Publications by authors named "Thomas Satyadas"

30 Publications

  • Page 1 of 1

Bile duct tumour thrombosis: hepatocellular carcinoma presenting with obstructive jaundice.

Br J Hosp Med (Lond) 2021 Aug 4;82(8). Epub 2021 Aug 4.

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.

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http://dx.doi.org/10.12968/hmed.2021.0030DOI Listing
August 2021

Liver Transplantation for Non-Resectable Liver Metastases from Colorectal Cancer: A Systematic Review and Meta-Analysis.

World J Surg 2021 Jul 28. Epub 2021 Jul 28.

Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK.

Backgrounds: Colorectal liver metastases were historically considered a contraindication to liver transplantation, but dismal outcomes for those with metastatic colorectal cancer and advancements in liver transplantation (LT) have led to a renewed interest in the topic. We aim to compare the current evidence for liver transplantation for non-resectable colorectal liver metastases (NRCLM) with the current standard treatment of palliative chemotherapy.

Methods: A systematic review and meta-analysis of proportions was conducted following screening of MEDLINE, EMBASE, SCOPUS and CENTRAL for studies reporting liver transplantation for colorectal liver metastases. Post-operative outcomes measured included one-, three- and five-year survival, overall survival, disease-free survival and complication rate.

Results: Three non-randomised studies met the inclusion criteria, reporting a total of 48 patients receiving LT for NRCLM. Survival at one-, three- and five-years was 83.3-100%, 58.3-80% and 50-80%, respectively, with no significant difference detected (p = 0.22, p = 0.48, p = 0.26). Disease-free survival was 35-56% with the most common site of recurrence being lung. Thirteen out of fourteen deaths were due to disease recurrence.

Conclusion: Although current evidence suggests a survival benefit conferred by LT in NRCLM compared to palliative chemotherapy, the ethical implications of organ availability and allocation demand rigorous justification. Concomitant improvements in the management of patients following liver resection and of palliative chemotherapy regimens is paramount.
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http://dx.doi.org/10.1007/s00268-021-06248-4DOI Listing
July 2021

Totally extra-peritoneal repair versus trans-abdominal pre-peritoneal repair for the laparoscopic surgical management of sportsman's hernia: A systematic review and meta-analysis.

Surg Endosc 2021 Oct 18;35(10):5399-5413. Epub 2021 May 18.

Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK.

Background: Open and laparoscopic modalities are employed for treatment of sportsman's hernia with totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) laparoscopic approaches both currently being utilised. At present, neither subtype has demonstrated a beneficial superiority for sportsman's hernia repair, as concluded in the most recent systematic review comparing the outcomes of each technique. The aim of this review was to evaluate current evidence to ascertain whether there was a difference in laparoscopic techniques following sportsman's hernia repair.

Methods: A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Databases searched included PubMed, Scopus and Web of Science to identify all randomised controlled trials (RCTs) and observational studies Risk of bias was assessed using the Cochrane risk of bias tool and Newcastle-Ottawa scale for RCTs and observational studies, respectively.The assessed outcomes included median time to return to sporting activity, complications and the degree of postoperative pain reduction within three months. Random effects model was used to calculate pooled proportion data where feasible. Subgroup analyses were also performed.

Results: 28 studies were identified including 2 RCTs and 26 observational studies. No significant differences were observed between techniques in the primary or secondary outcomes. Significant heterogeneity was observed in all outcomes. This was more pronounced for return to sporting activity meaning that meta-analysis was not feasible in this domain. Median time to return to sporting activity was 28 days for both techniques.

Conclusions: There is no observed difference in the primary and secondary outcomes in either technique. An RCT comparing TEP and TAPP repair is needed to provide definitive data on this matter.
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http://dx.doi.org/10.1007/s00464-021-08554-3DOI Listing
October 2021

The risk and predictors of mortality in octogenarians undergoing emergency laparotomy: a multicentre retrospective cohort study.

Langenbecks Arch Surg 2021 Apr 7. Epub 2021 Apr 7.

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK.

Objectives: This study aims to evaluate the risk of postoperative mortality in octogenarians undergoing emergency laparotomy.

Methods: In compliance with STROCSS guideline for observational studies, we conducted a multicentre retrospective cohort study. All consecutive patients aged over 80 with acute abdominal pathology requiring emergency laparotomy between April 2014 and August 2019 were considered eligible for inclusion. The primary outcome measure was 30-day postoperative mortality, and the secondary outcome measures were in-hospital mortality and 1-year mortality. Statistical analyses included simple descriptive statistics, binary logistic regression analyses, and Kaplan-Meier survival statistics.

Results: A total of 523 octogenarians were eligible for inclusion. Emergency laparotomy in octogenarians was associated with 21.8% (95% CI 18.3-25.6%) 30-day postoperative mortality, 22.6% (95% CI 19.0-26.4%) in-hospital mortality, and 40.2% (95% CI 35.9-44.5%) 1-year mortality. Binary logistic regression analysis identified ASA status (OR, 2.49; 95% CI 1.82-3.38, P < 0.0001) and peritoneal contamination (OR, 2.00; 95% CI 1.30-3.08, P = 0.002) as predictors of 30-day postoperative mortality. The ASA status (OR, 1.92; 95% CI 1.50-2.46, P < 0.0001), peritoneal contamination (OR, 1.57; 95% CI 1.07-2.48, P = 0.020), and presence of malignancy (OR, 2.06; 95% CI 1.36-3.10, P = 0.001) were predictors of 1-year mortality. Log-rank test showed significant difference in postoperative survival rates among patients with different ASA status (P < 0.0001) and between patients with and without peritoneal contamination (P = 0.0011).

