Nationwide use and Outcome of Minimally Invasive Distal Pancreatectomy in IDEAL Stage IV following a Training Program and Randomized Trial

OBJECTIVE

To assess the nationwide long-term uptake and outcomes of minimally invasive distal pancreatectomy (MIDP) after a nationwide training program and randomized trial.

BACKGROUND

Two randomized trials demonstrated the superiority of MIDP over open distal pancreatectomy (ODP) in terms of functional recovery and hospital stay. Data on implementation of MIDP on a nationwide level are lacking.

METHODS

Nationwide audit-based study including consecutive patients after MIDP and ODP in 16 centers in the Dutch Pancreatic Cancer Audit (2014 to 2021). The cohort was divided into three periods: early implementation, during the LEOPARD randomized trial, and late implementation. Primary endpoints were MIDP implementation rate and textbook outcome.

RESULTS

Overall, 1496 patients were included with 848 MIDP (56.5%) and 648 ODP (43.5%). From the early to the late implementation period, the use of MIDP increased from 48.6% to 63.0% and of robotic MIDP from 5.5% to 29.7% ( P <0.001). The overall use of MIDP (45% to 75%) and robotic MIDP (1% to 84%) varied widely between centers ( P <0.001). In the late implementation period, 5/16 centers performed >75% of procedures as MIDP. After MIDP, in-hospital mortality and textbook outcome remained stable over time. In the late implementation period, ODP was more often performed in ASA score III-IV (24.9% vs. 35.7%, P =0.001), pancreatic cancer (24.2% vs. 45.9%, P <0.001), vascular involvement (4.6% vs. 21.9%, P <0.001), and multivisceral involvement (10.5% vs. 25.3%, P <0.001). After MIDP, shorter hospital stay (median 7 vs. 8 d, P <0.001) and less blood loss (median 150 vs. 500 mL, P <0.001), but more grade B/C postoperative pancreatic fistula (24.4% vs. 17.2%, P =0.008) occurred as compared to ODP.

CONCLUSION

A sustained nationwide implementation of MIDP after a successful training program and randomized trial was obtained with satisfactory outcomes. Future studies should assess the considerable variation in the use of MIDP between centers and, especially, robotic MIDP.

Disparities in Surgical Treatment of Resectable Pancreatic Adenocarcinoma at Minority Serving Hospitals

INTRODUCTION

Minority serving hospitals (MSH) are those serving a disproportionally high number of minority patients. Previous research has demonstrated that treatment at MSH is associated with worse outcomes. We hypothesize that patients treated at MSH are less likely to undergo surgical resection of pancreatic adenocarcinoma compared to patients treated at non-MSH.

METHODS

Patients with resectable pancreatic cancer were identified using the National Cancer Database. Institutions treating Black and Hispanic patients in the top decile were categorized as an MSH. Factors associated with the primary outcome of definitive surgical resection were evaluated using multivariable logistic regression. Univariate and multivariable survival analysis was performed.

RESULTS

Of the 75,513 patients included in this study, 7.2% were treated at MSH. Patients treated at MSH were younger, more likely to be uninsured, and higher stage compared to those treated at non-MSH (P < 0.001). Patients treated at MSH underwent surgical resection at lower rates (MSH 40% versus non-MSH 44.5%, P < 0.001). On multivariable logistic regression, treatment at MSH was associated with decreased likelihood of undergoing definitive surgery (odds ratio 0.91, P = 0.006). Of those who underwent surgical resection, multivariable survival analysis revealed that treatment at an MSH was associated with increased morality (hazard ratio 1.12, P < 0.001).

CONCLUSIONS

Patients with resectable pancreatic adenocarcinoma treated at MSH are less likely to undergo surgical resection compared to those treated at non-MSH. Targeted interventions are needed to address the unique barriers facing MSH facilities in providing care to patients with pancreatic adenocarcinoma.

Clamp-crushing Pancreatic Transection in Minimally Invasive Distal Pancreatectomy

BACKGROUND

Minimally invasive distal pancreatectomy has become a widely accepted procedure for tumors located in the pancreatic body or tail. However, pancreatic transection by linear stapler is generally avoided for pancreatic body tumors located above the portal vein because the surgical margin width is narrowed after taking into account the cutting allowance for insertion of the stapling device. Herein, we report a parenchymal clamp-crushing procedure that provides a sufficient surgical margin in pancreatic transection.

