This study sought to evaluate the accuracy of intraoperative detection and prognostic significance of these lymph nodes in patients with resected adenocarcinoma of the pancreatic head. METHODS: From 2000 to 2010, para-aortic node sampling was performed prospectively in all patients before pancreatoduodenectomy. Frozen sections were created and nodes categorized as positive or negative for metastases. Surgeons were blinded to the frozen-section results. This was followed by standard histopathological assessment of corresponding paraffin-embedded, haematoxylin and eosin-stained material. Nodes considered uninvolved by this analysis were examined immunohistochemically for micrometastases. RESULTS: A total of 111 consecutive patients were included, with a median follow-up of 20·8 (range 1·5-126) months. The 1-, 2- and 5-year overall survival (OS) and disease-free survival (DFS) rates were 73·6, 54·0 and 24·7 per cent, and 51·8, 28·1 and 18·8 per cent respectively. Para-aortic node involvement was always associated with peripancreatic lymph node metastasis, and was detected by frozen-section analysis in 12 patients and by haematoxylin and eosin staining in 17. Sensitivity and specificity of frozen-section examination for detecting para-aortic lymph node metastases were 71 and 100 per cent respectively. Median OS for patients with and without para-aortic node involvement on frozen-section analysis was 9·7 versus 28·5 months respectively (P = 0·012), and 15·7 versus 27·2 months (P = 0·050) when assessed by haematoxylin and eosin staining. Median DFS for patients with and without para-aortic node involvement on frozen-section examination was 5·6 versus 12·9 months respectively (P = 0·041), and 8·4 versus 12·9 months (P = 0·038) for haematoxylin and eosin analysis. The presence of micrometastases in para-aortic nodes was not significantly associated with altered OS or DFS. CONCLUSION: Para-aortic node sampling with frozen-section examination detects distant lymphatic involvement reliably. It should be performed systematically. When metastases are found, they should be considered a contraindication to pancreatic resection.

Esophagojejunostomy after total gastrectomy for caustic injuries.

The objective of the study was to compare outcomes of emergency esophagogastrectomy (EGT) and total gastrectomy with immediate esophagojejunostomy (EJ) in patients with full-thickness caustic necrosis of the stomach and mild esophageal injuries. After caustic ingestion, optimal management of the esophageal remnant following removal of the necrotic stomach remains a matter of debate. Between 1987 and 2012, 26 patients (men 38%, median age 44 years) with isolated transmural gastric necrosis underwent EGT (n = 14) or EJ (n = 12). Early and long-term outcomes of both groups were compared. The groups were similar regarding age (P = 0.66), gender (0.24), and severity of esophageal involvement. Functional success was defined as nutritional autonomy after removal of the jejunostomy and tracheotomy tubes. Emergency morbidity (67% vs. 64%, P = 0.80), mortality (17% vs. 7%, P = 0.58), and reoperation rates (25% vs.14%, P = 0.63) were similar after EJ and EGT. One patient (8%) experienced EJ leakage. One patient in the EJ group and 13 patients in the EGT group underwent esophageal reconstruction (P < 0.0001). Aggregate in hospital length of stay was significantly longer in patients who underwent EGT (median 83 [33-201] vs. 36 [10-82] days, P = 0.001). Functional success after EJ and EGT was similar (90% vs.69%, P = 0.34). Immediate EJ can be safely performed after total gastrectomy for caustic injuries and reduces the need of further esophageal reconstruction.

Number of examined lymph nodes and nodal status assessment in pancreaticoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND: The accuracy of the assessment of the nodal status in resected cephalic pancreatic adenocarcinoma (PA) depends on the number of examined lymph nodes (NELN). This study assesses the impact of the NELN on N staging and survival and propose a minimal number of examined lymph nodes (MNELN) ensuring reliability of the pN status determination. METHODS: 188 consecutive patients treated by pancreaticoduodenectomy (PD) for PA. Correlations between NELN and survivals of pN0 and pN1 groups and with the rate of pN1 patients were studied. A probability model based on the binomial law was built to estimate the MNELN able to detect pN1 patients with a sensitivity ≥ 95%. RESULTS: Overall and disease free 5-year survivals were 27.2% and 24.6% respectively. 135 patients (71.8%) were staged pN1. The median NELN was 17 (range 0-68). Overall and disease free survivals of pN1 patients were not related to NELN. The influence of NELN on survival in pN0 patients due to stage migration did not reach significance. The probability model showed that a MNELN of 16 nodes was required to detect pN1 patients with a sensitivity of 95%. CONCLUSION: A MNELN of 16 is required to assess pN status and should be considered as a quality criterion in future studies and trials on PD for PA.