Background
Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). This is an update to a previous Cochrane Review published in 2013 evaluating the role of diagnostic laparoscopy in assessing the resectability with curative intent in people with pancreatic and periampullary cancer.

Objectives
To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 15 May 2016), and Science Citation Index Expanded (from 1980 to 15 May 2016).

Selection criteria
We included diagnostic accuracy studies of diagnostic laparoscopy in people with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

Data collection and analysis
Two review authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. The sensitivities were therefore meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in people who had a negative laparoscopy (post-test probability for people with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies, and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

Main results
We included 16 studies with a total of 1146 participants in the meta-analysis. Only one study including 52 participants had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 41.4% (that is 41 out of 100 participants who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 64.4% (95% confidence interval (CI) 50.1% to 76.6%). Assuming a pre-test probability of 41.4%, the post-test probability of unresectable disease for participants with a negative test result was 0.20 (95% CI 0.15 to 0.27). This indicates that if a person is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 20% probability that their cancer will be unresectable compared to a 41% probability for those receiving CT alone.

A subgroup analysis of people with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40.0% for those receiving CT alone.

Authors' conclusions
Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in people with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 21 unnecessary laparotomies in 100 people in whom resection of cancer with curative intent is planned.

/pdf/diagnostic-accuracy-of-laparoscopy-following-computed-4nupb444fq.pdf

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUNDSurgery is the treatment of choice for perforated peptic ulcer disease. The aim of the present review was to compare the perioperative outcomes of acute laparoscopic versus open repair for peptic ulcer disease.METHODSA systematic literature search was performed for randomized controlled tr

Meta-analysis of perioperative outcomes of acute laparoscopic versus open repair of perforated gastroduodenal ulcers.

Foreign bodies in the gastrointestinal tract.

Primary gallbladder cancer is an aggressive and uncommon cancer with poor outcomes. Our study examines epidemiology, trend, and survival of gallbladder cancer in the United States from 1973 to 2009. We utilized the Surveillance Epidemiology and End Results database (SEER). Frequency and rate analyses on demographics, stage, and survival were compared among non-Hispanic whites, Hispanics, African American, and Asian/Pacific Islanders. A total of 18,124 cases were reported in SEER from 1973 to 2009 comprising 1.4% of all reported gastrointestinal cancers. Gallbladder cancer was more common in females than males (71 vs. 29%, respectively). The age-adjusted incidence rate was 1.4 per 100,000, significantly higher in females than males (1.7 vs. 1.0). Trend analysis showed that the incidence rate has been decreasing over the last three decades for males. However, among females, the incidence rate had decreased from 1973 to mid-90s but has remained stable since then. Trend analysis for stage at diagnosis showed that the proportion of late-stage cases has been increasing significantly since 2001 after a decreasing pattern since 1973. Survival has improved considerably over time, and survival is better in females than males and in Asian/Pacific Islanders than other racial groups. The highest survival was in patients who received both surgery and radiation. Trend analysis revealed a recent increase of the incidence of late-stage gallbladder cancer. Highest survival was associated with receiving both surgery and radiation.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/cam4.1044

Trend analysis and survival of primary gallbladder cancer in the United States: a 1973-2009 population-based study.

Importance While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD. Objective The aim of this consensus statement is to guide the continued safe progression and adoption of LPD. Evidence review An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China. Findings Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument. Conclusions and relevance The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

/pdf/international-expert-consensus-on-laparoscopic-eeh8ch6nsf.pdf

International expert consensus on laparoscopic pancreaticoduodenectomy.

Introduction Peptic ulcer perforation (PPU) is a common surgical emergency and the mortality rate ranges 10% to 40%, especially in elderly patients. Laparoscopic repair achieved encouraging results. Materials and methods We enrolled patients performing surgical repair for PPU from January 2007 to December 2015 in our surgical unit. The aim of this retrospective observational study was to compare the results of PPU laparoscopic repair with open technique. The following characteristics of patients were evaluated: age, sex and American Society of Anesthesiologists classification. The site and the diameter of perforation were recorded: gastric, pyloric, duodenal, and the location on the anterior or posterior wall. Results In total, 59 patients (39 males and 20 females) with a mean age of 58.85 years (±SD) were treated surgically. Laparoscopic repair was accomplished in 21 patients. The mean operative time for laparoscopic repair was 72 minutes (±SD), significantly shorter than open repair time (180 min ±SD). The results demonstrated that laparoscopic repair is associated with a shorter operative time, reduced postoperative pain (4.75 vs. 6.42) and analgesic requirements, a shorter hospital stay (7.5 vs. 13.1), and earlier return to normal daily activities. Discussion Laparoscopic surgery minimizes postoperative wound pain and encourages early mobilization and return to normal daily activities. The benefit of early discharge and return to work may outweigh the consumable cost incurred in the execution of laparoscopic procedures. Conclusions Complications in both procedures are similar but laparoscopic procedure shows economic advantages for reducing postoperative hospital stay, postoperative pain, and for a good integrity of abdominal wall.

