Advances in surgery
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Both morbidity and mortality rates following pancreatic resection increase with advanced age. The reported mortality rates following pancreatic surgery arc underestimated in single-institution studies. There is a significant publication bias where only centers with good results report their outcomes. ⋯ The effect of patient comorbidities, cognitive status, preoperative functional status, and frailty need to be more formally assessed to select patients, maximize surgical resection in appropriate candidates, and improve short-term outcomes. Once better characterized, specialized geriatric pathways may optimize surgical resection rates, streamline care, and improve outcomes in this challenging population. Age alone, however, should not be a contraindication to pancreatic resection in elderly patients with pancreatic cancer.
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Advances in surgery · Jan 2009
ReviewShould all distal pancreatectomies be performed laparoscopically?
Despite the relatively slow start of laparoscopic pancreatectomy relative to other laparoscopic resections, an increasing number of these procedures are being performed around the world. Operations that were once considered impossible to perform laparoscopically, such as pancreaticoduodenectomy and central pancreatectomy are gaining momentum. Technology continues to improve, as does surgical experience and prowess. ⋯ NOTES represents the "holy grail" of incisionless surgery. Can we enucleate a small tumor off the pancreatic body by passing an endoscope through the gastric (or colonic) wall, and bring the specimen out via the mouth or anus? Can we use this approach for formal left pancreatectomies? Pioneers have already developed a porcine model of left pancreatectomy. This technology must clear several hurdles before it is cancer ready; however, technology is moving at a rapid pace.
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The last decade has seen an increase in the application of minimally invasive surgical procedures to the management of pancreatic disease. Laparoscopic pancreatic surgery is an advanced laparoscopic procedure with a significant learning curve. ⋯ Early reports suggest that laparoscopic pancreatic surgery can be accomplished with acceptable morbidity and mortality for the resection of small benign and low-grade malignant lesions in the body and tail of the pancreas and for the internal drainage of pancreatic pseudocysts. Its role in the management of lesions in the head, neck, and uncinate process of the pancreas is yet to be determined.
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Advances in surgery · Jan 2009
ReviewAdjuncts to liver surgery: is acute normovolemic hemodilution useful for major hepatic resections?
For patients undergoing major hepatic resection, acute normovolemic hemodilution is a safe technique that effectively reduces allogeneic red blood cell transfusions. In the recent prospective randomized controlled trial completed at MSKCC, there was no difference in the extent of resection, intraoperative blood loss, operative time, incidence and grade of complications, or length of hospital stay between patients who underwent ANH versus standardintraoperative management. ⋯ Thus, ANH should be considered for routine use in patients undergoing major hepatectomy who have an expected considerable blood loss. However, given the relatively low transfusion rate overall, future efforts should be directed at preoperatively identifying patients most likely to benefit from ANH.