Laparoscopic radical 'no-touch' left pancreatosplenectomy for pancreatic ductal adenocarcinoma: technique and results

Background Laparoscopic left pancreatectomy has been well described for benign pancreatic lesions, but its role in pancreatic adenocarcinoma remains open to debate. We report our results adopting a laparoscopic technique that obeys established oncologic principles of open distal pancreatosplenectomy. Methods This is a post hoc analysis of a prospectively kept database of 135 consecutive patients undergoing laparoscopic left pancreatectomy, performed across two sites in the UK and the Netherlands (07/2007–07/2015 Southampton and 10/2013–07/2015 Amsterdam). Primary outcomes were resection margin and lymph node retrieval. Secondary endpoints were other perioperative outcomes, including post-operative pancreatic fistula. Definition of radical resection was distance tumour to resection margin >1 mm. All patients underwent ‘laparoscopic radical left pancreatosplenectomy’ (LRLP) which involves ‘hanging’ the pancreas including Gerota’s fascia, followed by clockwise dissection, including formal lymphadenectomy. Results LRLP for pancreatic adenocarcinoma was performed in 25 patients. Seven of the 25 patients (28 %) had extended resections, including the adrenal gland (n = 3), duodenojejunal flexure (n = 2) or transverse mesocolon (n = 3). Mean age was 68 years (54–81). Conversion rate was 0 %, mean operative time 240 min and mean blood loss 340 ml. Median intensive/high care and hospital stay were 1 and 5 days, respectively. Clavien–Dindo score 3+ complication rate was 12 % and ISGPF grade B/C pancreatic fistula rate 28 %; 90-day (or in-hospital) mortality was 0 %. The pancreatic resection margin was clear in all patients, and the posterior margin was involved (<1 mm) in 6 patients, meaning an overall R0 resection rate of 76 %. No resection margin was microscopically involved. Median nodal sample was 15 nodes (3–26). With an average follow-up of 17.2 months, 1-year survival was 88 %. Conclusions A standardised laparoscopic approach to pancreatic adenocarcinoma in the left pancreas can be adopted safely. Our study shows that these results can be reproduced across multiple sites using the same technique

Multiracial Representations of Self, Otherness, and ‘Disalienation’ on The Middle Passage: C1770-1810

Scholarships & Prizes Office. University of Sydne

Achieving Near-Optimal Traffic Engineering Solutions for Current OSPF/IS-IS Networks

Traffic engineering is aimed at distributing traffic so as to optimize a given performance criterion. The ability to carry out such an optimal distribution depends on the routing protocol and the forwarding mechanisms in use in the network. In IP networks running the OSPF or IS-IS protocols, routing is along shortest paths, and forwarding mechanisms are constrained to distributing traffic uniformly over equal cost shortest paths. These constraints often make achieving an optimal distribution of traffic impossible. In this paper, we propose and evaluate an approach that is capable of realizing near optimal traffic distribution without any change to existing routing protocols and forwarding mechanisms. In addition, we explore the trade-off that exists between performance and the overhead associated with the additional configuration steps that our solution requires. The paper\u27s contributions are in formulating and evaluating an approach to traffic engineering for existing IP networks that achieves performance levels comparable to that offered when deploying other forwarding technologies such as MPLS

Nationwide trends in chemotherapy use and survival of elderly patients with metastatic pancreatic cancer

Despite an aging population and underrepresentation of elderly patients in clinical trials, studies on elderly patients with metastatic pancreatic cancer are scarce. This study investigated the use of chemotherapy and survival in elderly patients with metastatic pancreatic cancer. From the Netherlands Cancer Registry, all 9407 patients diagnosed with primary metastatic pancreatic adenocarcinoma in 2005–2013 were selected to investigate chemotherapy use and overall survival (OS), using Kaplan–Meier and Cox proportional hazard regression analyses. Over time, chemotherapy use increased in all age groups (<70 years: from 26 to 43%, 70–74 years: 14 to 25%, 75–79 years: 5 to 13%, all P < 0.001, and ≥80 years: 2 to 3% P = 0.56). Median age of 2,180 patients who received chemotherapy was 63 years (range 21–86 years, 1.6% was ≥80 years). In chemotherapy-treated patients, with rising age (<70, 70–74, 75–79, ≥80 years), microscopic tumor verification occurred less frequently (91-88-87-77%, respectively, P = 0.009) and OS diminished (median 25-26-19-16 weeks, P = 0.003). After adjustment for confounding factors, worse survival of treated patients ≥75 years persisted. Despite limited chemotherapy use in elderly age, suggestive of strong selection, elderly patients (≥75 years) who received chemotherapy for metastatic pancreatic cancer exhibited a worse survival compared to younger patients receiving chemotherapy

Robotic Pancreatoduodenectomy: Patient Selection, Volume Criteria, and Training Programs

