Pancreaticoduodenectomy with and without routine intraperitoneal drainage

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Van Buren G 2nd, Bloomston M, Hughes SJ, et al. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg. 2014 Apr;259(4):605-12.

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Results: There were no differences between drain and no-drain cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, baseline quality of life, or operative technique. PD without intraperitoneal drainage was associated with an increase in the number of complications per patient [1 (0-2) vs 2 (1-4), P = 0.029]; an increase in the number of patients who had at least 1 ≥grade 2 complication [35 (52%) vs 47 (68%), P = 0.047]; and a higher average complication severity [2 (0-2) vs 2 (1-3), P = 0.027]. PD without intraperitoneal drainage was associated with a higher incidence of gastroparesis, intra-abdominal fluid collection, intra-abdominal abscess (10% vs 25%, P = 0.027), severe (≥grade 2) diarrhea, need for a postoperative percutaneous drain, and a prolonged length of stay. The Data Safety Monitoring Board stopped the study early because of an increase in mortality from 3% to 12% in the patients undergoing PD without intraperitoneal drainage.

Conclusions: This study provides level 1 data, suggesting that elimination of intraperitoneal drainage in all cases of PD increases the frequency and severity of complications.

See also: Van Buren G 2nd, Fisher WE. Pancreaticoduodenectomy Without Drains: Interpretation of the Evidence. Ann Surg. 2016 Feb;263(2):e20-1.

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Klebsiella pneumoniae liver abscess

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Jun JB. Klebsiella pneumoniae Liver Abscess. Infect Chemother. 2018 Sep;50(3):210-218. doi: 10.3947/ic.2018.50.3.210.

Abstract: Since the mid 1980s, the prevalence of liver abscess caused by hypervirulent Klebsiella pneumoniae strain has increased in Asia, particularly in Taiwan and Korea. This strain is mostly K1 or K2 serotype, and has hypercapsular and hypermucoid phenotypes. Most infections are community acquired, and patients rarely have a hepatobiliary disease prior to infection. Clinical manifestations are characterized by fever and high C-reactive protein, and metastatic infections, such as septic emboli in the lung and endophthalmitis and meningitis are frequently observed. Antibiotic resistance is rare. Antibiotic treatment and abscess drainage are needed, and early diagnosis and treatment of endophthalmitis is also important.

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What is the classification of choledochal cysts?

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Choledochal Cyst. In: Doherty GM. eds. Quick Answers Surgery. McGraw-Hill; Accessed April 02, 2021. 

  • Type I cysts (fusiform dilation of common bile duct [CBD]) account for 85-90%
  • Type II (true diverticula of CBD) 1-2% of cases
  • Type III (choledochocele—dilation of distal/intramural portion of CBD) < 2% of cases
  • Type IV (multiple cysts involving intrahepatic and extrahepatic ducts) as high as 15% of cases in some series
  • Type V (cystic malformation of intrahepatic ducts) rare
  • 3-5% incidence of carcinoma
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Solid pseudopapillary neoplasms (SPN) of the pancreas

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Gandhi D, et al. Solid pseudopapillary Tumor of the Pancreas: Radiological and surgical review. Clin Imaging. 2020 Nov;67:101-107.

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Highlights:

  • Solid Pseudopapillary Neoplasms of the pancreas are rare pancreatic tumors with low grade malignant potential, typically affecting young females.
  • Small SPNs (< 3cm in diameter) usually appear as completely solid tumors with sharp margins and gradually enhancing, well encapsulated masses in the pancreas and may demonstrate varying amounts of hemorrhage.
  • Large lesions have mixed solid – cystic components showing early weak enhancement with gradual increase in enhancement in the hepatic venous phase.
  • Atypical features including extracapsular, as well as parenchymal invasion, simulation of islet cell tumors, calcifications, ductal obstruction, and metastasis are suspicious for malignant degradation.
  • The tumor is considered unresectable in the event that it invades or encases the aorta, encases >180 degree of the SMA regardless of tumor location in the pancreas, abuts the celiac artery (when the tumor is located in the pancreatic head) or encases >180 degree of the celiac artery (when the tumor is located in the body/tail of the pancreas).
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Totally Extra Peritoneal (e-TEP) Approach for Ventral Hernias

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Bui NH, Jørgensen LN, Jensen KK. Laparoscopic intraperitoneal versus enhanced-view totally extraperitoneal retromuscular mesh repair for ventral hernia: a retrospective cohort study. Surg Endosc. 2021 Mar 15.

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Results: A total of 72 patients were included in the study, 43 and 29 of whom underwent IPOM and eTEP-RM repair, respectively. Patient demographics showed no differences in terms of gender, age, smoking and comorbidity. The median age was 57 years and body mass index 30.5 kg/m2. The rate of patients with incisional hernia was higher in the IPOM group (39.5% vs. 20.7%, p = 0.154). There was no difference in horizontal and vertical hernia size defect. The duration of surgery was significantly shorter for IPOM (mean 82.4 vs. 103.4 min, p = 0.010), whereas the length of stay was significantly longer after IPOM (median 1 days vs. 0 days (p < 0.001). The rate of patients requiring postoperative transversus abdominis plane (TAP) block or epidural analgesia was significantly higher after IPOM (33% vs. 0%, p = 0.002). A subgroup analysis on patients undergoing primary ventral hernia showed similar results.

Conclusion: The study found laparoscopic eTEP-RM safe and effective compared to traditional laparoscopic IPOM. The patients undergoing eTEP-RM had significantly reduced need for additional analgesic treatment and length of stay.

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Article of interest: Resuscitative Endovascular Balloon Occlusion of Aaorta Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience.

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Hatchimonji JS, Chipman AM, McGreevy DT, et al. Resuscitative Endovascular Balloon Occlusion of Aaorta Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience. J Surg Res. 2020 Dec;256:149-155.

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Background: The aim of this study was to determine the current utilization patterns of resuscitative endovascular balloon occlusion of aorta (REBOA) for hemorrhage control in nontrauma patients.

Methods: Data on REBOA use in nontrauma emergency general surgery patients from six centers, 2014-2019, was pooled for analysis. We performed descriptive analyses using Fisher’s exact, Student’s t, chi-squared, or Mann-Whitney U tests as appropriate.

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Article of interest: Bleeding complications after pancreatic surgery: interventional radiology management

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Biondetti P, Fumarola EM, Ierardi AM, Carrafiello G. Bleeding complications after pancreatic surgery: interventional radiology management. Gland Surg. 2019 Apr;8(2):150-163. doi: 10.21037/gs.2019.01.06.

Surgical intervention in the pancreas region is complex and carries the risk of complications, also of vascular nature. Bleeding after pancreatic surgery is rare but characterized by high mortality. This review reports epidemiology, classification, diagnosis and treatment strategies of hemorrhage occurring after pancreatic surgery, focusing on the techniques, roles and outcomes of interventional radiology (IR) in this setting. We then describe the roles and techniques of IR in the treatment of other less common types of vascular complications after pancreatic surgery, such as portal vein (PV) stenosis, portal hypertension and bleeding of varices.