24 research outputs found
Surgical management of Pancreatic Mucinous Cystic Neoplasms (MCNs)
No full textBackground: Pancreatic mucinous cystic neoplasms (MCN) are rare mucin-producing cystic tumors. They are predominantly found, incidentally, in middle-aged women and usually located in the pancreatic body or tail. They are differentiated from other mucin producing neoplasms by the presence of ovarian-type stroma. The current management of MCN is defined by the consensus European, International Association of Pancreatology (IAP) and the American Association of Gastroenterology guidelines. However, the malignant potential of these lesions remains uncertain, with differing rates of malignant potential being described. Since the criteria for surgical resection differs between the current guidelines, the aims of this large multi-institution study were to determine the rate of associated malignancy in resected MCNs and to determine predictor features, clinical and radiological, for malignant transformation in MCN. Methods: All surgically resected MCNs between January 2003 and December 2015 were included in this international multicentre retrospective study. Lesions without ovarian type stroma were excluded. All lesions found in men had the diagnosis of MCN confirmed by two experienced pancreatic pathologists. Malignant MCNs were defined by the presence of invasive adenocarcinoma. Results: 211 patients with a confirmed and surgically resected MCN were included. Median age was 53 (range 18–82) years, and 95.7% (202/211) were in women. Median pre-operative tumour size was 52 (range 12-230) mm. 16.1% (34/211) were malignant. The rates of malignancy (33.3% (3/9) vs. 15.3% (31/202)) and high-grade dysplasia (33.3% (3/9) vs. 15.8% (32/202) were double in men compared to women. In all cases of malignancy or high-grade dysplasia, at least one of the following characteristics was seen: male patient, symptoms, or a preoperative worrisome feature (solid component, septations, main pancreatic duct dilatation >6mm, elevated serum ca 19-9). A total of five cases of malignant transformation occurred in MCNs less than 4 cm in size. All these cases were associated with features of concern on pre-operative cross-sectional imaging. Conclusion: In female patients in this large multicentre study, malignancy or high-grade dysplasia was solely seen in MCNs with symptoms or worrisome features on preoperative imaging, regardless of the size of the tumour. In males, the risk of malignancy was significantly higher than in females, suggesting that operative treatment should be considered in all male patients with a suspected MCN of any size. In female patients, conservative management seems to be a safe approach for suspected MCNs of any size without symptoms or worrisome features
Pancreaticoduodenectomy for nonampullary duodenal lesions: indications and results
No full textPD carries a high mortality and morbidity, especially for duodenal lesions. We recommend a careful endoscopic review after the index case with a high-definition optical evaluation of duodenal lesions. This, in addition to an experienced histological assessment of the index biopsy material, forms an essential prerequisite in aiding the multidisciplinary team in the decision-making process with respect to triage of these lesions to conservative management, surveillance, endoscopic resection or finally surgical resection
Implementation of enhanced recovery after surgery for pancreatoduodenectomy increases the proportion of patients achieving textbook outcome: A retrospective cohort study
No full textBackground: Enhanced Recovery After Surgery (ERAS) for patients undergoing pancreatoduodenectomy is associated with reduced length of stay (LOS) and morbidity. However, external validating of the impact is difficult due to the multimodal aspects of ERAS. This study aimed to assess implementation of ERAS for pancreatoduodenectomy with a composite measure of multiple ideal outcome indicators defined as ‘textbook outcome’ (TBO). Methods: In a tertiary referral center, 250 patients undergoing pancreatoduodenectomy were included in ERAS (May 2012–January 2017) and compared to a cohort of 125 patients undergoing traditional perioperative management (November 2009–April 2012). TBO was defined as proportion of patients without prolonged LOS, Clavien-Dindo ≥ III complications, postoperative pancreatic fistula, postpancreatectomy hemorrhage, bile leakage, readmissions or 30-day/in-hospital mortality. Additionally, overall treatment costs were calculated and compared using bootstrap independent t-test. Results: The two cohorts were comparable in terms of demographic and surgical details. Implementation of ERAS was associated with reduced median LOS (10 days vs 13 days, p < 0.001) and comparable overall complication rate (62.0% vs 61.6%, p = 0.940) when compared to the traditional management group. In addition, a higher proportion of patients achieved TBO (56.4% vs 44.0%, p = 0.023) when treated according to ERAS principles. Furthermore, ERAS was associated with reduced mean total costs (£18132 vs £19385, p < 0.005). Conclusion: Implementation of ERAS for patients undergoing pancreatoduodenectomy is beneficial for both patients and hospitals. ERAS increased the proportion of patients achieving TBO and reduced overall costs. TBO is a potential measure for the evaluation of ERAS
