EUS-guided pancreatic pseudocyst drainage: review and experience at Harbor-UCLA Medical Center

Pancreatic pseudocyst, the most common cystic lesion of the pancreas, is a localized collection of fluid rich in amylase within or adjacent to the pancreas and enclosed by a nonepithelialized wall, occurring as a result of acute or chronic pancreatitis, pancreatic trauma, or pancreatic duct obstruction. Currently, at least 3 major forms of therapy are available: percutaneous drainage, surgical intervention, and endoscopic drainage. Controversy exists concerning which of these techniques should be offered to the patient as initial therapy. Three options exist for the surgical management of pancreatic pseudocysts: excision, external drainage, and internal drainage. Surgery, which traditionally was the major treatment approach for pancreatic pseudocysts, has been challenged by newer endoscopic techniques. Given the low complication and mortality rates and the high success rate of endoscopic drainage when compared with surgery, surgical intervention should be reserved only for certain cases. Addition of endoscopic ultrasonography (EUS) for endoscopic drainage is a new and exciting development and may decrease the risks associated with endoscopic drainage. We report our experience of 14 cases of EUS-guided pancreatic pseudocyst drainage and review the literature for advantages and disadvantages of these pancreatic pseudocyst drainage procedures. Complications, recurrence, success, and mortality rates for each procedure are described. Our approach to pancreatic pseudocyst management is described in the form of an algorithm.     

Robotic versus Laparoscopic Distal Pancreatectomy: A Meta-Analysis of Short-Term Outcomes

AIM

To compare the safety and efficacy of robotic-assisted distal pancreatectomy (RADP) and laparoscopic distal pancreatectomy (LDP).

METHODS

A literature search of PubMed, EMBASE, and the Cochrane Library database up to June 30, 2015 was performed. The following key words were used: pancreas, distal pancreatectomy, pancreatic, laparoscopic, laparoscopy, robotic, and robotic-assisted. Fixed and random effects models were applied. Study quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Seven non-randomized controlled trials involving 568 patients met the inclusion criteria. Compared with LDP, RADP was associated with longer operating time, lower estimated blood loss, a higher spleen-preservation rate, and shorter hospital stay. There was no significant difference in transfusion, conversion to open surgery, R0 resection rate, lymph nodes harvested, overall complications, severe complications, pancreatic fistula, severe pancreatic fistula, ICU stay, total cost, and 30-day mortality between the two groups.

CONCLUSION

RADP is a safe and feasible alternative to LDP with regard to short-term outcomes. Further studies on the long-term outcomes of these surgical techniques are required.

Core tip

To date, there is no consensus on whether laparoscopic or robotic-assisted distal pancreatectomy is more beneficial to the patient. This is the first meta-analysis to compare laparoscopic and robotic-assisted distal pancreatectomy. We found that robotic-assisted distal pancreatectomy was associated with longer operating time, lower estimated blood loss, a higher spleen-preservation rate, and shorter hospital stay. There was no significant difference in transfusion, conversion to open surgery, overall complications, severe complications, pancreatic fistula, severe pancreatic fistula, ICU stay, total cost, and 30-day mortality between the two groups.     

Massive and recurrent hernias; use of dermal grafts in carrying out repair

Nonpenetrating abdominal injuries are commonly seen in a general hospital. High speed traffic accidents are responsible for the majority of these injuries. The mortality rate is high. Deaths were from associated injuries, failure to recognize abdominal trauma, hemorrhage and from acute renal insufficiency. Careful observation of every severely injured person, vigorous treatment of hemorrhagic shock with whole blood, and prompt surgical intervention when indicated will improve the mortality figures.     

