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Background: Somatostatin analogues are used for the treatment of pancreatic fistula, with the aim of achieving fistula closure or reduction of output. Method: MEDLINE, Embase and Cochrane databases were searched systematically for relevant articles followed by hand-searching of reference lists. Data on patient recruitment, intervention and outcome were extracted and meta-analysis performed where reasonable. Results: Seven randomized clinical trials met the inclusion criteria and included a total of 297 patients with fistulas of the gastrointestinal tract; of these, 102 patients had fistulas of pancreatic origin. Pooling of closure rates showed no significant difference between patients treated with somatostatin analogues compared with controls: odds ratio 1·52 (95 per cent confidence interval 0·88 to 2·61). Owing to inconsistent descriptions, pooling of results was not possible for other endpoints, such as time to fistula closure. Conclusion: There is no solid evidence that somatostatin analogues result in a higher closure rate of pancreatic fistula compared with other treatments. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article explores the role of immunoglobulin G4-related sclerosing cholangitis in patients resected for presumed hilar cholangiocarcinoma (HCCA). Results reveal that features of autoimmune-like bile duct diseases were seen in nearly half of patients with benign hilar strictures resected for presumed HCCA. Frank immunoglobulin G4-related sclerosing disease was found in just two of the 15 patients with autoimmune-like bile duct disease.

Summary Background The differentiation between benign and malignant strictures at the hepatic hilum is difficult. The aim of this study was to assess the clinical and radiographical features of hilar lesions in a series of patients resected for a presumed cholangiocarcinoma. Methods Of 132 consecutive patients undergoing resection for a suspicious lesion at the hepatic hilum, 20 (15 per cent) had a histopathologically proven benign tumour, diagnosed as chronic fibrosing or erosive inflammation, sclerosing cholangitis, or a granular cell tumour. All medical files and radiological examinations of the patients were reassessed. Results Clinical symptoms were considered suspicious in 16 of 19 patients. At ultrasonography only one of 16 patients had an unsuspicious examination. In 14 of 18 patients cholangiographic images were considered suspicious. Overall reassessment confirmed a suspicious lesion in all 20 patients. Conclusion Because of the limitations of current diagnostic tools, a false-positive preoperative diagnosis of malignancy resulted in a 15 per cent resection rate of benign lesions in this series of suspicious hilar strictures. [ABSTRACT FROM AUTHOR]

Summary Background Spontaneous closure of an external pancreatic fistula is unlikely when a concomitant downstream obstruction of the pancreatic duct inhibits downstream flow. Early endoscopic retrograde pancreatography (ERP) and stent insertion may enhance fistula closure in these patients. Methods The results of endoscopic stenting of the pancreatic duct were evaluated in 15 patients with an external pancreatic fistula that developed after operative necrosectomy and debridement of the pancreas (seven men and eight women, median age 45 (range 25–68) years). Results Median drainage before ERP was 50–800 ml/day, with an amylase content of 21 000–493 000 units/l. ERP was performed after a median time of 35 days and revealed leakage of the duct and a downstream obstruction in all patients. An endoprosthesis was inserted beyond the site of obstruction. Within a median time of 10 (range 2–64) days drainage stopped in all patients. In one patient ERP failed and pancreaticojejunostomy was performed. During follow-up (median 24 (range 2–55) months) three patients required resection of the pancreatic tail because of pseudocyst formation, all of whom originally had leakage from the tail area. Conclusion Based on these data, an active approach for external pancreatic fistula seems warranted. Early ERP and stent insertion enhances fistula resolution, facilitates wound care and surgery is postponed or even avoided. [ABSTRACT FROM AUTHOR]

SummaryBackground: Pancreatic cancer is often locally invasive. Preoperative staging attempts to identify patients suitable for resection, in order to minimize unnecessary operations. The aim of this study was to assess the improved imaging provided by spiral computed tomography (CT) in the preoperative staging of potentially resectable pancreatic head carcinoma. Methods: In 56 consecutive patients with pancreatic head carcinoma spiral CT findings were correlated prospectively with operative and histopathological findings. Criteria for irresectability at CT were infiltration of the peripancreatic fat and vascular ingrowth grade D, on a scale from A to F. Results: At operation 27 (48 per cent) of 56 tumours were irresectable. Small metastases were found in seven patients (12 per cent). Ingrowth (adherence) to the portal or mesenteric vein was present in 19 patients (34 per cent). The sensitivity and specificity of CT for irresectability were 78 and 76 per cent respectively. Resection rates with a vascular margin free of tumour were 100 per cent for grade A, 63 per cent for grade B, 44 per cent for grade C, 15 per cent for grade D and 0 per cent for grade E, with a predictive value for ingrowth of 88 per cent for grades D or higher. The resectability rate was 11 per cent (one of nine) when infiltration of the anterior peripancreatic fat was present and 67 per cent when infiltration was absent (P < 0·01). Conclusion: Spiral CT with thin slices seems to improve detection of distant metastases and vascular ingrowth in patients with pancreatic head carcinoma. [ABSTRACT FROM AUTHOR]

Background Recent reports suggest a better postoperative weight gain after pylorus-preserving pancreatoduodenectomy (PPPD) compared with standard pancreatoduodenectomy (PD). Factors that could also influence postoperative weight gain, such as tumour-positive resection margins and tumour recurrence, have not been taken into account in these studies. The aim of this prospective study was to evaluate weight gain in the first 15 months after PD or PPPD and to investigate the influence of other tumour-related factors. Methods From 1991 to 1995, 140 patients underwent subtotal pancreatoduodenectomy; 125 patients underwent resection for malignant disease of the pancreatic head region (56 had PD and 69 PPPD). Patients' weights were evaluated in the pre-illness phase, before operation and during four postoperative phases (at 3, 7, 11 and 15 months). Weight was calculated as a percentage of the pre-illness weight. Patients were subdivided according to tumour status: PD with positive and PD with negative tumour status; PPPD with positive and PPPD with negative tumour status. Tumour-positive status was defined as either microscopically tumour-positive resection margins or radiologically or cytologically proven tumour recurrence within 2 years of surgery. Results Five patients died during the hospital stay (PD, four; PPPD, one) (overall mortality rate 4 per cent). There was no difference in overall weight gain between patients having PD and PPPD. There was, however, a difference in patients with positive and negative tumour status for PD (P=0·0003) and PPPD (P<0·0001). Conclusion There is only a minimal difference in postoperative weight gain between patients having PD and PPPD. Differences in postoperative weight gain are related more to positive resection margins and tumour recurrence than to the type of resection. [ABSTRACT FROM AUTHOR]