Conclusions: Emergency laparotomies in patients older than 80 years with ASA status more than 3 in the presence of peritoneal contamination carry a high risk of immediate postoperative and 1-year mortality. This should be taken into account in communications with patients and their relatives, consent process, and multidisciplinary decision-making process for operative or non-operative management of such patients.
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http://dx.doi.org/10.1007/s00423-021-02168-yDOI Listing
April 2021

Roux-en-Y versus single loop reconstruction in pancreaticoduodenectomy: A systematic review and meta-analysis.

Int J Surg 2021 Apr 24;88:105923. Epub 2021 Mar 24.

Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK.

Background: Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications.

Methods: A systematic review and meta-analysis was conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models.

Results: Fourteen studies were identified including four randomised controlled trials (RCTs) and 10 observational studies reporting a total of 2,031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction.

Discussion: Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomised studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.
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http://dx.doi.org/10.1016/j.ijsu.2021.105923DOI Listing
April 2021

Elevation of High-sensitive Troponin T Predicts Mortality After Open Pancreaticoduodenectomy.

World J Surg 2021 06 16;45(6):1913-1920. Epub 2021 Mar 16.

Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK.

Background: Open pancreaticoduodenectomy has a high complication and measurable mortality rate. Recent reports (based across multiple surgical disciplines) demonstrate that elevated postoperative high sensitivity troponin T (hsTnT) predicts adverse outcomes in non-cardiac surgery. The aim of this study was to evaluate postoperative hsTnT as a prognostic marker of mortality, major adverse cardiovascular events (MACE), post-operative non-cardiac complications and length of stay (including intensive care stay) in open pancreaticoduodenectomy.

Methods: A retrospective review of open pancreaticoduodenectomy patients was undertaken from 01/10/2017-31/03/2019. Receiver operating characteristic (ROC) curves were calculated to identify ideal cut-off values for hsTnT. Univariate and multivariate analyses were performed to scrutinize the relationship between mean hsTnT and 30-day, 90-day mortality, MACE, post-operative non-cardiac complications and length of stay.

Results: One hundred and nine patients were identified. ROC curves demonstrated a strong correlation between elevated mean hsTnT and 30-day, 90-day mortality and MACE (AUC = 0.937, AUC = 0.852, AUC = 0.779, respectively). Multivariate analysis showed mean hsTnT > 21 ng/l was significantly associated with 90-day mortality (OR 43.928, p = 0.004) and MACE (OR 8.177, p = 0.048).

Conclusions: HsTnT is predictive of mortality and MACE in the context of open pancreaticoduodenectomy. Association between hsTnT and prolonged critical care stay was less significant. Non-cardiac complications and length of stay show no significant association with hsTnT.
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http://dx.doi.org/10.1007/s00268-021-06056-wDOI Listing
June 2021

Meta-analysis and trial sequential analysis of three-port vs four-port laparoscopic cholecystectomy (level 1 evidence).

Updates Surg 2021 Apr 15;73(2):451-471. Epub 2021 Feb 15.

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK.

To compare the outcomes of three-port and four-port laparoscopic cholecystectomy. In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port vs four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certainty of evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data. Analysis of 2524 patients from 17 studies showed that both techniques were comparable in terms of operative time (MD:- 0.13, P = 0.88), conversion to open operation (OR:0.80, P = 0.43), gallbladder perforation (OR: 1.43, P = 0.13), bleeding from gallbladder bed (OR:0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD: - 0.00, P = 0.81), bile or stone spillage (OR:1.67, P = 0.08), port site infection (OR: 0.90, P = 0.76), port site hernia (RD: 0.00, P = 0.89), port site haematoma (RD: - 0.01, P = 0.23), port site seroma (RD: 0.00, P = 1.00), and need for reoperation (RD: - 0.00, P = 0.94). However, the three-port technique was associated with lower VAS pain score at 12 h (MD: - 0.66, P < 0.00001) and 24 h (MD: - 0.54, P < 0.00001) postoperatively, shorter length of hospital stay (MD:-0.09, P = 0.41), and shorter time to return to normal activities (MD: - 0.79, P = 0.02). Trial sequential analysis confirmed that the meta-analysis was conclusive with no significant risks of type 1 or type 2 error. Robust evidence (level 1 with high certainty) suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities.
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http://dx.doi.org/10.1007/s13304-021-00982-zDOI Listing
April 2021

A systematic review into patient reported outcomes following pancreaticoduodenectomy for malignancy.

Eur J Surg Oncol 2021 May 8;47(5):970-978. Epub 2020 Dec 8.

HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK. Electronic address:

Background: Pancreaticoduodenectomy is associated with high rates of morbidity. This combined with the psychological burden of cancer, may impact on a patient's quality of life (QoL), which can be measured by using patient-reported outcomes (PRO).

Objective: To perform a systematic review to evaluate the measurement of PRO after pancreaticoduodenectomy for cancer.

Methods: 7 different databases were searched using 2 groups of search terms, one relating to pancreaticoduodenectomy, and one to PRO. Three authors screened the search results independently in a systematic manner based on predefined inclusion and exclusion criteria.

Results: 27 studies, with 2173 eligible patients were included in the final analysis. Most of the included studies used validated instruments. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire was most popular and used in 12 studies. The methodology of all included studies was also scrutinised. 12 studies were deemed to have high quality methodology according to pre-defined criteria.

