Gastrinomas: a difficult tumour to diagnose and treat
Gastrinomas are rare neuroendocrine tumours that can occur sporadically or in association with MEN 1 syndrome. For most HPB surgeons they represent an interesting but rare reprieve from treating pancreatic adenocarcinoma given their favourable outcomes. Just how rare they are is demonstrated in this issue of HPB by Atema et al. A 20 year retrospective review from a large tertiary centre managed to find only eleven patients who underwent potentially curable surgery. Despite this small number of patients, a number of important issues can be identified. It was notable that the median time to diagnosis was 8 years, highlighting the need to be vigilant for symptoms other than those related to complicated ulcer disease. Five of the 11 patients complained of persistent diarrhoea. The level of serum gastrin was 600 ng/l or less in five of the 11 patients. All patients had tumours that were identified on cross sectional imaging although in one patient the primary tumour was not found at subsequent surgery. The surgery was tailored to the individual patient and ranged from enucleation or central pancreatectomy through to pancreaticoduodenectomy. However it should be kept in mind that gastrinomas frequently (50–70%) metastasize to draining lymph nodes but whether upfront radical surgery can offer survival benefit could not be determined from this study. Given the rarity and complexity of these tumours the authors conclude these patients are best managed through a multidisciplinary pathway to optimise the diagnosis, investigation, treatment and follow up.
Saxon Connor
Zacharias & Ferreira, p. 839
Closing the book on open cholecystectomy in cirrhosis
Offer most surgeons the opportunity to take out the gall bladder in a patient with cirrhosis and they will run a mile. The perceived wisdom for many years was that if you were forced to perform a cholecystectomy in a cirrhotic patient this would be better done as an open procedure as the potential for rapid control of bleeding was much better. The trouble was that no single centre had enough cases to test this anecdotal opinion. Chmielecki and colleagues in this month's edition of HPB have undertaken a population based study to address the question of whether it is better to undertake a laparoscopic or an open cholecystectomy in a patient with cirrhosis. Using Nationwide Inpatient Sample data they identified over 3000 patients with cirrhosis who had undergone cholecystectomy. Twelve percent of these patients had open cholecystectomy with the majority having an attempt at laparoscopic cholecystectomy. Conversion rates to open surgery were high with 14% converted, but outcomes were much better in those patients undergoing laparoscopic surgery. Specifically, transfusion requirements, postoperative liver failure and infection rates were all lower in laparoscopically treated patients. The stand out result, however, was a 6 fold lower operative mortality in laparoscopic (1.3%) versus open cholecystectomy patients (8.3%). The dataset does not allow analysis of severity of liver disease which would have allowed greater confidence in excluding selection bias. The message seems fairly clear, however, if your patient has cirrhosis and they need a cholecystectomy – unless there are compelling reasons otherwise, this should be attempted laparoscopically.
Stephen J Wigmore
Pandanaboyana et al., p. 812
Preventing pancreatic fistula: we need an App for that
Isn't it amazing in 2012 that no consensus has been reached as to the best way to close the pancreatic remnant after a distal pancreatectomy (DP)? Today, a rover cruises Mars, the internet and mobile devices unite the world but we still cannot reliably prevent post-operative pancreatic fistula (POPF) after a relatively common operation. Beyond our ISGPF classification, agreed-upon risk factors and new predictive models, we thankfully have committed surgeons driven to solve this troublesome and uncompromising complication. Among them are Klein et al. from Berlin who summarize outcomes in 47 DP patients who had a pancreatoenteral (PE) anastomosis (jejunum or stomach) to the transected pancreatic remnant instead of precise direct closure (DC) alone (n = 151). The incidence of POPF was higher following DC (22% vs. 11% PE), however more patients bled post-operatively after PE (11% vs. 7% DC). Ultimately, no significant differences in mortality or overall morbidity were seen regardless of what surgical approach was taken. The authors duly note the limitations of their retrospective study that evaluated a limited sample size. Nonetheless, they show as others have that PE is a safe, reliable and likely equivalent option for preventing POPF in selected patients. It requires technical prowess, however, and may be impractical for laparoscopic or robotic-assisted DP. Until a technical solution is achieved, we must rely on individual risk-stratification and meticulous peri-operative care. We do have an App for that.
Mark Callery
Govil, p. 874