How severe is diabetes after total pancreatectomy?:A case-matched analysis

OBJECTIVES: Total pancreatectomy (TP) is associated with significant morbidity and mortality. The severity of postoperative diabetes and existence of ‘brittle diabetes’ are unclear. This study sought to identify quality of life (QoL) and diabetes-specific outcomes after TP. METHODS: Patients who underwent TP were matched for age, sex and duration of diabetes with patients with type 1 diabetes. General QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) core quality of life questionnaire QLQ-C30 and the PAN26 tool. Diabetes-specific outcomes were assessed using the Problem Areas in Diabetes (PAID) tool and an assessment of diabetes-specific complications and outcomes. RESULTS: A total of 123 patients underwent TP; 88 died (none of diabetic complications) and two were lost to follow-up. Of the remaining 33 patients, 28 returned questionnaires. Fourteen general and pancreas-specific QoL measurements were all significantly worse amongst the TP cohort (QLQ-C30 + PAN26). However, when diabetes-specific outcomes were compared using the PAID tool, only one of 20 was significantly worse. HbA1c values were comparable (P = 0.299), as were diabetes-related complications such as hypoglycaemic attacks and organ dysfunction. CONCLUSIONS: Total pancreatectomy is associated with impaired QoL on general measures compared with that in type 1 diabetes patients. Importantly, however, there was almost no significant difference in diabetes-specific outcomes as assessed by a diabetes-specific questionnaire, or in diabetes control. This study does not support the existence of ‘brittle diabetes’ after TP

Predictors of early recurrence after resection of colorectal liver metastases

BACKGROUND: Early recurrence after resection of colorectal liver metastases (CLM) is common. Patients at risk of early recurrence may be candidates for enhanced preoperative staging and/or earlier postoperative imaging. The aim of this study was to determine if there are any risk factors that specifically predict early liver-only and systemic recurrence. METHODS: Retrospective analysis of prospective database of patients undergoing liver resection (LR) for CLM from 2004 to 2006 was undertaken. Early recurrence was defined as occurring within 18 months of LR. Patients were classified into three groups: early liver-only recurrence, early systemic recurrence and recurrence-free. Preoperative factors were compared between patients with and without early recurrence. RESULTS: Two hundred and forty-three consecutive patients underwent LR for CLM. Twenty-seven patients (11%) developed early liver-only recurrence. Dukes C stage and male sex were significantly associated with early liver-only recurrence (P < 0.05). Sixty-six patients (27%) developed early systemic recurrence. Tumour size ≥3.6 cm and tumour number (>2) were significantly associated with early systemic recurrence (P < 0.001). CONCLUSIONS: It is possible to stratify patients according to the risk of early liver-only or systemic recurrence after resection of CLM. High-risk patients may be candidates for preoperative MRI and/or computed tomography-positron emission tomography (CT-PET) scan and should receive intensive postoperative surveillance

Global management of a common, underrated surgical task during the COVID-19 pandemic: Gallstone disease - An international survery

Background: Since the Coronavirus disease-19(COVID-19) pandemic, the healthcare systems are reallocating their medical resources, with consequent narrowed access to elective surgery for benign conditions such as gallstone disease(GD). This survey represents an overview of the current policies regarding the surgical management of patients with GD during the COVID-19 pandemic. Methods: A Web-based survey was conducted among 36 Hepato-Prancreato-Biliary surgeons from 14 Countries. Through a 17-item questionnaire, participants were asked about the local management of patients with GD since the start of the COVID-19 pandemic. Results: The majority (n = 26,72.2%) of surgeons reported an alarming decrease in the cholecystectomy rate for GD since the start of the pandemic, regardless of the Country: 19(52.7%) didn't operate any GD, 7(19.4%) reduced their surgical activity by 50–75%, 10(27.8%) by 25–50%, 1(2.8%) maintained regular activity. Currently, only patients with GD complications are operated. Thirty-two (88.9%) participants expect these changes to last for at least 3 months. In 15(41.6%) Centers, patients are currently being screened for SARS-CoV-2 infection before cholecystectomy [in 10(27.8%) Centers only in the presence of suspected infection, in 5(13.9%) routinely]. The majority of surgeons (n = 29,80.6%) have adopted a laparoscopic approach as standard surgery, 5(13.9%) perform open cholecystectomy in patients with known/suspected SARS-CoV-2 infection, and 2(5.6%) in all patients. Conclusion

Managing the 2-Week Wait for Breast Patients

INTRODUCTION Published data suggest that the 2-week wait system and triple assessment at one fast-track clinic visit is an out-dated method of capturing disease from a referral population. These studies report up to 32% of breast cancer coming from routine referrals. It has been recommended, therefore, that all breast referrals should be seen within 2 weeks. The sheer volume of referrals are likely to prevent this target being achieved. The aim of this study was to analyse the performance of our fast-track system. PATIENTS AND METHODS The Birmingham Heartlands and Solihull fast-track clinics were set up in 1999 with a prospective audit system. The data from this audit were retrospectively analysed and cross-referenced with the cancer data base to determine the referral origin of breast cancers from November 1999 to February 2005. RESULTS A total of 14,303 (fast-track, n = 6678; routine referral, n = 7625) patients were seen over a 5-year period. Overall, 1095 cancers (91.8% of the total) came from the fast-track clinics which had a pick-up rate of 16.4% compared with 98 cancers (8.2% of the total) and a pick-up rate of 1.3% for routine referrals (P < 0.001). The appropriateness of fast-track referral was also analysed which showed that 14.4% of cancers were detected if the referral criteria were met compared to 0.55% if they were inappropriate (P < 0.001). CONCLUSIONS The traditional fast-track, triple assessment breast clinic is an efficient and well-structured way of diagnosing disease. We recommend that the two system referral pattern should continue

Meta-analysis of interrupted versus continuous suturing for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy.