Conclusion: The instruments and methods used to measure PRO are variable. The quality of PRO within the available literature has improved over time, as has the number of studies measuring PRO. PRO should be measured with uniformity in future trials so that patients can be provided with more comprehensive information regarding post-operative recovery and QoL during the shared decision-making process preoperatively.
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http://dx.doi.org/10.1016/j.ejso.2020.11.146DOI Listing
May 2021

Meta-analysis and trial sequential analysis of randomised controlled trials comparing standard versus extended lymphadenectomy in pancreatoduodenectomy for adenocarcinoma of the head of pancreas.

Langenbecks Arch Surg 2021 May 26;406(3):547-561. Epub 2020 Sep 26.

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK.

Purpose: To compare baseline demographics, operative, and survival outcomes of randomised controlled trials (RCTs) comparing standard lymphadenectomy versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer METHODS: In compliance with PRISMA standards we performed a meta-analysis of baseline demographics, operative, and survival outcomes of RCTs comparing standard lymphadenectomy versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The uncertainties associated with varying follow-up periods among the included studies were resolved by analysis of time-to-event outcomes. Moreover, we performed trial sequential analysis (TSA) to determine whether the available evidence is conclusive and to assess the risk of type 1 or type 2 errors.

Results: Overall, 724 patients from 5 RCTs were included. The included populations were comparable in terms of baseline characteristics. There was no difference between standard and extended lymphadenectomy in terms of pancreatic fistula (OR 0.64, P = 0.11), delayed gastric emptying (OR 0.68, P = 0.40), bile leak (OR 0.33, P = 0.06), wound infection (OR 0.53, P = 0.06), abscess (OR 0.83, P = 0.63), total complications (OR 0.73, P = 0.27), postoperative mortality (OR 1.01, P = 0.85), and overall survival (HR 1.10, P = 0.46). TSA suggested that meta-analysis was conclusive with low risk of type 2 error. The results remained consistent through subgroup analyses based on lymph node positive or negative status and studies from the West and East.

Conclusions: Robust evidence from randomised controlled trials (Level 1) suggests no difference in postoperative and survival outcomes between standard and extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The findings were consistent in patients with positive and negative lymph node status and in studies from the West or East.
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http://dx.doi.org/10.1007/s00423-020-01999-5DOI Listing
May 2021

Procedural Outcomes of Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Previous Roux-en-Y Gastric Bypass Surgery: a Systematic Review and Meta-analysis.

Obes Surg 2021 01 15;31(1):282-298. Epub 2020 Sep 15.

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK.

Purpose: To investigate the procedural outcomes of laparoscopic-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with previous Roux-en-Y gastric bypass (RYGB) surgery.

Materials And Methods: We performed a systematic review in accordance with PRISMA statement standards to identify all studies reporting procedural outcomes of laparoscopic-assisted ERCP in patients with previous RYGB. The ROBINS-I tool was used to assess the risk of bias of the included studies. Fixed-effect and random-effects models were applied to calculate pooled outcome data.

Results: A total of 17 case series, enrolling 256 patients, were included. The mean age of included patients was 49. The mean procedure time was 137 min (95% CI 102-172). In terms of procedural success rates, the overall technical success was 95.3% (95% CI 92.5-97.5, I = 0%), papillary access success was 95.3% (95% CI 92.5-97.5, I = 0%), cannulation success was 95.3% (95% CI 92.5-97.5, I = 0%), sphincterotomy success was 96.1% (95% CI 93.5-98.1, I = 0%), and stone removal success was 95.9% (95% CI 92.4-98.4, I = 0%). Conversion to open was required in 4.7% (95% CI 2.5-7.6, I = 0%). In terms of complications, pancreatitis occurred in 4.7% (95% CI 2.3-8, I = 17%), cholangitis in 1.7% (95% CI 0.5-3.6, I = 0%), and perforation in 3.7% (95% CI 1.8-6.3, I = 0%). The length of hospital stay was 3 days (95% CI 2-4).

Conclusions: Laparoscopic-assisted ERCP seems to be feasible, effective, and a safe method to access the biliary tract in patients with previous RYGB as indicated by high technical success rates and low complication rates. There is a need for comparative evidence regarding outcomes of laparoscopic ERCP in comparison with alternative treatment options.
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http://dx.doi.org/10.1007/s11695-020-04954-xDOI Listing
January 2021

Meta-Analysis of Spinal Anesthesia Versus General Anesthesia During Laparoscopic Total Extraperitoneal Repair of Inguinal Hernia.

Surg Laparosc Endosc Percutan Tech 2020 Aug;30(4):371-380

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK.

Objectives: To evaluate comparative outcomes of spinal anesthesia (SA) and general anesthesia (GA) during laparoscopic total extraperitoneal (TEP) repair of inguinal hernia.

Methods: We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Postoperative pain assessed by visual analogue scale (VAS), individual and overall perioperative morbidity, procedure time and time taken to normal activities, were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models.

Results: We identified 5 comparative studies reporting a total of 1518 patients (2134 hernia) evaluating outcomes of laparoscopic TEP inguinal hernia repair under SA (n=1277 patients, 1877 hernia) or GA (n=241 patients, 257 hernia). SA was associated with significantly lower post-operative pain assessed by VAS at 12 hours [mean difference (MD): -0.32; 95% confidence interval (CI), -0.45 to -0.20; P<0.0001] and shorter time to normal activities (MD: -0.30; 95% CI, -0.48 to -0.11; P=0.002) compared with GA. However, it significantly increased risk of urinary retention [odds ratio (OR): 4.02; 95% CI, 1.32-12.24; P=0.01], hypotension (OR: 3.97; 95% CI, 1.57-10.39; P=0.004), headache (OR: 7.65; 95% CI, 1.98-29.48, P=0.003), and procedure time (MD: 3.82; 95% CI, 1.22-6.42; P=0.004). There was no significant difference in VAS at 24 hours (MD: 0.06; 95% CI, -0.06 to 0.17; P=0.34), seroma (OR: 1.54; 95% CI, 0.73-3.26; P=0.26), wound infection (OR: 1.03; 95% CI, 0.45-2.37; P=0.94), and vomiting (OR: 0.84; 95% CI, 0.39-1.83; P=0.66) between the 2 groups. There was a nonsignificant decrease in overall morbidity in favor of GA (OR: 1.84; 95% CI, 0.77-4.40; P=0.17) which became significant following sensitivity analysis (OR: 2.59; 95% CI, 1.23-5.49; P=0.01).