Fine needle aspiration cytology of endocrine neoplasms of the pancreas. Morphologic and immunocytochemical findings in 20 cases

OBJECTIVE: To analyze the role of fine needle aspiration (FNA) cytology in the preoperative diagnosis of pancreatic endocrine neoplasms. METHODS: Cytologic and histologic diagnoses of pancreatic endocrine tumors were reviewed. A total of 20 FNA cytologic procedures from 20 patients were selected. A false positive case, a retroperitoneal paraganglioma, was also reviewed. Two groups of patients were established: (1) those in whom a surgical biopsy with an immunohistochemical study was available (n = 13), and (2) those with a pancreatic tumor in which the diagnosis was confirmed by immunocytochemical studies (n = 7). In 13 cases the pancreatic tumor was aspirated, while in 7, liver metastases were studied. The immunoexpression of chromogranin and synaptophysin was evaluated in alcohol-fixed smears from 12 and 11 cases, respectively. RESULTS: One false negative and 1 false positive diagnosis were present. In the remaining 19 cases a cytologic diagnosis of pancreatic endocrine tumor was given. Main cytologic features were: (1) a prominent cellular dissociation with many single cells and small, poorly cohesive groups; (2) intermediate to large size cells with ill-defined cytoplasm, naked or eccentric nuclei, and frequent binucleation; and (3) variable nuclear pleomorphism with the characteristic finely granular distribution of the chromatin. Immunocytochemical evidence of endocrine differentiation (chromogranin or synaptophysin) was present in the 12 cases analyzed. CONCLUSION: FNA cytology offers the possibility of a precise preoperative, noninvasive diagnosis of pancreatic endocrine tumors. Cytologic features differ considerably from those of pancreatic adenocarcinoma, allowing differentiation from nonfunctioning endocrine neoplasms. In difficult cases immunocytologic studies are very helpful.     

Less Aggressive Surgical Procedure for Treatment of Solid Pseudopapillary Tumor: Limited Experience from a Single Institute

Objectives

To evaluate the clinical characteristics and radiological features of solid pseudopapillary tumor (SPT) and assess surgical therapy strategy.

Methods

A retrospective review was performed in 62 patients pathologically confirmed of SPT treated between 2003 and 2014. The clinical features, radiological examinations and surgical strategies were analyzed.

Results

56 females and 6 males were included in this study, mean age was 26 years old (range: 8–66 years old) with mean size of the tumor was 7.2 cm (range: 3–15 cm), and most tumor were commonly located in the head of pancreas (n = 29). Among all the cases, 3 patients had liver metastasis and underwent resection of SPT and liver metastasis. Furthermore, we performed 29 cases of local tumor excision; other patients underwent pancreaticoduodenectomy, middle pancreatectomy, middle pancreatectomy with splenectomy, distal pancreatectomy with spleen preservation, distal pancreatectomy with splenectomy and duodenum-preserving pancreatic head resection. No patient suffered from lymph node metastases. After median follow-up of 46 months (range: 2–135 months), no mortality or local recurrence or distant metastasis was found.

Conclusions

Solid pseudopapillary tumor is a latent malignant tumor with excellent prognosis. If feasible, less aggressive resection without regular lymphadenectomy is recommended for treatment of patients with SPT.     

Combined effect of nicotinamide and streptozotocin on diabetic status in partially pancreatectomized adult BALB/c mice.

Pancreatic regeneration after pancreatectomy has been well documented in the animal models. We have recently reported that STZ diabetic animals operated for partial pancreatectomy showed normoglycemic status after the operation as compared to uncontrolled hyperglycemia and even death in the diabetic sham operated animals. In drug and virus-induced experimental diabetic models there is a high mortality of animals due to uncontrolled destruction of the beta-cells. In order to destroy sufficient beta-cell mass so as to induce diabetes but prevent mortality, we designed present studies to investigate the combined effect of pancreatectomy, nicotinamide, and streptozotocin (STZ) on diabetic status of BALB/c mice. BALB/c mice of either sex were subjected to 50% pancreatectomy. These were then treated with nicotinamide (350 mg/kg body weight) before and after streptozotocin (200 mg/kg body weight) administration. The changes in body weight, blood glucose levels, serum and pancreatic insulin contents of these animals were monitored in experimental and control group for 12 weeks, and follow up studies were made of these animals for further 12 weeks. It was found that there was a drastic loss of body weight, decreased serum and pancreatic insulin levels coupled with sustained and low levels of hyperglycemia in the experimental group as opposed to the control group. The results indicate that partial pancreatectomy followed by nicotinamide and streptozotocin treatment leads to a long-lasting hyperglycemic state, depicting the clinical symptom of NIDDM without mortality. The study probably reveals a new model for experimental diabetes.     