INTRODUCTION: There has been a rapid development in minimally invasive pancreas surgery in recent years. The most recent innovation is robotic pancreatoduodenectomy. Several studies have suggested benefits as compared to the open or laparoscopic approach. This review provides an overview of studies concerning patient selection, volume criteria, and training programs for robotic pancreatoduodenectomy and identified knowledge gaps regarding barriers for safe implementation of robotic pancreatoduodenectomy. MATERIALS AND METHODS: A Pubmed search was conducted concerning patient selection, volume criteria, and training programs in robotic pancreatoduodenectomy. RESULTS: A total of 20 studies were included. No contraindications were found in patient selection for robotic pancreatoduodenectomy. The consensus and the Miami guidelines advice is a minimum annual volume of 20 robotic pancreatoduodenectomy procedures per center, per year. One training program was identified which describes superior outcomes after the training program and shortening of the learning curve in robotic pancreatoduodenectomy. CONCLUSION: Robotic pancreatoduodenectomy is safe and feasable for all indications when performed by specifically trained surgeons working in centers who can maintain a minimum volume of 20 robotic pancreatoduodenectomy procedures per year. Large proficiency-based training program for robotic pancreatoduodenectomy seem essential to facilitate a safe implementation and future research on robotic pancreatoduodenectomy

Guest-Dependence on Spin Crossover and Thermal Expansion in Nanoporous Coordination Framework Materials

Coordination framework materials have attracted much interest in modern chemistry due to the plethora of properties that they may possess. The frameworks described in this thesis demonstrate the properties of spin crossover, anomalous thermal expansion, and nanoporosity, which enables guest-dependent studies into the material behaviour. The first frameworks described are the [Fe(bpac)M(CN)4]•x(bpac){guest} (M = Ni, Pd, Pt; bpac = 1,4-bis(4′-pyridyl)acetylene) family. The properties of the alcohol-solvated [Fe(bpac)Pd(CN)4]•x(bpac) (x = 0.4, 0.5) frameworks were studied, and the major guest influence on the resulting spin crossover behaviour was determined to be due to an internal pressure effect produced by the kinetic volume and compressibility of the guest. By obtaining a variety of EtOH adsorption isotherms and isobars, a Temperature-Pressure phase diagram of SCO was produced for the [Fe(bpac)Pd(CN)4]•0.4(bpac){EtOH} material. In addition to these frameworks, the behaviour of the [Fe(bpac)(Au(CN)2)2)]•{guest} framework material was also investigated. This framework demonstrated unprecedented multifunctional behaviour, with a synergistic interplay between the spin crossover, lattice structure and host–guest properties. The framework lattice was exceptionally flexible, and displayed a facile ‘scissor-type’ motion of the {Fe(Au(CN)2)2} (4,4) grids. Due to the extreme conformational flexibility of the {Fe(Au(CN)2)2} (4,4)-grids of this material, the [Fe(bpac)(Au(CN)2)2)]•{EtOH} sample displayed colossal uniaxial thermal expansion behaviour. Below the spin transition, the a parameter displayed a maximum thermal expansion coefficient of −1070 × 10−6 K−1, which is an order of magnitude greater than any yet reported for this quantity. Guest-dependent studies on this framework demonstrate the strong effect of guest properties on the conformation of the framework lattice and the spin transition behaviour

Inspiring Womanhood: A re-interpretation of The Dawn

This thesis explores the diversity of content and ideas found in Louisa Lawson’s The Dawn, Australia’s first successful magazine ‘by women and for women’, showing that every element of the journal promoted a womanhood ideal for Australian women. Though remembered for the challenging arguments it made for women’s rights, most of the journal was taken up by beauty tips, household hints, recipes, women’s stories, health ideas, fashion articles and the like. This thesis examines such elements, noting how they served to help readers progress towards its womanhood ideal. It highlights the way that The Dawn’s discourse on women’s right was integrated into this ideal. It also analyses some of the key themes and ideas central to the ideal constructed in The Dawn, such as motherhood, beauty, and success in work and study

Effect of structured use of preoperative portal vein embolization on outcomes after liver resection of perihilar cholangiocarcinoma

BACKGROUND: Portal vein embolization (PVE) is performed to reduce the risk of liver failure and subsequent mortality after major liver resection. Although a cut-off value of 2·7 per cent per min per m2 has been used with hepatobiliary scintigraphy (HBS) for future remnant liver function (FRLF), patients with perihilar cholangiocarcinoma (PHC) potentially benefit from an additional cut-off of 8·5 per cent/min (not corrected for body surface area). Since January 2016 a more liberal approach to PVE has been adopted, including this additional cut-off for HBS of 8·5 per cent/min. The aim of this study was to assess the effect of this approach on liver failure and mortality. METHODS: This was a single-centre retrospective study in which consecutive patients undergoing liver resection under suspicion of PHC in 2000-20