Pan-European survey on the implementation of minimally invasive pancreatic surgery with emphasis on cancer
No full textBackground: Minimally invasive (MI) pancreatic surgery appears to be gaining popularity, but its implementation throughout Europe and the opinions regarding its use in pancreatic cancer patients are unknown.Methods: A 30-question survey was sent between June and December 2014 to pancreatic surgeons of the European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association and 5 European national pancreatic societies. Incomplete responses were excluded.Results: In total, 237 pancreatic surgeons responded. After excluding 34 incomplete responses, 203 responses from 27 European countries were included. 164 (81%) surgeons were employed at a university hospital, 184 (91%) performed advanced MI surgery and 148 (73%) performed MI distal pancreatectomy. MI pancreatoduodenectomy was performed by 42 (21%) surgeons, whereas 9 (4.4%) surgeons had performed more than 10 procedures. Robot-assisted MI pancreatic surgery was performed by 28 (14%) surgeons. 63 (31%) surgeons expected MI distal pancreatectomy for cancer to be inferior to open distal pancreatectomy concerning oncological outcomes. 151 (74%) surgeons expected to benefit from training in MI distal pancreatectomy and 149 (73%) were willing to participate in a randomized trial on this topic.Conclusions: MI distal pancreatectomy is a common procedure, although its use for cancer is still disputed. MI pancreatoduodenectomy is still an uncommon procedure. Specific training and a randomized trial regarding MI pancreatic cancer surgery are welcomed
Duration of delayed graft function and outcomes after kidney transplantation from controlled donation after circulatory death donors:a retrospective study
No full textThe impact of the duration of delayed graft function (DGF) on graft survival is poorly characterized in controlled donation after circulatory death (DCD) donor kidney transplantation. A retrospective analysis was performed on 225 DCD donor kidney transplants between 2011 and 2016. When patients with primary nonfunction were excluded (n = 9), 141 recipients (65%) had DGF, with median (IQR) duration of dialysis dependency of 6 (2-11.75) days. Longer duration of dialysis dependency was associated with lower estimated glomerular filtration rate at 1 year, and a higher rate of acute rejection. On Kaplan-Meier analysis, the presence of DGF was associated with lower graft survival (log-rank test P = 0.034), though duration of DGF was not (P = 0.723). However, multivariable Cox regression analysis found that only acute rejection was independently associated with lower graft survival [HR (95% CI) 4.302 (1.617-11.450); P = 0.003], whereas the presence of DGF and DGF duration were not. In controlled DCD kidney transplantation, DGF duration itself may not be independently associated with graft survival; rather, it may be that acute rejection associated with prolonged DGF is the poor prognostic factor.</p
Tired of Being a Refugee
No full textAfter six decades of protracted refugeehood, patterns of social identification are changing among the young people of the fourth refugee generation in the Palestinian refugee camp Burj al-Shamali in Southern Lebanon. Though their identity as Palestinian refugees remains the same compared to older refugee generations, there is an important shift in the young refugees’ relationship towards the homeland, their status as refugees, Islam, the camp society, as well as in their relationship towards religious or ethnic “others” in and outside Lebanon. This ePaper examines how technology, globalisation and outside influences have impacted the young Palestinians’ interpretation of their identity and their understanding of Palestinianness. The author concludes with reflections on the young refugees’ attitudes towards their Palestinian identity in the diaspora, which, as she argues, can only survive when the young refugees see their identity as a virtue rather than as a hindrance
Surface water resources management using runoff harvesting and spreading techniques in the Syrian steppe (1995 - 1998) seasons
No full textLaparoscopic Surgical Treatment of Ileocecal Crohn's Disease: Impact of Obesity on Short Term Results
No full textElderly patients have similar short term outcomes and five-year survival compared to younger patients after pancreaticoduodenectomy
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