Traumatic suprahepatic inferior vena cava injury: surgical management

SUMMARY:: Suprahepatic inferior vena caval (IVC) injuries are rare but carry nearly a 100% mortality rate. The main problem with its surgical management is the technical difficulty in draining the IVC during cardiopulmonary bypass. In this report, an efficient method of IVC drainage for repair of the IVC on cardiopulmonary bypass is described.     

Les lésions de l’urètre associées à une fracture des corps caverneux. A propos d’une série de 4 cas et revue de la littérature

Introduction

Urethral injury associated with corpora cavernosa fracture is a relatively uncommon form of urological trauma. Early diagnosis and immediate surgical repair are essential.

Patients and methods

Between January 1990 and December 2004, a total of 4 male patients with urethral injury associated with fracture of the corpora cavernosa were retrospectively studied from a series of 96 cases of penile fracture.

Results

The mean age of the patients was 36.5 years (range: 27–45 years). Urethral bleeding was noted in all patients. Immediate surgical repair via a penile circular subcoronal incision was performed in all cases. Two partial urethral injuries associated with a unilateral corpus cavernosum lesion were identified. In the other cases, total urethral injury was associated with bilateral rupture of the corpora cavernosa. The tunica albuginea defect was closed and the urethral laceration repaired over a urethral catheter. With a mean follow-up of 2.5 years, 2 short urethral strictures were observed and were managed non-operatively with good outcome.

Comments

Secondary urethral lesions associated with corpora cavernosa fracture most frequently affect young adults. In North African countries, forced self-manipulation of an erect penis is the most frequent cause, but the associated urethral lesion is usually related to vaginal intercourse. The diagnosis can generally be made on the basis of history and physical examination alone. Blood at the meatus or haematuria or voiding difficulties suggest associated trauma to the urethra [4]. Additional imaging examinations are rarely required. The standard treatment is prompt surgical exploration, evacuation of haematoma, and primary repair of the urethral and corpora cavernosa defects. Late complications after surgical repair are penile curvature and pain during coitus. They are usually attributable to a residual fibrotic area.

Conclusion

Urethral injury associated with corpora cavernosa fracture usually has typical signs. The mechanism of trauma is very suggestive. Early surgical treatment is the only guarantee of a satisfactory functional result.     

The Association of Statin Use after Cancer Diagnosis with Survival in Pancreatic Cancer Patients: A SEER-Medicare Analysis

Background

Pancreatic cancer has poor prognosis and existing interventions provide a modest benefit. Statin has anti-cancer properties that might enhance survival in pancreatic cancer patients. We sought to determine whether statin treatment after cancer diagnosis is associated with longer survival in those with pancreatic ductal adenocarcinoma (PDAC).

Methods

We analyzed data on 7813 elderly patients with PDAC using the linked Surveillance, Epidemiology, and End Results (SEER) - Medicare claims files. Information on the type, intensity and duration of statin use after cancer diagnosis was extracted from Medicare Part D. We treated statin as a time-dependent variable in a Cox regression model to determine the association with overall survival adjusting for follow-up, age, sex, race, neighborhood income, stage, grade, tumor size, pancreatectomy, chemotherapy, radiation, obesity, dyslipidemia, diabetes, chronic pancreatitis and chronic obstructive pulmonary disease (COPD).