METHODS

Two patients with suspected early pancreatic cancer underwent pancreatic transection using the clamp-crushing procedure. The planned pancreatic transection line was set just to the left of the gastroduodenal artery in both cases. Robotic and laparoscopic distal pancreatectomy were performed in 1 patient each. Patients were positioned supine with split legs. Parenchymal transection was performed with crushing by VIO 3 (ERBE Elektromedizin) operated in softCOAG Bipolar mode with Effect 2/modulation 50. After crushing, remnant tissue was cut in autoCUT Bipolar mode operated by VIO 3 with Effect 2/modulation 50, or cut after secured by clipping.

RESULTS

The surgical duration was 253 and 212 minutes, and estimated blood loss was 0 and 50 mL in the 2 patients, and both were discharged with uneventful courses. Pathologic examination confirmed a negative surgical margin in both patients.

CONCLUSION

Clamp-crushing pancreatic transection for distal pancreatectomy might be a suitable treatment option for achieving sufficient surgical margin in pancreatic body tumors located close to the portal vein.

A nomogram to preoperatively predict the aggressiveness of non-functional pancreatic neuroendocrine tumors based on CT features

OBJECTIVES

To develop a nomogram to predict the aggressiveness of non-functional pancreatic neuroendocrine tumors (NF-pNETs) based on preoperative computed tomography (CT) features.

METHODS

This study included 176 patients undergoing radical resection for NF-pNETs. These patients were randomly divided into the training (n = 123) and validation sets (n = 53). A nomogram was developed based on preoperative predictors of aggressiveness of the NF-pNETs which were identified by univariable and multivariable logistic regression analysis. The aggressiveness of NF-pNETs was defined as a composite measure including G3 grading, N+, distant metastases, and/ or disease recurrence.

RESULTS

Altogether, the number of patients with highly aggressive NF-pNETs was 37 (30.08 %) and 15 (28.30 %) in the training and validation sets, respectively. Multivariable logistic regression analysis identified that tumor size, biliopancreatic duct dilatation, lymphadenopathy, and enhancement pattern were preoperative predictors of aggressiveness. Those variables were used to develop a nomogram with good concordance statistics of 0.89 and 0.86 for predicting aggressiveness in the training and validation sets, respectively. With a nomogram score of 59, patients with NF-pNETs were divided into low-aggressive and high-aggressive groups. The high-aggressive group had decreased overall survival (OS) and disease-free survival (DFS). Moreover, the nomogram showed good performance in predicting OS and DFS at 3, 5, and 10 years.

CONCLUSION

The nomogram integrating CT features helped preoperatively predict the aggressiveness of NF-pNETs and could potentially facilitate clinical decision-making.

[Two Cases of Portal Vein Stent Placement for Portal Vein Stenosis Due to Recurrence of Pancreatic Cancer]

We report 2 cases of portal vein stent placement for malignant portal stenosis due to recurrence of pancreatic cancer with symptoms of portal hypertension. Case 1: The patient was a 68-year-old female. Five years ago, a mass was found around the aorta on a computerized tomography(CT)scan taken after a residual pancreatectomy for pancreatic cancer. It was diagnosed as lymph node recurrence and S-1 therapy was started. As further tumor enlargement led to portal vein compression, venostasis around the ascending jejunum, anemia, and black stools, a portal vein stent was placed. The portal vein blood flow was improved, the collateral vessels disappeared, and the patient no longer experienced anemia or black stool. Case 2: A 75-year-old female patient underwent a subtotal gastric-sparing pancreaticoduodenectomy and combined resection of the portal vein for pancreas head cancer. On a postoperative CT scan taken 6 months later, a mass compressing the portal vein appeared, which was diagnosed as a local recurrence. As thrombocytopenia was observed, a portal vein stent was placed before starting chemotherapy. The portal vein blood flow and the platelet count improved. Portal vein stenting is an effective procedure for malignant portal stenosis, improving portal blood flow and clinical symptoms.

The Gastrohepatic Ligament Approach Using Multiple Traction Tapes in Laparoscopic Spleen-Preserving Distal Pancreatectomy with Preservation of Splenic Vessels (with Video)

BACKGROUND

The gastrohepatic ligament approach is a form of robot-assisted spleen-preserving distal pancreatectomy (SPDP).1,2 This approach does not require omentum transection, peri-splenic dissection, or stomach traction.

