Distal Remnant Research Articles

Enveloped double curse-string versus conventional pancreatico-gastrostomy: comparative study

Background: Pancreatico-gastrostomy (PG) is widely applied for restoration of connection between the distal pancreatic remnant and digestive tract. So far, comparative studies on the clinical outcome of various PG techniques are scarse. Methods: EDPS-PG entails telescoping the pancreatic remnant into the interior of the stomach via posterior gastrostomy. The telescoped pancreatic stump is encircled by two purse-string sutures which are tied in opposite directions at 180 degrees angle. The purse-string sutures are enveloped inside two layers of transfixing sutures. Results: Thirty-three patients (22 conventional PG and 11 EDPS-PG) with operable pancreatic head cancer (31) or traumatic pancreas transection (2) were enrolled. Grade C postoperative pancreatic fistula occurred only in the conventional PG group. Patients in the EDPS-PG group needed significantly shorter time before removal of the abdominal drains (p< 0.05), significantly reduced length of hospital stay (p<0.05) and significantly lower grades of postoperative complications (p< 0.05) compared with the conventional PG group. Postoperative death occurred only in one patient in the control group. No significant difference could be found regarding operative time, postoperative bleeding delayed gastric emptying or bile leak. Conclusion: EDPS is simple and safe technique for PG. EDPS-PG is associated with significant reduction in postoperative pancreatic fistula and overall complications.

Surgical technique and results of intrapancreatic bile duct resection for hilar malignancy (with video)

BackgroundHilar malignancy can occasionally be associated with high grade dysplasia (HGD) adjacent to invasive malignancy. For patients with HGD extending into the intrapancreatic bile duct, the authors adopted intrapancreatic bile duct resection (IP-BDR). The aims of this study were to compare the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF), distal R0 resection and local recurrence within the distal bile duct remnant for patients undergoing extrahepatic bile duct resection without pancreaticoduodenectomy (with or without IP-BDR). MethodsPatients who presented with hilar malignancy and underwent extrahepatic bile duct resection without pancreaticoduodenectomy between January 2005 and December 2016 were identified and the outcomes retrospectively evaluated. ResultsOf 217 patients who met the inclusion criteria 62 (29%) patients underwent IP-BDR. There was a significant difference between patients undergoing standard resection vs. IP-BDR in terms of CR-POPF (5% (8/155) patients: vs 18% (11/62), p < 0.001). There were no significant differences between two groups of R0 status on distal margin (5% (8/155) patients: vs 10% (6/62), p = 0.359). No patient developed recurrence within the residual intrapancreatic bile duct. DiscussionThe incidence of CR-POPF after IP-BDR for hilar malignancies was 18%. IP-BDR was associated with CR-POF, but does not appear to alter survival or local recurrence rate.

Isolated pancreatic tail remnants after transgastric necrosectomy can be observed

BackgroundSevere necrotizing pancreatitis may result in midbody necrosis and ductal disruption leaving an isolated pancreatic tail. The purpose of this study was to characterize outcomes among patients with an isolated tail remnant who underwent transgastric drainage or necrosectomy (endoscopic or surgical) and determine the need for subsequent operative management. Materials and methodsPatients with necrotizing pancreatitis and retrogastric walled-off collections treated by surgical transgastric necrosectomy or endoscopic cystgastrostomy ± necrosectomy between 2009 and 2017 were identified by a retrospective chart review. All available preprocedure and postprocedure imaging was reviewed for evidence of isolated distal pancreatic tail remnants. ResultsSeventy-four patients were included (40 surgical and 34 endoscopic). All the patients in the surgical group underwent laparoscopic transgastric necrosectomy; the endoscopic group consisted of 26 patients for pseudocyst drainage and eight patients for necrosectomy. A disconnected pancreatic tail was identified in 22 (29%) patients (13 laparoscopic and nine endoscopic). After the creation of the “cystgastrostomy,” there were no external fistulas despite the viable tail. Of the 22 patients, four patients developed symptoms at a median of 23 months (two, recurrent episodic pancreatitis; two, intractable pain). Two patients (both initially in endoscopic group) ultimately required distal pancreatectomy and splenectomy at 24 and 6 months after index procedure. ConclusionsPatients with a walled-off retrogastric collection and an isolated viable tail are effectively managed by a transgastric approach. Despite this seemingly “unstable anatomy,” the creation of an internal fistula via surgical or endoscopic “cystgastrostomy” avoids external fistulas/drains and the short-term necessity of surgical distal pancreatectomy. A very small subset requires intervention for late symptoms.