Conclusions: Although TEP inguinal hernia repair under SA may reduce pain in early postoperative period, it seems to be associated with increased postoperative morbidity and longer procedure time. It may be an appropriate anesthetic modality in selected patients who are considered high risk for GA. Higher level of evidence is needed.
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http://dx.doi.org/10.1097/SLE.0000000000000783DOI Listing
August 2020

Endoscopic Versus Percutaneous Preoperative Biliary Drainage in Patients With Klatskin Tumor Undergoing Curative Surgery: A Systematic Review and Meta-Analysis of Short-Term and Long-Term Outcomes.

Surg Innov 2020 Jun 14;27(3):279-290. Epub 2020 Mar 14.

Manchester Royal Infirmary Hospital, Manchester, UK.

. To compare short-term and long-term outcomes of preoperative endoscopic biliary drainage (EBD) and percutaneous biliary drainage (PBD) in patients with Klatskin tumor undergoing curative surgery. . We conducted a search of electronic information sources to identify all studies comparing EBD and PBD in patients with Klatskin tumor undergoing curative surgery. We used the Newcastle-Ottawa Scale to assess the risk of bias observational studies. Random-effects or fixed-effects modeling was applied as appropriate to calculate pooled outcome data. . We identified 9 observational studies, enrolling a total of 1436 patients. The patients in the PBD group had more advanced disease than those in EBD group in terms of Bismuth-Corlette classification and tumor classification. EBD was associated with higher risks of postprocedural complications (odds ratio [OR] =2.24, = .001), conversion to another drainage method (OR =11.16, < .00001), cholangitis (OR = 4.58, < .0001), and pancreatitis (OR = 8.90, = .009) than PBD; there was no difference between the 2 methods in terms of technical success (OR = 0.79, = .50) and tube dislocation (OR = 0.81, = .54). Regarding the postoperative outcomes, there was no difference in terms of 30-day mortality (OR = 0.61, = .16) and major postoperative complications (OR = 0.60, = .06). Regarding the long-term outcomes, EBD was associated with lower risks of seeding metastasis (OR = 0.46, = .0004) and 5-year recurrence (OR = 0.72, = .010), and better 5-year survival (OR = 1.62, = .001). . EBD may be associated with higher procedure-related complications compared with PBD as a preoperative biliary drainage method in patients with Klatskin tumor undergoing curative surgery. The available evidence on long-term oncological and survival outcomes are subject to confounding by indication, and high-quality randomized controlled trials are required for definite conclusions.
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http://dx.doi.org/10.1177/1553350620911291DOI Listing
June 2020

The Influence of Patients' Age on the Outcome of Treatment for Pancreatic Ductal Adenocarcinoma.

Pancreas 2020 02;49(2):201-207

From the Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary, Manchester University Hospitals Foundation Trust.

Objective: The aim of the study was to determine the impact of age on curative management and outcomes of patients with pancreatic ductal adenocarcinoma.

Methods: Patients who underwent resection for pancreatic ductal adenocarcinoma at 2 units were retrospectively reviewed (between 2005 and 2017) and stratified by age (older patients ≥70 years). Regression analysis was used to explore factors impacting administration of adjuvant chemotherapy and survival. The Kaplan-Meier method was used to estimate overall survival (time from surgery to death). Statistical significance was set at P < 0.05.

Results: From 2005 to 2014, 222 patients were identified (<70 years, n = 128; ≥70 years, n = 94). Elderly patients were less likely to receive adjuvant chemotherapy compared with younger patients (odds ratio, 0.57, P = 0.041). Tumor stage, margin, and year of surgery (post-2011 vs pre-2011) were not predictors for chemotherapy receipt (P > 0.05). Frailty was the commonest reason (36.8%) to decline chemotherapy in elderly patients. In patients receiving adjuvant chemotherapy, completion rates (P = 0.32) and overall survival (24 months vs 30 months, P = 0.50) were no different.

Conclusions: Elderly patients demonstrate similar outcomes to younger yet are less likely to commence chemotherapy because of frailty. Holistic preoperative assessment may improve selection for curative treatment.
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http://dx.doi.org/10.1097/MPA.0000000000001486DOI Listing
February 2020

Laparoscopic Versus Open Liver Resection for Tumors in the Posterosuperior Segments: A Systematic Review and Meta-analysis.

Surg Laparosc Endosc Percutan Tech 2020 Apr;30(2):93-105

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK.

Objective: The objective of this study was to compare the outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments.