METHODS

Considering the advantages of preserving collateral pathways around the spleen, the authors performed the gastrohepatic ligament approach in laparoscopic SPDP while preserving splenic vessels (LSPDP), with specific modifications for laparoscopic surgery. The following surgical technique was performed. First, the gastrohepatic ligament was divided extensively, and all subsequent procedures were performed through the gastrohepatic ligament route. The superior and inferior borders of the pancreas then were dissected to encircle the common hepatic and splenic arteries with vessel loops and to expose the superior mesenteric vein (SMV) and portal vein. After taping of the pancreas on the SMV, the pancreas was divided using a linear stapler. Next, the pancreas was dissected from proximal to distal with preservation of the splenic vessels. Re-taping and traction of the splenic vessels and pancreas could facilitate the dissection of the pancreas body, especially at the splenic hilum. The appropriate counter traction using traction tapes allowed efficient laparoscopic procedures. The LSPDP was performed for three patients, including one obese patient (body mass index, 36 kg/m2) and two patients with an anomalous left hepatic artery branching from the left gastric artery.

RESULTS

The mean operation time was 186 min, and the intraoperative blood loss was 37 mL.

CONCLUSION

The gastrohepatic ligament approach could be an option for performing LSPDP with the counter traction technique for low-grade malignant tumors.

Surgery as a Principle and Technical Consideration for Primary Tumor Resection of Small Bowel Neuroendocrine Tumors

Small bowel neuroendocrine tumors (SB-NETs) are increasingly identified and have become the most frequent entity among small bowel tumors. An increasing incidence, a high prevalence, and a prolonged survival with optimal modern multidisciplinary management makes SB-NETs a unique set of tumors to consider for surgical oncologists. The major goals of surgical treatment in the setting of SB-NET include control of tumor volume, control of endocrine secretion, and prevention of locoregional complications. Key considerations include assessment of multifocality and resection of mesenteric nodal masses with the use of mesenteric-sparing approaches and acceptance of R1 margins if necessary to clear disease while avoiding short bowel syndrome. A description through eight steps for consideration is presented to allow for systematic surgical planning and execution of resection. Moreover, some controversies and evolving considerations to the surgical principles and technical procedures remain. The role of primary tumor resection in the presence of (unresectable) liver metastasis is still unclear. Reports of feasibility of minimally invasive surgery are emerging, with undetermined selection criteria for appropriateness or long-term outcomes. Resection of SB-NETs should be considered in all patients fit for surgery and should follow principles to achieve surgical oncological control that is appropriate for the stage and tumor burden, considering the age and comorbidity of the individual patient.

Tumor-to-blood pool ratio of 18F-fluorodeoxyglucose-positron emission tomography's standardized uptake value as a useful parameter indicating malignant transformation in pancreatic branch-duct intraductal papillary mucinous neoplasm compared to the international Fukuoka guidelines: a retrospective cohort study from surgical resections

BACKGROUND

Identifying malignant transformation in pancreatic branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) remains challenging, but the standardized uptake value (SUV) obtained from 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT has the potential to become a valuable parameter for differentiation. This study aimed to assess the effectiveness of SUV of FDG-PET/CT in distinguishing low-grade dysplasia (LGD), high-grade dysplasia (HGD), and intraductal papillary mucinous carcinoma (IPMC) within BD-IPMNs.

METHODS

We assessed 58 patients with confirmed BD-IPMN undergoing surgery between 2008 and 2022. Receiver operating characteristic curves were plotted using the tumor-to-blood pool ratio (TBR) of FDG-PET/CT in two scenarios: one considering HGD + IPMC as positive and the other considering only IPMC as positive.

RESULTS

In the cohort of 58 cases, there were 39 females, and the median age was 71 years. The median TBR value was 1.45 (range, 0.35-25.44). The TBRs exhibited a significant correlation with each histopathology (p < 0.001). Furthermore, in the multivariate analysis, TBR was independently significant in both scenarios, with HGD + IPMC defined as malignant (p = 0.001) and with only IPMC defined as malignant (p = 0.024).

CONCLUSIONS

TBR might have the potential to serve as a valuable parameter for indicating malignant transformation in pancreatic BD-IPMNs.

Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer

Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.

Computed tomography and guidelines-based human-machine fusion model for predicting resectability of the pancreatic cancer

BACKGROUND AND AIM

The study aims to develop a hybrid machine learning model for predicting resectability of the pancreatic cancer, which is based on computed tomography (CT) and National Comprehensive Cancer Network (NCCN) guidelines.