Distal Bowel Re-feeding in Patients with Proximal Jejunostomy

BackgroundPatients who have a proximal jejunostomy are difficult to manage because of their high stoma output which results in fluid and electrolyte imbalance with repeated hospital admissions and the necessity for expensive parenteral nutrition (PN). There are few reports on the use of re-feeding of the proximal effluents in this situation. MethodsWe here relate our experience with this manoeuvre in 35 patients between Jan 2010 and Feb 2016 who had stomas less than 120 cm away from the duodenojejunal flexure. ResultsThere were 26 males and 9 females, whose median age was 47 (19–74) years. The most common indications for massive bowel resection were gangrene in 25 (71%) and intestinal perforation in 7 (20%). The median proximal and distal small bowel lengths were 45 (15–120) cm and 90 (0–240) cm respectively. The ileocaecal (IC) valve was preserved in 33 (94%) and there was only colon distally (without the ileocaecal valve) in 2 (6%) patients. Twenty-five (71%) patients required post-operative ICU care. Additional PN was required in 6 (17%) patients during their index admission with the average extra cost of treatment being 20,000 rupees. Their median hospital stay was 13 (6–60) days. Patients were discharged without intravenous (IV) lines. Eight (26%) patients required re-admission for acute renal failure which was managed conservatively. No major problems were associated with re-feeding. None of the patients required PN after discharge from hospital. Thirty (86%) patients had their stomas closed at 65 (14–224) days. Both the patients with colon only as their distal bowel remnant died. Sepsis was the cause of mortality in 4 (11%) during index admission and 3 after their discharge. On follow-up after bowel re-connection, 2 patients died after 1 and 12 months, both due to intracranial bleeding, and the overall survival was 74%. ConclusionsPatients with proximal jejunostomies can be managed with distal re-feeding. It is a cost-effective and effective substitute for PN, is associated with few problems, and has a fairly good long-term outcome.

415 - The Dilemma of the Dilated Main Pancreatic Duct in the Distal Pancreatic Remnant after Proximal Pancreatectomy for Intraductal Papillary Mucinous Neoplasm

415 - The Dilemma of the Dilated Main Pancreatic Duct in the Distal Pancreatic Remnant after Proximal Pancreatectomy for Intraductal Papillary Mucinous Neoplasm

An Attempt to Build a National Prospective Electronic Database for Pancreaticoduodenectomies in Romania - Preliminary Results of the First Year Enrollment.

Introduction: National databases for pancreaticoduodenectomies (PD) have contributed to better postoperative outcomes after such complex surgical procedure because the multicentre collection of data allowed more reliable analyses with quality assessment and further improvement of technical issues and perioperative management. The current practice and outcomes after PD are poorly known in Romania because there was no national database for these patients. Thus, in 2016 a national-intent electronic registry for PD was proposed for all Romanian surgical centers. The study aims to present the preliminary results of this national-intent registry for PD after one-year enrollment. Patients Methods: The database was started on October 1st, 2016. Data were prospectively collected with an electronic online form including 102 items for each patient. The registry was opened to all the Departments of Surgery from Romania performing PD, with no restriction. Results: During the first year of enrollment were collected the data of 181 patients with PD performed by 24 surgeons from four surgical centers. The age of patients was 64 years (28 - 81 years), with slightly male predominance (61.3%). Computed tomography was the main preoperative imaging investigation (84.5%). All the PDs were performed by an open approach. The Whipple technique was used in 53% of patients, and a venous resection was required in 14.3% of cases. A posterior approach PD was considered in 16.6% of patients. The stomach was used to treat the distal remnant pancreas in 50.1% of patients. The operative time was 285 min (110 - 615 min), and the estimated blood loss was 400 ml (80 - 3000 ml). The overall morbidity rate was 55.8%, with severe (i.e., grade III-IV Dindo-Clavien) morbidity rate of 10%, and 3.9% in-hospital mortality rate. The overall pancreatic fistula, delayed gastric emptying and hemorrhage rates were 19.9%, 39.8% and 15.5%. Periampullary malignancies were the main indications for PD (78.9%), with pancreatic cancer on the top (48%). Conclusions: To build a prospective electronic online database for PD in Romania appears to be a feasible project and a useful tool to know the current practice and outcomes after PD in our country. However, improvements are still required to encourage a larger number of surgical centers to introduce the data of patients with PD.

