How to Reliably Assess Nodal Status in Distal Pancreatectomy for Adenocarcinoma.

OBJECTIVES: The optimal number of lymph nodes that need to be analyzed to reliably assess nodal status in distal pancreatectomy for adenocarcinoma is still unknown. METHODS: Two hundred seventy-eight patients who underwent distal pancreatectomy for adenocarcinoma were retrieved from a retrospective French nationwide database. The relations between the number of analyzed lymph nodes and the nodal status of the tumor were studied. The beta-binomial law was used to estimate the probability of being truly node negative depending on the number of analyzed lymph nodes. Cox proportional hazard model was used for the survival analysis. RESULTS: The median number of analyzed lymph nodes was 15. There was a positive correlation between the number of positive lymph nodes and the number of lymph nodes analyzed. The curve reached a plateau at approximately 25 lymph nodes. The beta binomial model demonstrated that an analysis of 21 negative lymph nodes shows a probability to be truly N0 at 95%. N+ status was associated with survival, but the number of lymph node analyzed was not. CONCLUSION: At least 21 lymph nodes should be analyzed to ensure a reliable assessment of the nodal status, but this number may be hard to reach in distal pancreatectomy.

Tracheobronchial Necrosis After Caustic Ingestion.

OBJECTIVE: The aim of this study was to describe the management and outcome of tracheobronchial necrosis (TBN) after caustic ingestion. BACKGROUND: Emergency pulmonary patch repair has been reported to be lifesaving in patients with caustic TBN. METHODS: Patients who underwent management of caustic TBN between 1989 and 2013, were included. TBN was defined as early if present on admission and late if occurring thereafter. Operative outcomes, long-term survival, and functional outcomes were compared with those of 269 patients without TBN who underwent esophagectomy for caustic injuries. RESULTS: Twenty patients were included (10 men; median age = 39 years). Early TBN was detected in 14 patients, and late TBN occurred in 7 patients, 8 days (range:: 6-10 days) after admission. TBN involved the left bronchus (n = 17; 85%), the carina (n = 10; 50%), the supracarinal trachea (n = 9; 45%), the right bronchus (n = 4; 20%), and the cervical trachea (n = 3; 15%). Seventeen patients underwent esophagogastrectomy, 2 underwent esophagectomy, and in 1 patient, resection was eventually abandoned. Pulmonary patch repair was performed in 16 patients (80%). Nine patients (45%) died and morbidity was 100%. In univariate analysis, late TBN (P = 0.017) and acid ingestion (P = 0.002) were predictors of mortality. All survivors underwent restoring colopharyngoplasty. Five-year survival (28%) and functional success (25%) rates were significantly impaired when compared with esophagectomy patients without TBN. CONCLUSIONS: TBN is one of the most devastating complications of caustic ingestion. Pulmonary patch repair is technically simple and can be lifesaving in this difficult situation.

Laparoscopic partial splenectomy: a technical tip.

BACKGROUND: Increased awareness of asplenia-related life-threatening complications has led to development of parenchyma sparing splenic resections. The aim of the study was to report a new technique of laparoscopic partial splenectomy, which helps minimize perioperative bleeding risks. METHODS: From November 2004 to October 2012, 12 patients underwent partial laparoscopic resection of the spleen. There were six men (50 %), and median age was 30 years (19-62). Transection of the splenic parenchyma was performed along a line situated 1 cm within the ischemic demarcation, which appeared after ligation of the sectorial vascular pedicles feeding the tumor. Antibiotic prophylaxis and preventive antibacterial immunization were prescribed systematically according to generally accepted guidelines. RESULTS: Mortality was nil, and operative complications occurred in 2 (17 %) patients. Conversion to open partial splenectomy and to laparoscopic total splenectomy was performed in one patient (8.3 %) each. Median operative time was 120 min (range 80-180 min). Median blood loss was 90 ml (range 10-450 ml), and transfusion was not required. Median tumor size was 7 cm (4-12 cm). The median in hospital stay was 5 days (4-7 days). Patients did not comply with long-term (>2 years) immunization and antibioprophylaxis rules. After a median follow-up of 5 years (18 months-9 years), no case of overwhelming post-splenectomy infections occurred. CONCLUSION: Laparoscopic partial splenectomy can be safely performed in patients with splenic tumors. Parenchyma transection 1 cm inside the ischemic demarcation line is a key technical point to minimize blood loss.