Results

Overall, statin use after cancer diagnosis was not significantly associated with survival when all PDAC patients were considered (HR = 0.94, 95%CI 0.89, 1.01). However, statin use after cancer diagnosis was associated with a 21% reduced hazard of death (Hazard ratio = 0.79, 95% confidence interval (CI) 0.67, 0.93) in those with grade I or II PDAC and to a similar extent in those who had undergone a pancreatectomy, in those with chronic pancreatitis and in those who had not been treated with statin prior to cancer diagnosis.

Conclusions

We found that statin treatment after cancer diagnosis is associated with enhanced survival in patients with low-grade, resectable PDAC.     

Optimal Surgical Options for Descending Necrotizing Mediastinitis of the Anterior Mediastinum

The mortality rates from descending necrotizing mediastinitis (DNM) are between 25 and 40 % mainly because of delayed diagnosis and inappropriate surgical treatment. This study was undertaken to examine two surgical options for DNM and determine the optimal surgical option for DNM of the anterior mediastinum. Fifteen cases of DNM of the anterior mediastinum, January 2001 and October 2010, were retrospectively reviewed. Eleven were anterosuperior mediastinitis, with infection located above the tracheal bifurcation and four had infections involving the entire anterior mediastinum. Depending on the location of mediastinitis, open drainage of the submandibular and neck abscesses, in addition to other surgical treatments, was performed. If the infection was anterosuperior, transcervical mediastinal drainage or thoracotomy was performed. If the entire anterior mediastinum was involved, necrotic tissue was removed with thoracoscopic via subxiphoid incision, the bilateral pleurae were opened for drainage, and a tunnel connecting the neck incision and the subxiphoid incision through the whole anterior mediastinum was made for drainage. The anterosuperior mediastinitis cases were treated with either transcervical mediastinal drainage (n = 8) or thoracotomy (n = 3). Patients healed after an average of 24.5 and 20.0 days in the hospital, respectively. For the four other cases, one patient died of septic shock, while the other three patients were healed after and an average of 43.3 days in the hospital. Mortality rate was 6.7 %. The surgical procedure used to treat DNM should be selected according to the location of the infection. DNM involving the anterosuperior mediastinum can be treated by transcervical mediastinal drainage. If anterosuperior mediastinitis spreads to the side of the trachea, open thoracotomy is a suitable therapy. If the entire anterior mediastinum is involved, debridement and drainage of the anterior mediastinum should be performed with a thoracoscope via the subxiphoid incision.     

556例多发伤患者的急诊救治临床分析

目的探讨多发伤患者的救治策略。方法回顾分析我科2000年1月至2008年5月急诊抢救的556例多发伤患者的临床资料。结果 16例患者经抢救无效死亡,死亡率2.88%;其余患者均经紧急抢救及行必要实验室检查,病情稳定,好转率达97.12%。平均抢救时间为(1.37±1.05)h。结论强化多发伤的急诊科早期救治,树立创伤急救"黄金1 h"观念,是提高多发伤患者生存率及降低死亡率的关键。     

骨折合并多发伤的诊治体会

目的:探讨基层医院骨折合并多发伤的诊治方法。方法:回顾性分析2003年06月-2007年10月本院救治的112例骨折合并多发伤病例,根据不同伤情采取了不同的救治措施。结果:112例经住院治疗的患者中,15例死亡,死亡率为13.4%。手术治疗92例多发骨折脱位208处,骨折达到解剖复位或近解剖复位者189处,占90.9%;达到功能复位者8例,占9.1%。骨延迟愈合4例。钢板断裂2例,髓内钉断裂2例。结论:尽早接诊病人、全面综合分析病情是抢救多发伤骨折病人的首要环节;及时诊断、早期救治是防止并发症、提高抢救成活率、降低病残率的关键。     

SMALL BOWEL RUPTURE FROM ABDOMINAL BLOWS

Rupture of the small bowel with nonpenetrating abdominal trauma occurs in one-third to one-fourth of all abdominal injuries. Perforation of the bowel can result from injuries of crushing, bursting or tearing type. The symptoms are those associated with peritoneal irritation. Repeated observation and examination is necessary for diagnosis. Operative repair is mandatory. Two cases, one in a child, are reported.     