/pdf/laparoscopic-and-open-surgical-treatment-in-gastroduodenal-4rzxgx78kn.pdf

Laparoscopic and Open Surgical Treatment in Gastroduodenal Perforations: Our Experience.

Introduction Extramammary Paget's disease (EMPD) occurs commonly in perineum, vulva and perineal region and is considered as a complex disorder due to different clinical and histological features. Presentation of case A 61 years old woman had a dermatologic evaluation for anal itch and underwent a skin biopsy with diagnostic of Paget disease in perianal region. Pelvic magnetic resonance showed a huge tumor which involved skin, derma and gluteus and she firstly refused any surgical treatment. One year later, because of increasing of the tumor and bleeding, she underwent the surgical procedure with a complete excision, resection of the skin of the anus, inguinal lymphadenectomy and left colostomy. Because of lymph nodes metastasis, a VLS Miles was sequentially performed. She started oncological follow up that showed liver, lung and pelvic metastasis. She survived for 24 months after surgery. Discussion In literature, less than 200 cases of perineal Paget's disease have been reported. EMPD in some cases has an associated adenocarcinoma, which has been associated with a worse prognosis and high mortality. Wrong diagnosis and a superficial consideration of a benign evolution should be considered as the first mistake in clinical practice. Conclusion Our surgical approach is considered in literature as the best one for those cases, followed by the oncological treatment. Those patients need to be better studied and more attention should be paid to the clinical presentation.

Perineal Paget's disease: A rare disorder and review of literature.

Aim. Gallbladder carcinoma is an uncommon cancer with a poor prognosis. In the era of laparoscopic cholecistectomy for treatment of benign diseases incidental gallbladder carcinoma has dramatically increased and now constitutes the major way patients present with gallbladder cancer and allows to detect cancer at early stages with a better prognosis. In this single-center study we report our experience with gallbladder carcinoma incidentally diagnosed during or after laparoscopic colecistectomy performed for cholelithiasis. Methods. From January 2003 to December 2011 a total of 1193 patients underwent cholecistectomy at General Surgical Unit III of University of Bari. The patients were 458 males and 735 females, mean age was 52 years (range 19-91). In 6 of 1188 patients adenocarcinoma was present in the pathologic specimens (0,5%). Results. Of 1188 patients in whom laparoscopic cholecistectomy was attempted adenocarcinoma was diagnosed histopathologically in 6 cases (0,5%). There was no suspicion of malignancy to any of them. Intraoperatively, gallbladder wall appeared abnormal in one patients and frozen section analysis revealed adenocarcinoma. In the remaining 5 cases routine histopathological studies revealed the diagnosis of gallbladder carcinoma. One patient had T1 tumor, two had T2 and three had T3 tumor. Conclusions. In the present study the rate of incidental gallbladder carcinoma was 0,5%, according to the published English language literature. The risk factors widely related to the gallbladder cancer are advanced age and gallstones disease. The therapeutic approach to gallbladder cancer was applied according to the stage of tumor, but in our study this was possible only in two patients with T2 and T3 tumor since high risk and important comorbidities were the main causes for the refusal of 3 patient out of 5. Only the T1 patient underwent simple cholecystectomy. Similar to other reports in this single-center study the diagnosis of incidental gallbladder carcinoma was found to be of 0,5%, thus the diagnosis of gallbladder stones is an indication to the cholecystectomy.

/pdf/incidental-gallbladder-carcinoma-our-experience-rghze0y82a.pdf

Incidental gallbladder carcinoma: our experience.

Liver abscess is a cause of febrile abdominal pain and usually the origin of a liver abscess is ascending cholangitis, hemathological diffusion, via the portal vein or the hepatic artery, or superinfection of necrotic tissue. Solitary pyogenic abscess with no obvious systemic cause may be secondary to a local event such as the migration of an ingested foreign body. We report the case of a solitary liver abscess caused by an ingested foreign body, a fish bone, migrated through the gastric wall into the left lobe.

Unusual liver abscess secondary to ingested foreign body: laparoscopic management.

Colorectal foreign bodies per annum introduced are not exceptional. They can be classified as high-lying or low-lying, depending on their location relative to the recto-sigmoid junction. High-lying rectal foreign bodies sometimes require surgery; low-lying ones are often palpable by digital examination and can removed at bedside. No reliable data exist regarding the frequency of inserted rectal foreign bodies and the literature is largely anecdotal. We review our experience on patients almost all males and heterosexual with retained colorectal foreign bodies and their outcome in Surgical Emergency Unit of a Southern Italy University hospital.

Colorectal retained foreign bodies per anum introduced. Three years retrospective study at Emergency Surgery Unit.

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