The incidence of papillary thyroid carcinoma and outcomes in operative patients according to their body mass indices.

BACKGROUND: The connection between high body mass index (BMI), risk of papillary thyroid carcinoma (PTC), and the aggressiveness of PTC is still debated. We aimed to establish the relationship between excess BMI and the risk of PTC in an operative population, and the impact of obesity on histopathologic aggressiveness of PTC and on the outcome of patients. METHODS: All consecutive patients who underwent thyroid operation from June 2002 to December 2009 were reviewed in this retrospective study. BMI groupings were based on standardized categories: normal-weight, overweight, and obesity. We performed a total thyroidectomy with lymph node dissection in patients with preoperative or operative diagnosis of PTC. Radioiodine ablation was performed in every N1 patient, in case of tumor size greater than 10 mm, and if there was extrathyroidal invasion. During a median follow-up of 6.2 years, patients who were retreated by operation or (131)I were considered to have a persistent (<18 months of the initial operative treatment) or recurrent (≥ 18 months) disease. RESULTS: Of 6,684 patients who had a thyroid gland resection, we identified 1,216 (18.2%) patients with PTC. Patients who were overweight or obese were not at greater risk of PTC than normal-weight subjects. Indications for operation or radioiodine therapy were similar in the three BMI groups. During follow-up, 86 patients (7.1%) experienced persistent (4.5%) or recurrent (2.5%) disease. When excluding micro-PTCs (≤ 10 mm), we found an association between recurrent or residual locoregional thyroid cancer and BMI: 18.7% in obese patients versus 8.5% if BMI <25 kg/m(2) and 9.8% if 25 ≥ BMI < 30 kg/m(2) (P = .03). This difference was clearly marked for persistence. When adjusted for other cofounder factors, we observed that BMI was an independent factor associated with the risk of postoperative locoregional event (odds ratio 3.8, 95% confidence interval 1.6-8.8), with sex, age, lymph node metastasis, and tumor bilaterality. CONCLUSION: In macro-PTC, obese patients had an increased risk of developing a locoregional event during the follow-up, specifically a persistence of the disease. According to these results, overweight and obese patients with macro-PTC should be monitored more carefully for early detection of cancer persistence.

Similar outcomes after primary and secondary esophagocoloplasty for caustic injuries.

BACKGROUND: The main purpose of the study was to report a comparative experience with primary and secondary esophagocoloplasty for caustic injuries. Secondary esophagocoloplasty is the main rescue option after graft loss, but data in the literature are scarce. METHODS: The operative characteristics, postoperative course, and functional outcomes of 21 secondary and of 246 primary esophagocoloplasty operations performed for caustic injuries between 1987 and 2006 were compared. Intraoperative events requiring significant changes in the planned operative strategy, such as graft ischemia or necrosis, were recorded. Statistical tests were performed in both cohorts to identify factors predictive of postoperative graft necrosis. Univariate analysis was performed to identify factors predictive of functional failure after secondary esophagocoloplasty. RESULTS: Operative mortality (5% vs 4%, p=0.56), morbidity (62% vs 59%, p=0.96), postoperative graft necrosis (14% vs 7%, p=0.16), and functional success (68% vs 70%, p=0.79) rates of the secondary and primary esophagocoloplasty operations were similar. Intraoperative graft ischemia at the time of secondary esophagocoloplasty was significantly associated with the risk of postoperative graft necrosis (p=0.015) and functional failure (p=0.046). At the time of primary esophagocoloplasty, intraoperative necrosis of the colon was the only independent predictive factor of postoperative graft necrosis (p<0.0001). CONCLUSIONS: Secondary esophagocoloplasty is a safe and reliable salvage option after primary graft loss in patients with caustic injuries. Delayed esophagocoloplasty should be considered if intraoperative colon necrosis occurs at the time of primary reconstruction.