A139 - Gastrogastric Fistula and Type 2 Diabetes: Can Fistula Closure Improve Diabetes?

Roux-en-Y gastric bypass (RYGB) has been shown to significantly improve glucose control in patients with type 2 diabetes. A gastrogastric fistula (GGF) is defined as a communication between the proximal gastric pouch and the distal gastric remnant following RYGB. The formation of a GGF allows nutrients to pass through the native route, rather than bypassing the duodenum in typical RYGB configuration. Patients with GGF can present with weight regain and recurrence of diabetes. We sought to evaluate the effect of revisional bariatric surgery for known GGF on control of diabetes.

Pancreatico-jejunostomy decreases post-operative pancreatic fistula incidence and severity after central pancreatectomy.

Central pancreatectomy (CP) is an alternative to pancreaticoduodenectomy and distal pancreatectomy in benign tumours of pancreatic isthmus management. It is known for a high post-operative pancreatic fistula (POPF) rate. The purpose of this study was to compare POPF incidence between pancreatico-jejunostomy (PJ) and pancreatico-gastrostomy (PG). Fifty-eight patients (mean age 53.9 ± 1.9 years) who underwent a CP in four French University Hospitals from 1988 to 2011 were analysed. The distal pancreatic remnant was either anastomosed to the stomach (44.8%, n = 25) or to a Roux-en-Y jejunal loop (55.2%, n = 35) with routine external drainage allowing a systematic search for POPF. POPF severity was classified according to the International Study Group on Pancreatic Fistula (ISGPF) and Clavien-Dindo classifications. The groups were similar on sex ratio, mean age, ASA score, pancreas texture, operative time and operative blood loss. Mean follow-up was 36.2 ± 3.9 months. POPF were significantly more frequent after PG (76.9 versus 37.5%, P = 0.003). PG was associated with significantly higher grade of POPF both when graded with ISGPF classification (P = 0.012) and Clavien-Dindo classification (P = 0.044). There was no significant difference in post-operative bleeding (0.918) and delayed gastric emptying (0.877) between the two groups. Hospital length of stay was increased after PG (23.6 ± 3.5 days versus 16.5 ± 1.9 days, P = 0.071). There was no significant difference in incidence of long-term exocrine (3.8 versus 19.2%, P = 0.134) and endocrine (7.7 versus 9.4%, P = 0.575) pancreatic insufficiencies. PG was associated with a significantly higher POPF incidence and severity in CP. We recommend performing PJ especially in older patients to improve CP outcomes.

The Locations of Anterior Cruciate Ligament Tears in Pediatric and Adolescent Patients: A Magnetic Resonance Study.