METHOD

We retrospectively studied 349 patients. One hundred seventy-one cases from Center 1 and 92 cases from Center 2 were used as the primary training cohort, and 66 cases from Center 3 and 20 cases from Center 4 were used as the independent test dataset. Semi-automatic module of ITK-SNAP software was used to assist CT image segmentation to obtain three-dimensional (3D) imaging region of interest (ROI). There were 788 handcrafted features extracted for 3D ROI using PyRadiomics. The optimal feature subset consists of three features screened by three feature selection methods as the input of the SVM to construct the conventional radiomics-based predictive model (cRad). 3D ROI was used to unify the resolution by 3D spline interpolation method for constructing the 3D tumor imaging tensor. Using 3D tumor image tensor as input, 3D kernelled support tensor machine-based predictive model (KSTM), and 3D ResNet-based deep learning predictive model (ResNet) were constructed. Multi-classifier fusion ML model is constructed by fusing cRad, KSTM, and ResNet using multi-classifier fusion strategy. Two experts with more than 10 years of clinical experience were invited to reevaluate each patient based on their CECT following the NCCN guidelines to obtain resectable, unresectable, and borderline resectable diagnoses. The three results were converted into probability values of 0.25, 0.75, and 0.50, respectively, according to the traditional empirical method. Then it is used as an independent classifier and integrated with multi-classifier fusion machine learning (ML) model to obtain the human-machine fusion ML model (HMfML).

RESULTS

Multi-classifier fusion ML model's area under receiver operating characteristic curve (AUC; 0.8610), predictive accuracy (ACC: 80.23%), sensitivity (SEN: 78.95%), and specificity (SPE: 80.60%) is better than cRad, KSTM, and ResNet-based single-classifier models and their two-classifier fusion models. This means that three different models have mined complementary CECT feature expression from different perspectives and can be integrated through CFS-ER, so that the fusion model has better performance. HMfML's AUC (0.8845), ACC (82.56%), SEN (84.21%), SPE (82.09%). This means that ML models might learn extra information from CECT that experts cannot distinguish, thus complementing expert experience and improving the performance of hybrid ML models.

CONCLUSION

HMfML can predict PC resectability with high accuracy.

Effect of laparoscopic and open distal pancreatectomy on postoperative wound complications in patients with pancreatic cancer: A meta-analysis

At present, it is regarded as a safe and efficient operation to treat terminal pancreatic disease. In this paper, we present a summary of the results of the clinical trials that have been conducted to evaluate the efficacy of laparoscopic and open-access pancreatic resection for pancreatic carcinoma of the end of the pancreas. Systematic review of the comparison between laparoscopy and open-access pancreatic resection was conducted. Comparative studies published before October 2023 were included. The selection of the studies was done according to a particular classification and exclusion criterion. A few of our results, which were post-surgery, were associated with injury, were compared. Where appropriate, the reliability of the data has been corroborated by a sensitive analysis. Six trials of 2075 patients with pancreatic cancer who underwent distal pancreatic resection to be included in the definitive data analysis. Among them, 447 were treated with open-access surgery and 296 were treated with laparoscope. Six trials showed that there was no statistically significant difference in the risk of postoperative wound infection in patients with pancreas cancer who received a distal pancreatectomy between laparoscopy and open surgery(OR, 1.66; 95% CI, 0.76-3.61 p = 0.20). Four trials did not reveal any statistically significant differences in the risk of postoperative haemorrhage among patients with pancreas cancer who received a distal pancreatectomy between laparoscopy and open surgery (OR, 1.84; 95% CI, 0.54-6.26 p = 0.33). Both trials did not reveal any statistically significant difference in the duration of operation for patients with pancreas cancer who received a distal pancreatectomy between laparoscopy and open surgery (MD, 13.58; 95% CI, -7.31-34.46 p = 0.2). Based on these meta-analyses, the use of laparoscopy or open surgery was not associated with an increase in the risk of postoperative infection or haemorrhage. Furthermore, the duration of the two operations did not differ significantly. These two procedures appear to be a safe and viable choice in the treatment of pancreatic carcinoma. Nevertheless, a randomized, controlled study should be performed to verify the validity of this observation.

Laparoscopic Duodenum-Preserving Pancreatic Head Resection: A Technique for the Treatment of Benign or Low-Grade Malignant Tumors (10 Cases Report)

Background: Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) is a surgical procedure that involves the removal of the pancreatic head while aiming to preserve the integrity of the digestive and biliary tracts. With advancements in laparoscopic techniques, the utilization of LDPPHR has been increasing. Methods: We retrospectively analyzed the clinical data of 10 patients who underwent laparoscopic duodenum-preserving total pancreatic head resection (LDPPHR-t) at our center from June 2019 to October 2021. Additionally, we analyzed the use of indocyanine green (ICG) in the initial stage of LDPPHR, based on current reports. Results: LDPPHR-t was successfully performed in all patients. After surgery, 3 patients experienced pancreatic fistula (Grade B), 2 patients experienced bile leakage, and 2 patients experienced postoperative hemorrhage. However, no patient exhibited recurrence or required secondary surgery. Conclusion: LDPPHR-t is a new method for treating benign and low-grade malignant tumors in the pancreatic head. However, it is associated with a high incidence of postoperative complications. In the initial stage, the use of ICG can assist surgeons in identifying the biliary duct and pancreaticoduodenal artery arcade.