Methods: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. We conducted a search of electronic information sources to identify all studies comparing outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments. We used the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I) tool to assess the risk of bias of the included studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

Results: We identified 11 observational studies, enrolling a total of 1023 patients. The included population in both groups were comparable in terms of baseline characteristics. Laparoscopic approach was associated with lower risks of total complications [odds ratio (OR): 0.45; 95% confidence interval (CI): 0.33, 0.61; P<0.00001], major complications (Dindo-Clavien III or more) (OR: 0.52; 95% CI: 0.36, 0.73; P=0.0002), and intraoperative blood loss [mean difference (MD): -114.71; 95% CI: -165.64, -63.79; P<0.0001]. Laparoscopic approach was associated with longer operative time (MD: 50.28; 95% CI: 22.29, 78.27; P=0.0004) and shorter length of hospital stay (MD: -2.01; 95% CI: -2.09, -1.92; P<0.00001) compared with open approach. There was no difference between the 2 groups in terms of need for blood transfusion (OR: 1.23; 95% CI: 0.75, 2.02; P=0.41), R0 resection (OR: 1.09; 95% CI: 0.66, 1.81; P=0.72), postoperative mortality (risk difference: -0.00; 95% CI: -0.02, 0.02; P=0.68), and need for readmission (OR: 0.70; 95% CI: 0.19, 2.60; P=0.60). In terms of oncological outcomes, there was no difference between the groups in terms disease recurrence (OR: 1.58; 95% CI: 0.95, 2.63; P=0.08), overall survival (OS) at maximum follow-up (OR: 1.09; 95% CI: 0.66, 1.81; P=0.73), 1-year OS (OR: 1.53; 95% CI: 0.48, 4.92; P=0.47), 3-year OS (OR: 1.26; 95% CI: 0.67, 2.37; P=0.48), 5-year OS (OR: 0.91; 95% CI: 0.41, 1.99; P=0.80), disease-free survival (DFS) at maximum follow-up (OR: 0.91; 95% CI: 0.65, 1.27; P=0.56), 1-year DFS (OR: 1.04; 95% CI: 0.60, 1.81; P=0.88), 3-year DFS (OR: 1.13; 95% CI: 0.75, 1.69; P=0.57), and 5-year DFS (OR: 0.73; 95% CI: 0.44, 1.24; P=0.25).

Conclusions: Compared with the open approach in liver resection for tumors in the posterosuperior segments, the laparoscopic approach seems to be associated with a lower risk of postoperative morbidity, less intraoperative blood loss, and shorter length of hospital stay with comparable survival and oncological outcomes. The best available evidence is derived from observational studies with moderate quality; therefore, high-quality randomized controlled trials with adequate statistical power are required to provide a more robust basis for definite conclusions.
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http://dx.doi.org/10.1097/SLE.0000000000000746DOI Listing
April 2020

Meta-analysis of Enhanced Recovery After Surgery (ERAS) Protocols in Emergency Abdominal Surgery.

World J Surg 2020 05;44(5):1336-1348

Manchester Royal Infirmary Hospital, Manchester, UK.

Objectives: To evaluate enhanced recovery after surgery (ERAS) protocols in emergency abdominal surgery.

Methods: The electronic data sources were explored to capture all studies that evaluated the impact of ERAS protocols in patients who underwent emergency abdominal surgery. The quality of randomised and non-randomised studies was evaluated by the Cochrane tool and the Newcastle-Ottawa scale, respectively. Random or fixed effects modelling were utilised as indicated.

Results: Six comparative studies, enrolling 1334 patients, were eligible. ERAS protocols resulted in shorter post-operative time to first flatus (mean difference: -1.40, P < 0.00001), time to first defecation (mean difference: -1.21, P = 0.02), time to first oral liquid diet (mean difference: -2.30, P < 0.00001), time to first oral solid diet (mean difference: -2.40, P < 0.00001) and length of hospital stay (mean difference: -3.09, -2.80, P < 0.00001). ERAS protocols also resulted in lower risks of total complications (odds ratio: 0.50, P < 0.00001), major complications (odds ratio: 0.60, P = 0.0008), pulmonary complications (odds ratio: 0.38, P = 0.0003), paralytic ileus (odds ratio: 0.53, 0.88, P = 0.01) and surgical site infection (odds ratio: 0.39, P = 0.0001). Both ERAS and non-ERAS protocols resulted in similar risk of 30-day mortality (risk difference: -0.00, P = 0.94), need for re-admission (risk difference: -0.01, P = 0.50) and need for re-operation (odds ratio: 0.83, P = 0.50).

Conclusions: Although ERAS protocols are commonly used in elective settings, they are associated with favourable outcomes in emergency settings as indicated by reduced post-operative complications, accelerated recovery of bowel function and shorter post-operative hospital stay without increasing need for re-admission or re-operation. There should be an effort to incorporate ERAS protocols into emergency abdominal surgery settings.
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http://dx.doi.org/10.1007/s00268-019-05357-5DOI Listing
May 2020

Impact of weekend effect on postoperative mortality in patients undergoing emergency General surgery procedures: Meta-analysis of prospectively maintained national databases across the world.

Surgeon 2020 Aug 18;18(4):231-240. Epub 2019 Oct 18.

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK.

Objectives: to investigate the impact of weekend effect on postoperative mortality in patients undergoing emergency General Surgery operations across the world.

Methods: A search of electronic information sources was conducted to identify all studies investigating the weekend effect in patients undergoing emergency General Surgery operations. Emergency operation during weekend was considered as exposure of interest, emergency operation during weekdays as comparison of interest, and postoperative mortality as the outcome of interest. Random or fixed effects modelling were applied to calculate pooled outcome data.