胆囊切除术医源性胆管损伤的处理

目的:探讨开腹胆囊切除术医源性胆道损伤的诊断、手术时机和手术方式的选择。方法:对18例胆道损伤进行分析总结:分别施行了胆管修补、T管引流术10例,保守治疗2例,Roux-en-Y胆肠吻合术6例。结果:3例术后过早拔管发生吻合口狭窄,再次手术。1例因梗阻性胆管炎并发肝功能衰竭、多器官功能衰竭死亡。1例因胆肠吻合术后并发消化道出血、肝昏迷死亡。余术后良好。结论:尽早发现及正确处理对提高疗效和预防术后胆管狭窄起着决定性的作用。术中发现胆管损伤立即行端端吻合加T管引流;术后数天发现或多次胆道修补术失败者,则宜行规范的Roux-en-Y胆肠吻合术。     

Traumatisme de la verge et des organes génitaux

The most frequent cause of testicular injuries is blunt trauma (following sports injuries or road accidents). Penetrating injuries are rare. Increased scrotal volume and a painful testis are the main symptoms and require scrotal ultrasonography. Scrotal ultrasonography is very sensitive and specific for testicular rupture or intratesticular haematoma. Two out of three patients with testicular injuries require surgical exploration. Secondary complications due to delayed management of trauma are testicular atrophy, sterility or impotence. Penile fracture (rupture of corpus cavernosum) is due to direct trauma by an excessive force applied to an erect penis. Swelling, penile ecchymosis, penile curvature and pain are the usual symptoms of rupture of the tunica albuginea. Urethral injury must be ruled out. Cavernosography, ultrasonography or MRI are not considered mandatory to establish a diagnosis but can be prescribed in the absence of typical signs or symptoms. Early surgical exploration and repair ensure a better outcome. Secondary complications are penile curvature, chronic pain and impotence.     

Thyroid cancer causing obstruction of the great veins in the neck

Tumor related pancreatic surgery has progressed significantly during recent years. Pancreatoduodenectomy (PD) with lymphadenectomy, including vascular resection, still presents the optimal surgical procedure for carcinomas in the head of pancreas. For patients with small or low-grade malignant neoplasms, as well as small pancreatic metastases located in the mid-portion of pancreas, central pancreatectomy (CP) is emerging as a safe and effective option with a low risk of developing de-novo exocrine and/or endocrine insufficiency. Total pancreatectomy (TP) is not as risky as it was years ago and can nowadays safely be performed, but its indication is limited to locally extended tumors that cannot be removed by PD or distal pancreatectomy (DP) with tumor free surgical margins. Consequently, TP has not been adopted as a routine procedure by most surgeons. On the other hand, an aggressive attitude is required in case of advanced distal pancreatic tumors, provided that safe and experienced surgery is available. Due to the development of modern instruments, laparoscopic operations became more and more successful, even in malignant pancreatic diseases. This review summarizes the recent literature on the abovementioned topics.     

Management of necrotizing pancreatitis.

A comprehensive management plan is presented for patients with severe acute pancreatitis. These patients may have pancreatic or peripancreatic necrosis or pancreatic fluid collections. Multiple organ failure often develops in patients with severe pancreatitis. We therefore recommend that all patients with acute pancreatitis be evaluated for pancreatic anatomy and function. If a patient is seriously ill, a computed tomographic (CT) scan with vascular enhancement should be done. Meanwhile, vigorous fluid replacement is necessary using Swan-Ganz monitoring. Patients with necrosis do not need surgical intervention unless the clinical course or CT scan-guided aspiration shows infection. The objective of an operation should be to remove all infected tissue and fluid. A preoperative CT scan with vascular enhancement should be used as a guide during the operation to ensure that all foci of infected necrosis or fluid are eliminated. We have found that open packing and irrigation with sodium oxychlorosene are helpful in patients with extensive necrosis or those who become infected early after the onset of symptoms. In all, 40% to 50% of patients treated by closed drainage will require reoperation because of incomplete debridement. Persistent sepsis is an indication for reoperation.     

