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

Postoperative complications; Pancreatoduodenectomy; RecurrenceComplicaciones postoperatorias; Pancreatoduodenectomía; RecurrenciaComplicacions postoperatòries; Pancreatoduodenectomia; RecurrènciaBackground 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 > 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 > II (P II patients were at increased risk of major morbidity (P < 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 > 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

Somatostatin and the 'Small-For-Size' Liver

"Small-for-size" livers arising in the context of liver resection and transplantation are vulnerable to the effects of increased portal flow in the immediate postoperative period. Increased portal flow is an essential stimulus for liver regeneration. If the rise in flow and stimulus for regeneration are excessive; however, liver failure and patient death may result. Somatostatin is an endogenous peptide hormone that may be administered exogenously to not only reduce portal blood flow but also offer direct protection to different cells in the liver. In this review article, we describe key changes that transpire in the liver following a relative size reduction occurring in the context of resection and transplantation and the largely beneficial effects that peri-operative somatostatin therapy may help achieve in this setting

Laparoscopic versus open hemihepatectomy: comprehensive comparison of complications and costs at 90 days using a propensity method

Laparoscopic hemihepatectomy (LHH) may ofer advantages over open hemihepatectomy (OHH) in blood loss, recovery, and hospital stay. The aim of this study is to evaluate our recent experience performing hemihepatectomy and compare complications and costs up to 90 days following laparoscopic versus open procedures. Retrospective evaluation of patients undergoing hemihepatectomy at our center 01/2010-12/2018 was performed. Patient, tumor, and surgical characteristics; 90-day complications; and costs were analyzed. Inverse probability of treatment weighting (IPTW) was used to balance covariates. A total of 141 hemihepatectomies were included: 96 OHH and 45 LHH. While operative times were longer for LHH, blood loss and transfusions were less. At 90 days, there were similar rates of liver-specifc and surgical complications but fewer medical complications following LHH. Medical complications that arose with greater frequency following OHH were primarily pulmonary complications and urinary and central venous catheter infections. Complications at 90 days were lower following LHH (Clavien-Dindo grade≥III OHH 23%, LHH 11%, p=0.130; Comprehensive Complication Index OHH 20.0±16.1, LHH 10.9±14.2, p=0.001). While operating costs were higher, costs for hospital stay and readmissions were lower with LHH. Patients undergoing LHH experience a signifcant reduction in postoperative medical complications and costs, resulting in 90-day cost equity compared with OHH

Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery

To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p &lt; 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

An Unusual Case of Fulminant Heart Failure

A 51-year-old patient presented with a 10-day history of breathlessness and back pain. Significant background his- tory included human immunodeficiency virus-2 and hepatitis C virus infections. Physical examination showed end-inspiratory crackles and muffled cardiac sounds and his blood test showed an increased aspartate aminotransferase level (500 IU/L), ala- nine aminotransferase level (654 IU/L), and lactate dehydroge- nase level (2354 IU/L). His chest radiograph confirmed pulmo- nary edema, and the echocardiogram showed severe pericardial effusion (2.5 cm). A computed tomography scan of the chest showed an incidental finding of a 5-cm liver mass at the liver dome. The patient was admitted to the intensive care unit to undergo percutaneous drainage of his pericardial effusion, and he died a few hours later of acute heart failure unresponsive to cardiovascular support. The patient underwent a post-mortem examination. The liver and the heart are shown in Figures A and B, respectively. Figure A shows a multifocal liver tumor ranging in size from 1 to 7 cm maximum. The heart, the pericardium, and the aortic arch were widely involved by metastatic deposits (Figure B). A section of the vertebral bones and the lungs also showed further small metastatic deposits. Initial histology of the liver lesions and the heart showed small-cell carcinoma (SmCC) (Figure C, tumor cells between myocardial cells, H&amp;E, original magnification, 100). We performed immunohisto- chemistry on the pulmonary deposits to rule out a primary pulmonary SmCC. No positivity was seen for thyroid transcrip- tion factor-1, caudal type homeobox transcription factor 2, CK7, CK20, chromogranin, synaptophysin, or CD56. Immuno- histochemical stains for hepatocyte paraffin 1 (Figure D), car- cinoembryonic antigen, and -fetoprotein showed a strong pos- itivity and TTF-1 negativity. On the basis of the macroscopic framework and immunohistochemical features, a diagnosis of metastatic SmCC of the liver was made. Cardiac metastases from hepatocellular carcinoma are very uncommon.1 Hepatic SmCCs are even more uncommon: to our knowledge, only 13 cases have been reported.2 They usually present with locally advanced or metastatic disease, and no disease-free survivors have been reported to date. Interestingly, they do not show any association with chronic liver disease or with hepatitis C/hepatitis B viruses, and high fetoprotein levels also seem to be uncommon

A wrong diagnosis of recurrent perineal hernia

We describe a case of a patient who had several operations for recurrent perineal hernia. She eventually had an abdominal surgical debulking for aggressive angiomyxoma

Microwave liver ablation and dark urine

Microwave assisted liver resection is a useful technique, especially when haemostasis could be difficult to achieve with conventional methods. However, prolonged administration of microwaves can be responsible for intraoperative haemoglobinuria. We describe the first case of acute haemolysis secondary to microwave assisted liver resection