Recently, a resurgence of interest has been noted in anterior cruciate ligament (ACL) preservation in pediatric and adolescent patients. Different tear types, defined by their tear location, require different preservation techniques: proximal and distal avulsion tears can be treated with arthroscopic primary repair, whereas primary repair with biological scaffold has been proposed for midsubstance tears. The goal of this study was to assess the distribution of different tear types in pediatric and adolescent patients, as these are currently unknown. A retrospective search in an institutional radiographic database was performed for patients under 18.0 years undergoing knee magnetic resonance imaging (MRI) for ACL tears between June 2005 and June 2016. Patients with reports of chronic tears, partial tears, and multiligamentous injuries were excluded.Tear locations were graded using MRI as: proximal avulsion (distal remnant length >90% of total length; type I), proximal (75% to 90%; type II), midsubstance (25% to 75%; type III), distal (10% to 25%; type IV), and distal avulsion (<10%; type V). A total of 274 patients (59% girls; mean±SD age, 15.1±2.1 y; range, 6.9 to 18.0 y) were included. Frequency of type I tears was 15%, type II 23%, type III 52%, type IV 1%, and type V 8% (of which 7% had bony avulsion).Prevalence of tear types varied with age. At age 6 to 10 years, 93% were type V (bony) avulsion tears. At age 11 to 13 years, 32% were type I, 16% type II, 32% type III, and 16% type V. At age 14 to 17 years, type III tears were more common (57%) than type I (14%), type II (25%) and type V (2%) tears. It was noted that the ACL was torn at different locations depending on the patients' age. These data provide more information on the potential application for ACL preservation in pediatric and adolescent patients. Future studies correlating these findings with arthroscopy are needed before using MRI for preoperative planning of ACL preservation surgery. Diagnostic level III.

Preoperative magnetic resonance imaging predicts eligibility for arthroscopic primary anterior cruciate ligament repair.

To assess the role of preoperative magnetic resonance imaging (MRI) on the eligibility for arthroscopic primary anterior cruciate ligament (ACL) repair. All patients undergoing ACL surgery between 2008 and 2017 were included. Patients underwent arthroscopic primary repair if sufficient tissue length and quality were present, or they underwent single-bundle ACL reconstruction. Preoperative MRI tear locations were graded with the modified Sherman classification: type I (>90% distal remnant length), type II (75-90%), or type III (25-75%). MRI tissue quality was graded as good, fair, or poor. Arthroscopy videos were reviewed for tissue length and quality, and final treatment. Sixty-three repair patients and 67 reconstruction patients were included. Repair patients had more often type I tears (41 vs. 4%, p<0.001) and good tissue quality (89 vs. 12%, p<0.001). Preoperative MRI tear location and tissue quality predicted eligibility for primary repair: 90% of all type I tears and 88% of type II tears with good tissue quality were repaired, while only 23% of type II tears with fair tissue quality, 0% of type II tears with poor tissue quality, and 14% of all type III tears could be repaired. This study showed that tear location and tissue quality on preoperative MRI can predict eligibility for arthroscopic primary ACL repair. These findings may guide the orthopaedic surgeon on the preoperative assessment for arthroscopic primary repair of proximal ACL tears. Level IV.

Peritonitis caused by Candida albicans: Rare presentation of a refluxing ureteral stump

Ureteral stump syndrome is a medical condition caused by a refluxing distal ureteral remnant left after nephrectomy. Fungal colonization of the ureteral stump is uncommon and distant site infection is exceptional. We present a unique case of fungal peritonitis in a 13-year-old boy who had a right lower-moiety heminephro-ureterectomy at age three with a ureteral stump that served as reservoir for Candida resulting in the subsequent spontaneous fungal passage to the peritoneum.

The Location of Anterior Cruciate Ligament Tears: A Prevalence Study Using Magnetic Resonance Imaging.