Experimental diabetes in cats induced by partial pancreatectomy alone or combined with local injection of alloxan

Experimental diabetes was produced in cats by partial pancreatectomy using a short and technically simple surgical procedure. Electrocautery was used to cauterize pancreatic blood vessels and seal free edges of remaining pancreatic tissue to prevent secretion of pancreatic enzymes into the peritoneal cavity. In a second group of animals, partial pancreatectomy was followed by local injection of alloxan into an arterial branch of the cranio-mesenteric artery. The combined procedure resulted in diabetes mellitus in 100% (8 of 8) animals as compared to only 70% (14 of 20) in those subjected to partial pancreatectomy alone. In addition, the alloxan-pancreatectomized cats had a reduced latency period prior to onset of chronic hyperglycemia (4.8 days compared to 19.3 days postoperatively in pancreatectomized cats). The diabetic cats were maintained in poor metabolic control (blood glucose approximately 300 mg/dl) by daily injections of low doses of long-acting insulin. Pancreatic enzyme supplementation was given by mouth. Weight changes and blood glucose levels were monitored carefully to maintain the health of the animals while keeping them in poor metabolic control.     

Prognosis of children with malignant pheochromocytoma. Report of 2 cases and review of the literature

Malignant pheochromocytomas are rare in childhood and the prognosis of children with this tumor is not well known. We present 2 pediatric observations of malignant pelvic pheochromocytoma. Symptoms in both cases were headache and hypertension. The tumor invaded the sacral bone. Angiogram helped to localize the tumor and metastases, and allowed preoperative embolization of the tumor in 1 case. The first child underwent incomplete surgical resection, (131)I-MIBG therapy and radiotherapy, and is still alive 2 years after diagnosis. The second child died from metastatic invasion a few weeks after discovery of the tumor. We reviewed previous reports of children with malignant pheochromocytomas (30 cases). Primary tumor was extraadrenal in 50% of cases. The 3-year survival rate was 73 +/- 9% (mean +/- SD). Apart from surgical resection, no particular treatment appeared to be more effective than others in reducing mortality.     

Prospective pricing and DRGs.

In the Congenital Heart Program at San Diego Children''s Hospital, alterations in medical practice have reduced costs without impairing quality or access. Pediatric cardiac catheterization was done in 483 consecutive elective patients without overnight hospital stay. Hospital readmission was required in one patient for psoas tendinitis. Avoiding overnight hospital stay minimized attendant risks of hospital care, lessened psychosocial trauma and reduced the average hospital bill by $493 (29%). Hospital stay was also reduced for elective surgical correction of congenital heart disease on a case-by-case basis. Review of 151 consecutive cases (1978 through 1982) showed a decrease in both preoperative days in hospital and postoperative days in an intensive care unit. The duration of the postoperative stay was shortened from 6.8 days in 1978-1979 to 4.4 days in 1982 (P <.05). No increase in morbidity and no mortality resulted from the shortened perioperative hospital stay. Financial savings from this process averaged $991 per procedure.Diagnostic tests were reassessed and many precatheterization laboratory tests were eliminated. Without change in new patients seen or surgical volume, the use of cardiac catheterization decreased from 241 procedures in 1981 to 161 in 1982 and the number of operations without catheterization increased (11 to 22, 1981 to 1982). No increase in surgical morbidity or mortality was found comparing those diagnosed only by echocardiography with those who had preoperative cardiac catheterization. The decrease of 80 catheterizations in one year resulted in a savings of $188,800.True cost containment (reducing cost without reducing quality) can be accomplished in congenital heart programs. Similar cost containments in other disciplines may also be achieved.