Resectable rectal cancer: which patient does not need preoperative radiotherapy?

It is well known that some patients with resectable rectal cancer benefit from preoperative radiotherapy in combination with or without chemotherapy. In order to reduce local recurrence and improve long-term survival, current guidelines advocate such neoadjuvant treatment in UICC (Union for International Cancer Control) stage II and III patients. However, the vast majority of patients may be adequately treated by rectal resection with total mesorectal excision (TME) alone. Recent evidence suggests an overtreatment of patients leading to unnecessary exposure to acute and long-term toxicity of radiation therapy. The question which consequently arises is which patient does not need preoperative radiotherapy. Improvements in MRI combined with better understanding of prognostic indicators suggest that patients with UICC stage I tumors, with tumors more than 12 cm proximal the anal verge can and patients with a circumferential resection margin 6 > 2 mm as assessed by preoperative MRI might be managed by radical surgery with adequate TME alone. Copyright © 2012 S. Karger AG, Base

Splenic and portal vein thrombosis in pancreatic metastasis from Renal cell carcinoma

BACKGROUND: Pancreatic metastases from previously treated renal cell carcinoma are uncommon. Surgical resection of pancreatic metastasis remains the only worthwhile modality of treatment. CASE PRESENTATION: A case where pancreatic metastasis from previously resected right sided renal cell carcinoma was resected with a subtotal left pancreatectomy is described. An unusual feature was the presence of a large splenic vein tumor thrombus extending into the portal vein with associated portal hypertension. The patient underwent an uneventful portal vein resection with primary anastomosis. CONCLUSION: This is possibly the first documented case of portal vein renal tumor thrombosis in a case of isolated pancreatic metastasis from previously operated renal cell carcinoma in published world surgical literature

The role of octreotide in preventing complications after pancreatoduodenectomy for cancer

Background Although the mortality rate of pancreatoduodenectomy has fallen sharply over the last two decades, there is still a risk of serious complications resulting from leakage at the site of anastomosis between the pancreatic remnant and the gastrointestinal tract. Numerous techniques have been described to minimise the risk of these anastomotic leaks, but they can be difficult to avoid if the distal pancreas is unobstructed with a soft parenchyma and a non-dilated duct. The risk of leakage is largely dependent upon the presence of activated pancreatic enzymes, and this fact provides a rationale for the perioperative use of the somatostatin analogue octreotide to inhibit exocrine pancreatic secretion. Discussion Six prospective randomised controlled trials have been published on the use of prophylactic octreotide in pancreatic surgery, five from Europe and one from the USA. The five (multicentre) European studies have consistently shown that octreotide reduces the postoperative complication rate, but the American study does not confirm this benefit. Methodological differences may explain the discrepancy, notably the fact that most of the US patients had received preoperative chemoradiation which is likely to have reduced enzyme secretion. A meta-analysis of four of these studies showed that octreotide lowered the rate of postoperative complications from 37 to 21%, chiefly by reducing the risk of pancreatic fistula. Prophylactic octreotide therapy is cost effective and should be used at least in patients with normal pancreatic parenchyma

A proposal for a new clinical classification of chronic pancreatitis

<p>Abstract</p> <p>Background</p> <p>The clinical course of chronic pancreatitis is still unpredictable, which relates to the lack of the availability of a clinical classification. Therefore, patient populations cannot be compared, the course and the outcome of the disease remain undetermined in the individual patient, and treatment is not standardized.</p> <p>Aim</p> <p>To establish a clinical classification for chronic pancreatitis which is user friendly, transparent, relevant, prognosis- as well as treatment-related and offers a frame for future disease evaluation.</p> <p>Methods</p> <p>Diagnostic requirements will include one clinical criterion, in combination with well defined imaging or functional abnormalities.</p> <p>Results</p> <p>A classification system consisting of three stages (A, B and C) is presented, which fulfils the above-mentioned criteria. Clinical criteria are: pain, recurrent attacks of pancreatitis, complications of chronic pancreatitis (e.g. bile duct stenosis), steatorrhea, and diabetes mellitus. Imaging criteria consist of ductal or parenchymal changes observed by ultrasonography, ERCP, CT, MRI, and/or endosonography.</p> <p>Conclusion</p> <p>A new classification of chronic pancreatitis, based on combination of clinical signs, morphology and function, is presented. It is easy to handle and an instrument to study and to compare the natural course, the prognosis and treatment of patients with chronic pancreatitis.</p

Surgical ampullectomy: an underestimated operation in the era of endoscopy

AbstractIntroductionBenign neoplastic, inflammatory or functional pathologies of the ampulla of Vater are mainly treated by primary endoscopic interventions. Consequently, transduodenal surgical ampullectomy (TSA) has been abandoned in many centres, although it represents an important tool not only after unsuccessful endoscopic treatment. The aim of the study was to analyse TSA for benign lesions of the ampulla of Vater.Patients and methodsAll patients who underwent TSA between 2001 and 2014 were included. Patients were analysed in terms of indications, postoperative morbidity and mortality as well as long-term success.ResultsEighty-three patients underwent TSA. Indications included adenomas in 44 and inflammatory stenosis in 39 patients. 96% of the patients had undergone endoscopic therapeutic approaches prior to TSA (median no. of interventions n = 3). Postoperative morbidity occurred in 20 patients (24%). There was one procedure-associated death (mortality 1.2%). The mean follow-up was 54 months. Long-term overall success rate for TSA was 83.6%. After TSA for ampullary adenoma, the recurrence rate was 4.5%.ConclusionTSA is an underestimated surgical procedure, which can be performed safely with high long-term efficacy. It can be implemented in clinical algorithms for patients with benign pathologies of the ampulla of Vater, particularly after unsuccessful endoscopic treatment