Background:Over the past decade, there has been a resurgence of interest in anterior cruciate ligament (ACL) preservation. Proximal and distal avulsion tears have been treated with arthroscopic primary repair, while augmented repair, remnant tensioning, primary repair with biological scaffold, and remnant preservation have been proposed for different types of midsubstance tears. Currently, the incidence of these different tear types is unknown.Purpose:To propose a magnetic resonance imaging (MRI) classification system for different tear types based on clinical relevance and to assess the distribution of these different ACL tear types.Study Design:Case series; Level of evidence, 4.Methods:A retrospective search in an institutional radiographic database was performed for patients who underwent knee MRI at our institution between June 2014 and June 2016. Patients younger than 18 years and those with reports of chronic tears, partial tears, multiligamentous injuries, were excluded. Tear types were graded as proximal avulsion (distal remnant length >90% of total ligament length, type I), proximal (75%-90%, type II), midsubstance (25%-75%, type III), distal (10%-25%, type IV), and distal avulsion (<10%, type V). An orthopaedic surgeon, a radiologist, and a research fellow graded the tear type on 30 MRIs to determine reliability, and the research fellow graded all MRIs. Inter- and intraobserver reliability were measured using kappa statistics.Results:A total of 353 patients (57% male; mean age, 37.1 years; range, 18.1-81.2 years) were included. Interobserver reliability was 0.670 (95% confidence interval, 0.505-0.836), and intraobserver reliability ranged from 0.741 to 0.934. Incidence of type I tears was 16%, type II tears 27%, type III tears 52%, type IV tears 1%, and type V tears 3% (2.5% with bony avulsion). Type I tears were more common in patients older than 35 years compared with those younger than 35 years (23% vs 8%; P < .001).Conclusion:This classification system was reliable in assessing tear location in acute ACL injuries. Type I tears were seen in 16%, type II in 27%, and type III in 52% of patients in our cohort. These data suggest that there may be greater potential application for ACL preservation techniques.

Epithelial IGF1R is dispensable for IGF2 mediated enhanced intestinal adaptation in retinoblastoma-deficient mice

PurposePreviously, we demonstrated enhanced adaptation after small bowel resection (SBR) in intestinal-specific retinoblastoma (Rb)-deficient mice along with elevated levels of insulin-like growth factor 2 (IGF2) expression within the villi. The purpose of this study was to verify that the insulin-like growth factor 1 receptor (IGF1R) plays a role in this phenomenon. MethodsInducible and intestinal specific Rb and IGF1R double knockout mice (iRb/IGF1R-IKO) (n=4) and Rb single knockout mice (iRb-IKO) (n=5) underwent 50% mid SBR. On post-operative day 28, mice were harvested, and structural adaptation was measured as changes in crypt depth and villus height. Rates of enterocyte proliferation were recorded. IGF2 expression within the remnant villi was measured via RT-PCR. ResultsBoth iRb-IKO and iRb/IGF1R-IKO mice demonstrated enhanced adaptation with at least a 45% increase in both crypt depth and villus height in the proximal and distal remnant bowel. Both groups showed elevation of IGF2 expression in the remnant villi, but there were no differences between the two groups. ConclusionEpithelial IGF1R is dispensable for IGF2-mediated enhanced intestinal adaptation in retinoblastoma-deficient mice. Our findings suggest that IGF2 signals for enhanced adaptation in cells outside of the epithelium. Further investigation is needed to study the IGF2/IGF1R signaling interaction within the mesenchyme. Level of EvidenceAnimal study - not clinical.

Enveloped double purse-string versus conventional pancreatico-gastrostomy during Whipple procedure: comparative study at Sohag university onco-surgery program

Background: Pancreatico-gastrostomy (PG) is widely applied for restoration of connection between the distal pancreatic remnant and digestive tract during Whipple procedure. Comparative studies on the clinical outcome of various PG techniques are scarce. Methods: Medical records of patients who underwent PG at Sohag University Hospital (November 2012-December 2015) were reviewed. Patients who had PG using our new technique of enveloped double purse-string sutures (EDPS-PG) were compared with control group of conventional transfixing suture PG regarding the postoperative outcome. Results: Twenty-seven patients (18 conventional PG and 9 EDPS-PG) were enrolled. Grade C postoperative pancreatic fistula (POPF) occurred only in the conventional PG group. Patients in the EDPS-PG group needed significantly shorter time before removal of the abdominal drains (p = 0.04), significantly reduced length of hospital stay (p = 0.03) and significantly lower grades of postoperative complications (p = 0.02) compared with the conventional PG group. Postoperative death occurred only in one patient in the control group. No significant difference could be found regarding operative time, postoperative bleeding delayed gastric emptying or bile leak. Conclusions: EDPS-PG is new, simple and safe technique for PG during Whipple procedure and results in significant reduction of POPF and overall complications.