Results: Overall, 10 studies, enrolling 394,646 patients, were included. Worldwide, emergency General surgery operation during weekend was associated with a higher risk of postoperative mortality compared to weekdays (OR: 1.08, 95% CI 1.02, 1.14, P = 0.008, moderate quality evidence). The weekend effect was variable across the world. Although emergency operation during weekend was associated with a higher risk of postoperative mortality in the USA (OR: 1.12, 95% CI 1.01, 1.24, P = 0.03, moderate quality evidence) and Europe (OR: 1.37, 95% CI 1.11, 1.69, P = 0.003, moderate quality evidence), there was no difference in postoperative mortality between weekend and weekday groups in the UK (OR: 1.04, 95% CI 0.97, 1.11, P = 0.30, moderate quality evidence) and South Africa (OR: 0.79, 95% CI 0.44, 1.42, P = 0.43, moderate quality evidence).

Conclusions: The weekend effect in emergency General Surgery is variable across the world. Although it seems to be significant in the USA and Europe, it does not increase the risk of postoperative mortality in the UK. Future studies should focus on differences in staffing levels and available resources at weekends in emergency General surgery settings across the world.
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http://dx.doi.org/10.1016/j.surge.2019.09.006DOI Listing
August 2020

PROCalcitonin-based algorithm for antibiotic use in Acute Pancreatitis (PROCAP): study protocol for a randomised controlled trial.

Trials 2019 Jul 29;20(1):463. Epub 2019 Jul 29.

Pharmacy Department, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK.

Background: Differentiating infection from inflammation in acute pancreatitis is difficult, leading to overuse of antibiotics. Procalcitonin (PCT) measurement is a means of distinguishing infection from inflammation as levels rise rapidly in response to a pro-inflammatory stimulus of bacterial origin and normally fall after successful treatment. Algorithms based on PCT measurement can differentiate bacterial sepsis from a systemic inflammatory response. The PROCalcitonin-based algorithm for antibiotic use in Acute Pancreatitis (PROCAP) trial tests the hypothesis that a PCT-based algorithm to guide initiation, continuation and discontinuation of antibiotics will lead to reduced antibiotic use in patients with acute pancreatitis and without an adverse effect on outcome.

Methods: This is a single-centre, randomised, controlled, single-blind, two-arm pragmatic clinical and cost-effectiveness trial. Patients with a clinical diagnosis of acute pancreatitis will be allocated on a 1:1 basis to intervention or standard care. Intervention will involve the use of a PCT-based algorithm to guide antibiotic use. The primary outcome measure will be the binary outcome of antibiotic use during index admission. Secondary outcome measures include: safety non-inferiority endpoint all-cause mortality; days of antibiotic use; clinical infections; new isolates of multiresistant bacteria; duration of inpatient stay; episode-related mortality and cause; quality of life (EuroQol EQ-5D); and cost analysis. A 20% absolute change in antibiotic use would be a clinically important difference. A study with 80% power and 5% significance (two-sided) would require 97 patients in each arm (194 patients in total): the study will aim to recruit 200 patients. Analysis will follow intention-to-treat principles.

Discussion: When complete, PROCAP will be the largest randomised trial of the use of a PCT algorithm to guide initiation, continuation and cessation of antibiotics in acute pancreatitis. PROCAP is the only randomised trial to date to compare standard care of acute pancreatitis as defined by the International Association of Pancreatology/American Pancreatic Association guidelines to patients having standard care but with all antibiotic prescribing decisions based on PCT measurement.

Trial Registration: International Standard Randomised Controlled Trial Number, ISRCTN50584992. Registered on 7 February 2018.
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http://dx.doi.org/10.1186/s13063-019-3549-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6664733PMC
July 2019

In Vivo Measurement of Surface Pressures and Retraction Distances Applied on Abdominal Organs During Surgery.

Surg Innov 2018 Feb 15;25(1):50-56. Epub 2017 Dec 15.

3 Manchester Royal Infirmary, Manchester University Foundation Trust, Manchester, UK.

This study undertook the in vivo measurement of surface pressures applied by the fingers of the surgeon during typical representative retraction movements of key human abdominal organs during both open and hand-assisted laparoscopic surgery. Surface pressures were measured using a flexible thin-film pressure sensor for 35 typical liver retractions to access the gall bladder, 36 bowel retractions, 9 kidney retractions, 8 stomach retractions, and 5 spleen retractions across 12 patients undergoing open and laparoscopic abdominal surgery. The maximum and root mean square surface pressures were calculated for each organ retraction. The maximum surface pressures applied to these key abdominal organs are in the range 1 to 41 kPa, and the average maximum surface pressure for all organs and procedures was 14 ± 3 kPa. Surface pressure relaxation during the retraction hold period was observed. Generally, the surface pressures are higher, and the rate of surface pressure relaxation is lower, in the more confined hand-assisted laparoscopic procedures than in open surgery. Combined video footage and pressure sensor data for retraction of the liver in open surgery enabled correlation of organ retraction distance with surface pressure application. The data provide a platform to design strategies for the prevention of retraction injuries. They also form a basis for the design of next-generation organ retraction and space creation surgical devices with embedded sensors that can further quantify intraoperative retraction forces to reduce injury or trauma to organs and surrounding tissues.
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http://dx.doi.org/10.1177/1553350617745952DOI Listing
February 2018

The safety and effectiveness of liver resection for breast cancer liver metastases: A systematic review.

Breast 2016 Dec 18;30:175-184. Epub 2016 Oct 18.

