Endoscopic Versus Surgical Management and Outcome of CBD Stones 2020

Background: Common bile duct stones are present in approximately 5% of the patients undergoing elective cholecystectomy and 10% of patients with acute cholecystitis with different modality of treatment. This study investigated  edoscopic and surgical management and outcome  of CBD stones among Sudanese patients at Ibn Sina Hospital October 2018 to October 2019. The study included 68 patients. Data was collected using a constructed structured pretest questionnaire. Objectives:To asses the outcome of endoscopic versus surgical management of common  Bile duct stones. Methods and patients:This is a hospital based descriptive cross-sectional study, which was conducted in Ibn Sena Specialized Hospital over a period of one year October 2018 to October 2019 . Results:68 patients involved in the study , male to female ratio 0.6:1,the mean age was 61.2 years , patients underwent surgical management were 51.5%, patients underwent endoscopic management were 48.5%,multiple stones  found in 73.5%,single stone found in 26.5%,stone found to be more than 1 cm in 41.2% less than 1cm in 58.8%,the success rate in achieving bile duct clearance in surgical group was 100% and in endoscopic group was 75.7%,complications developed in surgical group was wound infection in 2.85%,complications developed in endoscopic group was cholangitis  9%,in adequate clearance with stenting 9%and failure of Ercp in 15.1%,prolonged hospital stay in surgical group in   comparison to endoscopic group                                                 . Conclusion:Surgical interventions were superior in achieving bile duct clearance there was significant correlation between size and number of stones and endoscopic failure and management

Prevalence of Pancreaticobiliary Maljunction (PBM) Among Sudanese Patients with Obstructive Jaundice in Ibnsina Specialized Hospital

Background: pancreaticobiliary maljunction is a congenital malformation in which the pancreatic and bile ducts join outside the duodenal wall. The common channel is long that leads to continuous reciprocal reflux between pancreatic juice and bile, resulting in various pathologic conditions in the biliary tract and pancreas. Methods and patients: This is a hospital based descriptive cross-sectional study, which was conducted in Ibn Sina Specialized Hospital over a period of one year (August 2018 – August 2019). The study included 62 patients. Data was collected using a constructed structure pretest questionnaire. Results: the mean age of the patients was 50.5, with male to female ratio 1:2.1. The majority of patients presented with the symptoms of bile obstruction .MRCP was done for all patients ; showed that CBD stones was the most common diagnosis in 82.3 %(n=51), followed by pancreatic carcinoma 6.5%(n=4). PBM found in 35.5 %( n= 22); the majority were type B 24.2% (n=15). In patients with CBD stones 82.3 %(n=51), PBM type B was the most common anomaly found 23.5% (n=12), the serum direct bilirubin was <5 mg/dl in 78%(n=40),and ALP more than 300 U/L in the majority of them. Conclusion : The prevalence of PBM is 35.5% , commonly found in female. The most common type of PBM is - type B, commonly found in patients with obstructive jaundice due to CBD stones

Outcome of Palliative Surgery in Advanced Pancreatic Cancer in Sudanese Patients in Ibn Sina Specialized Hospital

Introduction: Pancreatic cancer is the 4thleading cause of death and due to late presentation, the curative procedures are more challenging and difficult. Pancreatic cancer is not uncommon in Sudanese patients and usually presents late. The aim of this study was to assess the outcome of palliative surgery in advanced pancreatic cancer and to reflect our local experience. Methodology: It was a prospective cross-sectional hospital-based study.  It included 92 patients with advanced pancreatic cancer in Ibn Sina Specialized Hospital. Data were collected and variables; age, gender, origin and clinical features were measured. Patients were classified based on type of surgery (single, double or triplebypass). Data collected and analyzed by using statistical package for social sciences (SPSS) computer program version 20.Qualitative data were analyzed by using descriptive statistic t test and pearson chi_square. The P value was considered significant if <0.05. Results:The mean age of the study was 65.4, (+/_13SD)male to female ratio was 1.8:1. The majority of the patients (36%) were from northern state; namely Shwaiga, Mahas, Bederia and Gaalian and 22% from Western state namely Baggara, Jamoaia and Foor. Nearly two-third of the patients had double bypass, and the remaining were equally single and triple bypass. The main presenting symptoms were jaundice, dyspepsia and vomiting and it is significantly common among alcohol consumers. Dyspepsia was statistically early symptoms and serum aspartate transaminase (AST) and alkaline phosphatase (ALP) were statistically high. There was less than 30 % of those who survived more than one year. There was no statistically significant difference between type of bypass and the outcome. Conclusion: The outcome of those patients was not affected by modality of bypass. Dyspepsia was the earliest complain and high serum aspartate transaminase (AST) and alkaline phosphatase (ALP) could be important prognostic factors. pancreatic cancer is common in certain populations

Predictors of actual five-year survival and recurrence after pancreatoduodenectomy for ampullary adenocarcinoma: results from an international multicentre retrospective cohort study

Background: pancreatoduodenectomy (PD) is recommended in fit patients with a resectable ampullary adenocarcinoma (AA). We aimed to identify predictors of five-year recurrence/survival.Methods: data were extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective study of PD patients with a confirmed head of pancreas or periampullary malignancy (June 1st, 2012-May 31st, 2015). Patients with AA who developed recurrence/died within five-years were compared to those who did not.Results: 394 patients were included and actual five-year survival was 54%. Recurrence affected 45% and the median time-to-recurrence was 14 months. Local only, local and distant, and distant only recurrence affected 34, 41 and 94 patients, respectively (site unknown: 7). Among those with recurrence, the most common sites were the liver (32%), local lymph nodes (14%) and lung/pleura (13%). Following multivariable tests, number of resected nodes, histological T stage &gt; II, lymphatic invasion, perineural invasion (PNI), peripancreatic fat invasion (PPFI) and ≥1 positive resection margin correlated with increased recurrence and reduced survival. Furthermore, ≥1 positive margin, PPFI and PNI were all associated with reduced time-to-recurrence.Conclusions: this multicentre retrospective study of PD outcomes identified numerous histopathological predictors of AA recurrence. Patients with these high-risk features might benefit from adjuvant therapy.</p