Revascularisation pattern of ruptured flexor tendon grafts in anterior cruciate ligament reconstruction: A histological study

IntroductionFor successful anterior cruciate ligament (ACL) reconstruction, revascularisation and histological maturation are necessary, as their failure can cause graft rupture. PurposeThe purpose of this study was to describe differences in the histological maturation of early failed plasty (less than 12 months after surgery) and late failed plasty (more than 12 months after surgery) in patients with re-rupture after ACL reconstruction with hamstring tendons. Material and methodsA descriptive observational study was conducted on a consecutive series of 20 patients whose ACL reconstruction had failed. Graft biopsy samples were obtained during the revision surgery from the proximal, medial, and distal graft remnants. The samples were evaluated by light microscopy, and the vascularity and maturation of the samples were established by histological scoring. ResultsThe most common aetiology of reconstruction failure (86.6%) was a specific event with non-contact mechanism. The patients with re-rupture of their ACL plasty less than 12 months after surgery had substance vessels that were less deep. The distal segment of the graft in those patients showed a delay in histological maturation with fewer collagen fibres. ConclusionIn patients whose ACL grafts failed less than 12 months after surgery, a lower distribution of blood vessels and collagen fibres was found that were less ordered in the distal graft. These results indicate a delay in maturation, which leads to a higher risk of graft failure.

Patrón de revascularización de injertos de tendones flexores rotos en reconstrucción de ligamento cruzado anterior: un estudio histológico

IntroductionFor successful anterior cruciate ligament (ACL) reconstruction, revascularisation and histological maturation are necessary, as their failure can cause graft rupture. PurposeThe purpose of this study was to describe differences in the histological maturation of early failed plasty (less than 12 months after surgery) and late failed plasty (more than 12 months after surgery) in patients with re-rupture after ACL reconstruction with hamstring tendons. Material and methodsA descriptive observational study was conducted on a consecutive series of 20 patients whose ACL reconstruction had failed. Graft biopsy samples were obtained during the revision surgery from the proximal, medial, and distal graft remnants. The samples were evaluated by light microscopy, and the vascularity and maturation of the samples were established by histological scoring. ResultsThe most common aetiology of reconstruction failure (86.6%) was a specific event with non-contact mechanism. The patients with re-rupture of their ACL plasty less than 12 months after surgery had substance vessels that were less deep. The distal segment of the graft in those patients showed a delay in histological maturation with fewer collagen fibres. ConclusionIn patients whose ACL grafts failed less than 12 months after surgery, a lower distribution of blood vessels and collagen fibres was found that were less ordered in the distal graft. These results indicate a delay in maturation, which leads to a higher risk of graft failure.

Long-Term Changes in the Distal Aorta after Aortic Arch Replacement in Acute DeBakey Type I Aortic Dissection.

BackgroundWe analyzed the long-term results of ascending aortic replacement and arch aortic replacement in acute DeBakey type I aortic dissections to measure the differences in the distal aortic changes with extension of the aortic replacement.MethodsWe reviewed 142 cases of acute DeBakey type I aortic dissections (1996–2015). Seventy percent of the cases were ascending aortic replacements, and 30% of the cases underwent total arch aortic replacement, which includes the aorta from the root to the beginning of the descending aorta with the 3 arch branches. Fourteen percent (20 cases) resulted in surgical mortality and 86% of cases that survived had a mean follow-up period of 6.6±4.6 years. Among these cases, 64% of the patients were followed up with computed tomography (CT) angiograms with the duration of the final CT check period of 4.9±2.9 years.ResultsThere were 15 cases of reoperation in 13 patients. Of these 15 cases, 13 cases were in the ascending aortic replacement group and 2 cases were in the total arch aortic replacement group. Late mortality occurred in 13 cases; 10 cases were in the ascending aortic replacement group and 3 cases were in the total arch aortic replacement group. Eight patients died of a distal aortic problem in the ascending aortic replacement group, and 1 patient died of distal aortic rupture in the total arch aortic replacement group. The follow-up CT angiogram showed that 69.8% of the ascending aortic replacement group and 35.7% of the total arch aortic replacement group developed distal aortic dilatation (p=0.0022).ConclusionThe total arch aortic replacement procedure developed fewer distal remnant aortic problems from dilatation than the ascending aortic replacement procedure in acute type I aortic dissections.