University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Woodville, Adelaide, South Australia, 5011, Australia. Electronic address:

Breast cancer liver metastases have traditionally been considered incurable and any treatment given therefore palliative. Liver resections for breast cancer metastases are being performed, despite there being no robust evidence for which patients benefit. This review aims to determine the safety and effectiveness of liver resection for breast cancer metastases. A systematic literature review was performed and resulted in 33 papers being assembled for analysis. All papers were case series and data extracted was heterogeneous so a meta-analysis was not possible. Safety outcomes were mortality and morbidity (in hospital and 30-day). Effectiveness outcomes were local recurrence, re-hepatectomy, survival (months), 1-, 2-, 3-, 5- year overall survival rate (%), disease free survival (months) and 1-, 2-, 3-, 5- year disease free survival rate (%). Overall median figures were calculated using unweighted median data given in each paper. Results demonstrated that mortality was low across all studies with a median of 0% and a maximum of 5.9%. The median morbidity rate was 15%. Overall survival was a median of 35.1 months and a median 1-, 2-, 3- and 5-year survival of 84.55%, 71.4%, 52.85% and 33% respectively. Median disease free survival was 21.5 months with a 3- and 5-year median disease free survival of 36% and 18%. Whilst the results demonstrate seemingly satisfactory levels of overall survival and disease free survival, the data are of poor quality with multiple confounding variables and small study populations. Recommendations are for extensive pilot and feasibility work with the ultimate aim of conducting a large pragmatic randomised control trial to accurately determine which patients benefit from liver resection for breast cancer liver metastases.
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http://dx.doi.org/10.1016/j.breast.2016.09.011DOI Listing
December 2016

Congenital extrahepatic portosystemic shunt complicated by the development of hepatocellular carcinoma.

Hepatobiliary Pancreat Dis Int 2015 Oct;14(5):552-7

Department of Hepatopancreaticobiliary Surgery, Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK.

Congenital extrahepatic portosystemic shunt, also known as Abernethy malformation, is a rare congenital malformation. It causes shunting of blood through a communication between the portal and systemic veins such as a patent ductus venous. We report 3 cases of Abernethy malformation complicated by the development of hepatocellular carcinoma. Additionally, we comprehensively reviewed all previously reported cases and highlighted common features that may help in early diagnosis and appropriate management. Patients with Abernethy malformation may have an increased propensity to develop hepatocellular carcinoma. All 5 previously reported cases, plus the three of our patients, have a type 1 (complete) shunt suggesting a role for absent portal blood flow in the pathogenesis of hepatocellular carcinoma. Congenital extrahepatic portosystemic shunt should be sought for in cases with raised serum ammonia, hepatic encephalopathy or hepatocellular carcinoma in the absence of cirrhosis.
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http://dx.doi.org/10.1016/s1499-3872(15)60418-0DOI Listing
October 2015

Use of Pharmacologic Agents for Modulation of Ischaemia-Reperfusion Injury after Hepatectomy: A Questionnaire Study of the LiverMetSurvey International Registry of Hepatic Surgery Units.

HPB Surg 2014 12;2014:437159. Epub 2014 Nov 12.

Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK.

Objectives. This study is a questionnaire survey on the use of pharmacological agents to modify liver ischaemia-reperfusion (IR) injury in patients undergoing hepatectomy for colorectal liver metastases with the target population being those units participating in the LiverMetSurvey international registry. Methods. Members of LiverMetSurvey were sent an online questionnaire using SurveyMonkey comprising ten questions on the use of pharmacological agents to modulate hepatic IR injury in the perioperative period after hepatectomy. The questionnaire was sent to 446 clinicians registered with the LiverMetSurvey. There were 83 (19%) respondents. Results. Fifty-two (77% of 68 respondents to this question) never used pharmacological agents to modify liver IR injury during hepatectomy. Thirteen (19%) used pharmacological agents selectively. Three (4%) used these routinely. N-Acetylcysteine was the most widely used pharmacological agent with equal distribution of use around intraoperative and postoperative periods. Conclusions. This is believed to be the first survey on the use of pharmacological agents to modify liver IR injury. The target population is clinicians involved in liver resection. The results show that pharmacological modulation is used by only a minority of respondents to this questionnaire and that when this treatment is selected, N-acetylcysteine is the most frequently used.
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http://dx.doi.org/10.1155/2014/437159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4244917PMC
December 2014

Pyogenic liver abscess trends in South Australia.

ANZ J Surg 2015 Mar 14;85(3):179-82. Epub 2013 Oct 14.

Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia.

Background: Pyogenic liver abscess (PLA) is an uncommon but potentially life-threatening condition. Due to advances in diagnostic and treatment methods, the mortality rate has reduced in recent decades. The aim of this study was to gather recent data to examine PLA trends in South Australia.

Methods: The medical records of all patients admitted to The Queen Elizabeth Hospital, South Australia, between November 2000 and November 2009 with a primary or secondary diagnosis of PLA were retrospectively reviewed.

Results: Thirty-six patients were identified. Twenty (55.6%) were male and 16 (44.4%) female. The mean patient age was 70.2 years. A single PLA was found in 21 (58.3%) patients and multiple abscesses in 15 (41.7%) patients. Segment 7 of the liver was most commonly affected (10 cases). In 12 patients, multiple organisms were identified. Escherichia coli, Klebsiella pneumonia and Streptococcus species were most commonly identified. All patients received antibiotics and 27 (75%) received additional treatment. Nine patients received open abscess drainage. Fourteen received ultrasound-guided or computed tomography-guided percutaneous drainage or aspiration. One patient died as a direct result of a PLA.

Discussion: Since its first description, the epidemiology of PLA has changed. Patients diagnosed with PLA are now older, the male predominance is less and the organism more likely to originate from the biliary tract. The approach to PLA has also progressed with more accurate imaging and better treatment methods becoming available, which has resulted in a low mortality rate. This series confirms the described trends in South Australia.
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http://dx.doi.org/10.1111/ans.12411DOI Listing
March 2015

Evolution in technique of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center.