AIMS To compare outcomes of interrupted (IS) and continuous (CS) suturing techniques for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy. METHODS The study protocol was prospectively registered in PROSPERO (registration number: CRD42021286294). A systematic search of MEDLINE, CENTRAL, and Web of Science and bibliographic reference lists were conducted (last search: 14th March 2022). All comparative studies reporting outcomes of IS and CS in hepaticojejunostomy and choledochocholedochostomy were included and their risk of bias was assessed using ROBINS-I tool. Overall biliary complications, bile leak, biliary stricture, cholangitis, liver abscess, and anastomosis time were the evaluated outcome parameters. RESULTS Ten comparative studies (2 prospective and 8 retrospective) were included which reported 1617 patients of whom 1186 patients underwent Roux-en-Y hepaticojejunostomy (IS: 789, CS: 397) and the remaining 431 patients underwent duct-to-duct choledochocholedochostomy (IS: 168, CS: 263). Although use of IS for hepaticojejunostomy was associated with significantly longer anastomosis time (MD: 14.15 min, p=0.0002) compared to CS, there was no significant difference in overall biliary complications (OR: 1.34, p=0.11), bile leak (OR: 1.64, p=0.14), biliary stricture (OR: 0.84, p=0.65), cholangitis (OR: 1.54, p=0.35), or liver abscess (OR: 0.58, p=0.40) between two groups. Similarly, use of IS for choledochocholedochostomy was associated with no significant difference in risk of overall biliary complications (OR: 0.92, p=0.90), bile leak (OR: 1.70, p=0.28), or biliary stricture (OR: 1.07, p=0.92) compared to CS. CONCLUSIONS Interrupted and continuous suturing techniques for Roux-en-Y hepaticojejunostomy or duct-to-duct choledochocholedochostomy seem to have comparable clinical outcomes. The available evidence may be subject to confounding by indication with respect to diameter of bile duct. Future high-quality research is encouraged to report the outcomes with respect to duct diameter and suture material

Does blood group affect survival following pancreatoduodenectomy for periampullary malignancy?

BACKGROUND Blood group is reported to have an effect upon survival following pancreatoduodenectomy for pancreatic ductal adenocarcinoma. The effect of blood group is not known, however, among patients with other periampullary cancers. This study sought to review this. METHODS Data were collected for a range of factors and survival outcomes from patients treated at two centres. Those with blood groups B and AB were excluded, due to small numbers. Patient survival was compared between patients with blood groups O and A using multivariable analysis which accounted for confounding factors. RESULTS Among 431 patients, 235 (54.5%) and 196 (45.5%) were of blood groups A and O respectively. Baseline comparisons found a significant difference in the distribution of tumour types (p = 0.011), with blood group O patients having more ampullary carcinomas (33.2% vs 23.4%) and less pancreatic ductal adenocarcinomas (45.4 vs 61.3%) than group A. On multivariable analysis, after accounting for confounding factors including pathologic variables, survival was found to be significantly shorter in those with blood group A than group O (p = 0.047, HR 1.30 [95%CI: 1.00-1.69]). CONCLUSIONS There is a difference in the distribution of blood groups across the different types of periampullary cancers. Survival is shorter among blood group A patients

Long-term outcome after sequential resections of liver and lung metastases from colorectal carcinoma

AbstractBackgroundSurgical resection of colorectal liver metastases (CLM) is an established form of treatment. Limited data exists on the value of sequential hepatic and pulmonary metastasectomy. We analysed patients who underwent sequential liver and lung resections for CLM.MethodsA total of 910 patients who underwent liver resection for CLM between January 2000 and December 2007, were analysed to identify patients with resectable pulmonary metastases (n= 43; 4.7%). Patient demographics, overall survival and survival difference between synchronous and metachronous pulmonary metastasectomy groups were compared. In addition, outcomes in the ‘liver and lung resection’ group were compared with a matched group of ‘liver resection only’ patients (matched for age, primary disease stage, interval to liver resection and liver disease stage).ResultsForty-three patients (median age 62, range 43–83 years, 22 males) underwent sequential liver and lung resection. A total of 36 patients underwent major hepatic resections, 18 patients had bilobar disease and the median number of liver lesions resected was 3 (range 1–5 lesions). Ten patients had synchronous liver and lung metastases. The median interval between liver and lung metastasectomy was 25 months (range 2–88 months). A total of two patients underwent major lobectomies, three patients had bilateral disease and the median number of lung lesions resected was one (range 1–3). The 1-, 3- and 5-year overall survival rates after first metastasectomy were 100%, 87.1% and 53.9%, respectively, with a median survival of 42 months.PatientsUndergoing metachronous pulmonary metastasectomy had better 1-, 3- and 5-year survival rates than those with synchronous disease (100%, 88.9% and 60.9% vs. 100%, 75% and 0%, respectively; P= 0.02, log rank test). There was no significant survival difference between the ‘liver and lung resection’ and the ‘liver resection only’ groups.ConclusionSequential liver and lung resection for CLM is associated with good long-term survival in selected patients, except in those presenting with synchronous lung and liver metastases