Radiofrequency-induced heating versus mechanical stapler for pancreatic stump closure: in vivo comparative study

Purpose: The aim of this study was to assess the capacity of two methods of surgical pancreatic stump closure in terms of reducing the risk of pancreatic fistula formation (POPF): radiofrequency-induced heating versus mechanical stapler. Materials and methods: Sixteen pigs underwent a laparoscopic transection of the neck of the pancreas. Pancreatic anastomosis was always avoided in order to work with an experimental model prone to POPF. Pancreatic stump closure was conducted either by stapler (ST group, n = 8) or radiofrequency energy (RF group, n = 8). Both groups were compared for incidence of POPF and histopathological alterations of the pancreatic remnant. Results: Six animals (75%) in the ST group and one (14%) in the RF group were diagnosed with POPF (p = 0.019). One animal in the RF group and three animals in the ST group had a pseudocyst in close contact with both pancreas stumps. On day 30 post-operation (PO), almost complete atrophy of the exocrine distal pancreas was observed when the main pancreatic duct was efficiently sealed. Conclusions: Our findings suggest that RF-induced heating is more effective at closing the pancreatic stump than mechanical stapler and leads to the complete atrophy of the distal remnant pancreas.

Alternativas para lograr la revascularización arterial total usando una o ambas arterias mamarias y el remanente distal de una de ellas como únicos injertos

IntroductionThe aim of all coronary artery bypass grafts should be to allow patients to stay as long as possible without the need to repeat revascularization. Total arterial revascularization contributes to achieving these purposes. ObjectiveTo demonstrate that both mammary arteries can be used in various configurations to achieve total arterial revascularization. Methods35 patients were included, 29 male and 6 female, with age average of 54.2 years, who were revascularized with one or both mammary arteries in the period between January 2012 and September 2014, with a mean follow-up time of 13.1 months. The additive EuroSCORE was 0 for men and 1 for women. ResultsSeven configurations are described to achieve total arterial revascularization using one or both mammary arteries and the distal remnant of a mammary arteries as single grafts. There were no deaths or major complications in patients revascularized. Six months later, all were asymptomatic with no new signs of ischemia in revascularized territories. ConclusionsTotal arterial revascularization using one or both mammary arteries and distal remaining one is possible and gives good results in selected patients.

Recurrence Rate and Pattern of Perihilar Cholangiocarcinoma after Curative Intent Resection

The aim of this study was to investigate the rate and pattern of recurrence after curative intent resection of perihilar cholangiocarcinoma (PHC). Patients were included from 2 prospectively maintained databases. Recurrences were categorized by site. Time to recurrence and recurrence-free survival (RFS) were estimated using the Kaplan-Meier method. Cox proportional hazards modeling was used to identify independent poor prognostic factors. Between 1991 and 2012, 306 consecutive patients met inclusion criteria. Median overall survival was 40 months. A recurrence was diagnosed in 177 patients (58%). An initial local recurrence was found in 26% of patients: liver hilum (11%), hepaticojejunostomy (8%), liver resection margin (8%), or distal bile duct remnant (2%). An initial distant recurrence was observed in 40% of patients: retroperitoneal lymph nodes (14%), intrahepatic away from the resection margin (13%), peritoneum (12%), and lungs (8%). Only 18% of patients had an isolated initial local recurrence. The estimated overall recurrence rate was 76% at 8 years. After a recurrence-free period of 5 years, 28% of patients developed a recurrence in the next 3 years. Median RFS was 26 months. Independent prognostic factors for RFS were resection margin, lymph node status, and tumor differentiation. Only node-positive PHC precluded RFS beyond 7 years. Perihilar cholangiocarcinoma will recur in most patients (76%) after resection, emphasizing the need for better adjuvant strategies. The high recurrence rate of up to 8 years justifies prolonged surveillance. Only patients with an isolated initial local recurrence (18%) may have benefited from a more extensive resection or liver transplantation. Node-positive PHC appears incurable.