Serious complications of pancreatoduodenectomy correlate with lower rates of adjuvant chemotherapy: results from the recurrence after Whipple's (RAW) study

Introduction: adjuvant chemotherapy (AC) can prolong overall survival (OS) after pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). However, fitness for AC may be influenced by postoperative recovery. We aimed to investigate if serious (Clavien-Dindo grade ≥ IIIa) postoperative complications affected AC rates, disease recurrence and OS.Materials and methods: data were extracted from the Recurrence After Whipple's (RAW) study (n = 1484), a retrospective study of PD outcomes (29 centres from eight countries). Patients who died within 90-days of PD were excluded. The Kaplan-Meier method was used to compare OS in those receiving or not receiving AC, and those with and without serious postoperative complications. The groups were then compared using univariable and multivariable tests.Results: patients who commenced AC (vs no AC) had improved OS (median difference: (MD): 201 days), as did those who completed their planned course of AC (MD: 291 days, p &lt; 0.0001). Those who commenced AC were younger (mean difference: 2.7 years, p = 0.0002), more often (preoperative) American Society of Anesthesiologists (ASA) grade I-II (74% vs 63%, p = 0.004) and had less often experienced a serious postoperative complication (10% vs 18%, p = 0.002). Patients who developed a serious postoperative complication were less often ASA grade I-II (52% vs 73%, p = 0.0004) and less often commenced AC (58% vs 74%, p = 0.002).Conclusion: in our multicentre study of PD outcomes, PDAC patients who received AC had improved OS, and those who experienced a serious postoperative complication commenced AC less frequently. Selected high-risk patients may benefit from targeted preoperative optimisation and/or neoadjuvant chemotherapy.</p

Does an extensive diagnostic workup for upfront resectable pancreatic cancer result in a delay which affects survival? Results from an international multicentre study

Backgrounds/aims: pancreatoduodenectomy (PD) is recommended in fit patients with a carcinoma (PDAC) of the pancreatic head, and a delayed resection may affect survival. This study aimed to correlate the time from staging to PD with long-term survival, and study the impact of preoperative investigations (if any) on the timing of surgery.Methods: data were extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective study of PD outcomes. Only PDAC patients who underwent an upfront resection were included. Patients who received neoadjuvant chemo-/radiotherapy were excluded. Group A (PD within 28 days of most recent preoperative computed tomography [CT]) was compared to group B (&gt; 28 days).Results: a total of 595 patents were included. Compared to group A (median CT-PD time: 12.5 days, interquartile range: 6-21), group B (49 days, 39-64.5) had similar one-year survival (73% vs. 75%, p = 0.6), five-year survival (23% vs. 21%, p = 0.6) and median time-todeath (17 vs. 18 months, p = 0.8). Staging laparoscopy (43 vs. 29.5 days, p = 0.009) and preoperative biliary stenting (39 vs. 20 days, p &lt; 0.001) were associated with a delay to PD, but magnetic resonance imaging (32 vs. 32 days, p = 0.5), positron emission tomography (40 vs. 31 days, p &gt; 0.99) and endoscopic ultrasonography (28 vs. 32 days, p &gt; 0.99) were not.Conclusions: although a treatment delay may give rise to patient anxiety, our findings would suggest this does not correlate with worse survival. A delay may be necessary to obtain further information and minimize the number of PD patients diagnosed with early disease recurrence.</p

Postoperative complications after pancreatoduodenectomy for malignancy: results from the Recurrence After Whipple's (RAW) study

Background: pancreatoduodenectomy (PD) is associated with significant postoperative morbidity. Surgeons should have a sound understanding of the potential complications for consenting and benchmarking purposes. Furthermore, preoperative identification of high-risk patients can guide patient selection and potentially allow for targeted prehabilitation and/or individualized treatment regimens. Using a large multicentre cohort, this study aimed to calculate the incidence of all PD complications and identify risk factors.Method: data were extracted from the Recurrence After Whipple's (RAW) study, a retrospective cohort study of PD outcomes (29 centres from 8 countries, 2012-2015). The incidence and severity of all complications was recorded and potential risk factors for morbidity, major morbidity (Clavien-Dindo grade &gt; IIIa), postoperative pancreatic fistula (POPF), post-pancreatectomy haemorrhage (PPH) and 90-day mortality were investigated.Results: among the 1348 included patients, overall morbidity, major morbidity, POPF, PPH and perioperative death affected 53 per cent (n = 720), 17 per cent (n = 228), 8 per cent (n = 108), 6 per cent (n = 84) and 4 per cent (n = 53), respectively. Following multivariable tests, a high BMI (P = 0.007), an ASA grade &gt; II (P &lt; 0.0001) and a classic Whipple approach (P = 0.005) were all associated with increased overall morbidity. In addition, ASA grade &gt; II patients were at increased risk of major morbidity (P &lt; 0.0001), and a raised BMI correlated with a greater risk of POPF (P = 0.001).Conclusion: in this multicentre study of PD outcomes, an ASA grade &gt; II was a risk factor for major morbidity and a high BMI was a risk factor for POPF. Patients who are preoperatively identified to be high risk may benefit from targeted prehabilitation or individualized treatment regimens.</p