BackgroundLaparoscopic left pancreatectomy has been well described for benign pancreatic lesions, but its role in pancreatic adenocarcinoma remains open to debate. We report our results adopting a laparoscopic technique that obeys established oncologic principles of open distal pancreatosplenectomy.MethodsThis is a post hoc analysis of a prospectively kept database of 135 consecutive patients undergoing laparoscopic left pancreatectomy, performed across two sites in the UK and the Netherlands (07/2007–07/2015 Southampton and 10/2013–07/2015 Amsterdam). Primary outcomes were resection margin and lymph node retrieval. Secondary endpoints were other perioperative outcomes, including post-operative pancreatic fistula. Definition of radical resection was distance tumour to resection margin >1 mm. All patients underwent ‘laparoscopic radical left pancreatosplenectomy’ (LRLP) which involves ‘hanging’ the pancreas including Gerota’s fascia, followed by clockwise dissection, including formal lymphadenectomy.ResultsLRLP for pancreatic adenocarcinoma was performed in 25 patients. Seven of the 25 patients (28 %) had extended resections, including the adrenal gland (n = 3), duodenojejunal flexure (n = 2) or transverse mesocolon (n = 3). Mean age was 68 years (54–81). Conversion rate was 0 %, mean operative time 240 min and mean blood loss 340 ml. Median intensive/high care and hospital stay were 1 and 5 days, respectively. Clavien–Dindo score 3+ complication rate was 12 % and ISGPF grade B/C pancreatic fistula rate 28 %; 90-day (or in-hospital) mortality was 0 %. The pancreatic resection margin was clear in all patients, and the posterior margin was involved (<1 mm) in 6 patients, meaning an overall R0 resection rate of 76 %. No resection margin was microscopically involved. Median nodal sample was 15 nodes (3–26). With an average follow-up of 17.2 months, 1-year survival was 88 %.ConclusionsA standardised laparoscopic approach to pancreatic adenocarcinoma in the left pancreas can be adopted safely. Our study shows that these results can be reproduced across multiple sites using the same technique.
A best evidence topic in surgery was written according to a structured protocol. The question addressed was: in patients with symptomatic gallstones and concomitant common bile duct (CBD) stones, is a single-stage surgical strategy (laparoscopic cholecystectomy (LC) with common bile duct exploration) preferable, or a two-stage procedure involving LC with pre or post-operative endoscopic retrograde cholangiography (ERCP)? Two hundred and six papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. A recent large meta-analysis concluded no significant difference in the clinical effectiveness or complication rate of either strategy. Three recent smaller studies concurred with this conclusion; however each noted improved cost-effectiveness of the single-stage approach advocating its use as the superior strategy when local resources and expertise are available. We conclude that for patients with symptomatic gallstones and concomitant choledocholithiasis, a single-stage surgical procedure is equivalent to two-stage LC and ERCP in terms of clinical outcomes, is associated with a shorter overall hospital stay and may be more cost-effective. On this basis a single-stage procedure is recommended for management of symptomatic gallstones and choledocholithiasis where local resources and expertise permit.
A 78-year-old woman presented with a right basal ganglia infarct 6 weeks after a left herpes zoster ophthalmicus. MR angiography showed focal segmental stenosis of the proximal segments of the anterior, middle, and posterior cerebral arteries. Varicella DNA was detected in the CSF by polymerase chain reaction (PCR). Treated with dexamethasone and acyclovir without improvement, she died 1 month later. There was focal endarteritis in the left anterior, middle, and posterior cerebral arteries at autopsy. Varicella DNA was detected by PCR of extracts from these vessels but not from the arteries on the right side. This study provides further evidence that the vasculopathy after herpes zoster ophthalmicus results from direct viral invasion of the vessel wall.
Implant success and survival was over 92% and 99%, respectively, in a formal 5-year prospective multicenter clinical trial involving 200 patients and 626 non-submerged TPS implants. These implants included hollow cylinder implants in the anterior maxilla and solid screw implants placed in the mandible. These findings document the predictability and patient satisfaction of tooth replacement using a non-submerged surgical technique involving a tissue-level, rough surfaced endosseous dental implant.
Atypical facial pain and permanent sensory loss in the second and third divisions of the trigeminal nerve developed in a patient who had had multiple attacks of herpes simplex neuralgia over a period of 8 years. Intravenous cytosine arabinoside failed to prevent a recurrence of the vasicular eruption, but carbamazepine produced symtomatic pain relief. This case demonstrates that herpes simplex can closely mimic herpes zoster as a cause of postherpetic neuralgia and suggests a possible etiology of atypical facial pain and/or trigeminal sensory neuropaty in some patients.
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