J Hepatobiliary Pancreat Sci 2010 May 10;17(3):367-8. Epub 2010 Apr 10.

The Queen Elizabeth Hospital, University of Adelaide Discipline of Surgery, 28 Woodville Road, Woodville South, Adelaide, SA, 5011, Australia.

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http://dx.doi.org/10.1007/s00534-010-0267-3DOI Listing
May 2010

Primary amyloidosis presenting as cholestatic jaundice.

BMJ Case Rep 2010 May 19;2010. Epub 2010 May 19.

Norfolk and Norwich University Hospital, Obstetrics and Gynaecology, Norwich, UK.

This case report describes a rare but fatal presentation of amyloidosis. Multiple organs and systems can be affected by the condition. Cholestatic jaundice is a infrequent manifestation of amyloidosis. An 80-year-old patient died within a month after onset of jaundice as a result of irreversible damage caused by deposition of amyloid. The relatively short period of time did not allow a tissue sample to be obtained from the patient and the final diagnosis was made postmortem.
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http://dx.doi.org/10.1136/bcr.06.2009.1974DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047012PMC
May 2010

Does moderate celiac axis stenosis identified on preoperative multidetector computed tomographic angiography predict an increased risk of complications after pancreaticoduodenectomy for malignant pancreatic tumors?

Pancreas 2007 Jan;34(1):80-4

Department of Radiology, Ipswich Hospital, Ipswich, UK.

Objectives: To identify any association between celiac artery compromise found on computed tomographic angiography and the incidence of postoperative and perioperative complications.

Methods: The computed tomographic angiograms of 36 patients who underwent the Whipple procedure for pancreatic adenocarcinoma were examined retrospectively. The association between the results and surgical course was investigated.

Results: Twelve patients (33%) had significant postoperative complications. Ten (28%) had evidence of celiac artery stenosis. Stenosis ranged from 20% to 60%. There was no evidence of a difference between the 2 groups.

Conclusion: There seems to be no evidence of an increased risk of postoperative or perioperative complication in patients undergoing the Whipple procedure, with a celiac stenosis of up to 60%.
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http://dx.doi.org/10.1097/01.mpa.0000240607.49183.7eDOI Listing
January 2007

An unusual case of ectopic or "parasitic" leiomyoma excised by laparoscopic surgery.

Int Surg 2004 Jul-Sep;89(3):161-3

Department of Surgery, Royal Free and University College Medical School, London, United Kingdom.

A 47-year-old woman underwent a laparoscopic resection of a large ectopic or "parasitic" fibroid filling the pelvis and placed within the rectosigmoid mesentery. The tumor was excised completely without a need for hysterectomy. Immunohistochemical and ultrastructural studies confirmed a "parasitic" leiomyoma, excluding sarcoma or a gastrointestinal stromal tumor. Because of its bizarre location in relation to the large bowel, a combined general surgical and gynecological approach was used successfully. The pathology of this rare tumor is reviewed.
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February 2005

Combined endoscopic approach for the management of a difficult recto-sigmoid anastomotic stricture.

Int Surg 2004 Apr-Jun;89(2):76-9

Department of Surgery, Royal Free and University College Medical School, London, NW3 2QG, United Kingdom.

A 48-year-old woman underwent an emergency laparotomy for a perforated diverticular abscess. At operation, a peritoneal lavage was carried out, but no colonic resection was undertaken. Subsequently, she developed recurrent sepsis and underwent a second laparotomy. The patient was referred to our institution for a definitive left hemicolectomy and diverting loop colostomy. Before closing the colostomy, a contrast enema revealed obstruction of the lumen at the anastomotic site. This was refractory to conventional colonoscopic dilatation. A simultaneous endoscope was passed through the distal loop of the colostomy in addition to a conventional approach. A defect was created that allowed passage of a guide-wire and balloon dilator. One week later, the anastomosis remained patent, and the colostomy closed. The patient remains well, with normal bowel function. This novel combined endoscopic approach for dealing with colonic stenoses avoids the higher morbidity and mortality associated with an open surgical procedure.
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November 2004

Spontaneous resolution of a superior mesenteric vein thrombosis after laparoscopic nissen fundoplication.

Ann R Coll Surg Engl 2002 May;84(3):177-80

University Department of Surgery, Royal Free and University College Medical School, London, UK.

A previously fit 37-year-old man developed superior mesenteric venous thrombosis after undergoing a laparoscopic Nissen fundoplication. Despite receiving thrombo-embolic prophylaxis on postoperative day 16, he presented with a gradual onset of vague, but severe, umbilical and epigastric pains. Laboratory tests, abdominal ultrasound scan and gastroscopy were all unremarkable. Contrast enhanced abdominal spiral computerised tomography (CT) revealed a partial occlusion of the superior mesenteric and portal vein due to a thrombus; abnormal flow was confirmed on colour Doppler ultrasound. A predisposing hyper-coagulable condition was excluded. The patient responded rapidly to expectant management and a repeat spiral CT scan, 3 weeks after the initial presentation, demonstrated complete re-canalisation of the vessel. Although rare, superior mesenteric venous thrombosis is probably underdiagnosed due to the vague nature of the symptoms, the lack of clinical signs, a low index of suspicion on the part of the clinician, and then subsequent failure to request the optimal investigation--namely contrast enhanced abdominal spiral CT scan. We discuss the possible mechanisms by which laparoscopic surgery may increase the risks of developing superior mesenteric venous thrombosis, the pitfalls in diagnosis and treatment options.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503813PMC
May 2002
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