Which Factors Are Associated with Distal Pancreatectomy Outcomes' Optimization with the Application of an Enhanced Recovery After Surgery Program?

Background: Distal pancreatectomy (DP) represents the best therapeutic option for patients with body-tail pancreatic neoplasms (PNs). The enhanced recovery after surgery protocol is widely used for treating patients with PN to speed up postoperative recovery. This study aims to describe our institute's experience in the application of fast recovery protocol in a cohort of patients treated with DP, identifying predictors facilitating a decrease in the length of hospital stay. Patient and Methods: Were retrospectively enrolled 60 consecutive cases of DP performed from January 2016 to June 2022 in patients treated with enhanced recovery protocol, 25% of them were treated with spleen preserving procedure. Single-variable logistic regression models were used to evaluate the potential association between patient characteristics and the probability of postoperative complications. Standard linear regression models were used for length of stay, number of postoperative days (PODs) from surgery to full bowel function recovery, and PODs to the interruption of intravenous analgesia administration. Results: Thirty-four (57%) patients underwent open surgery and 26 (43%) laparoscopic surgery. Patients who underwent laparoscopic surgery and spleen-preserving procedures experienced a lower complication rate (P = .037), shorter length of stay, and time of analgesic requirements. With single-variable logistic regression models patients treated with laparoscopic surgery had statistically significant higher recovery times in terms of nasogastric tube removal (P = .004) and early enteral nutrition (P = .001). Conclusion: Continual refinement with enhanced recovery protocol for treating PN patients based on perioperative counseling and surgical decision-making is crucial to reduce patient morbidity and time for recovery.

Percutaneous Cryoablation of Recurrent or Oligometastatic Tumors in Thoracoabdominal Soft Tissues: Safety, Effectiveness, and Technical Aspects

PURPOSE

To assess the effectiveness and safety of cryoablation (CRA) for the treatment of recurrent or oligometastatic solid tumors located in the thoracoabdominal soft tissues.

MATERIALS AND METHODS

Twenty-two percutaneous CRA procedures performed in 19 patients to treat recurrent or oligometastatic tumors in thoracoabdominal soft tissue were retrospectively examined. All procedures were performed between January 2015 and June 2021 under ultrasound and computed tomography (CT) guidance, and the most complex procedures were performed with CT-based navigation systems. The histology of the primary tumors included colorectal adenocarcinoma, squamous cell lung carcinoma, pancreatic adenocarcinoma, renal cell carcinoma, and hepatocellular carcinoma. Adverse events, technical success, and local tumor control were analyzed.

RESULTS

The mean age of the patients was 66.5 years, with a mean tumor size of 24.8 mm. The mean time of the procedures was 68 minutes, with a mean number of 2.5 cryoprobes used. Hydrodissection was performed in 63% of the procedures to protect the surrounding anatomical structures. The mean size of the ice ball, measured on axial CT scans at the end of the procedures, was 43.5 mm. No severe adverse events were observed. Technical success was achieved in all cases. Three patients experienced local tumor progression (2 residual disease and 1 recurrence), which were successfully treated with a second CRA procedure.

CONCLUSIONS

Percutaneous CRA is a safe and effective therapy in selected cases of recurrent or oligometastatic tumors in the thoracoabdominal soft tissues.

Meta-analysis of laparoscopic spleen-preserving distal pancreatectomy versus laparoscopic distal pancreatectomy with splenectomy: An insight into confounding by indication

AIMS

To evaluate comparative outcomes of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and laparoscopic distal pancreatectomy with splenectomy (LDPS).

METHODS

A systematic search of multiple electronic data sources and bibliographic reference lists were conducted. Comparative studies reporting outcomes of LSPDP and LDPS were considered followed by evaluation of the associated risk of bias according to ROBINS-I tool. Perioperative complications, clinically important postoperative pancreatic fistula (POPF), infectious complications, blood loss, conversion to open, operative time and duration of hospital stay were the investigated outcome parameters.

RESULTS

Nineteen studies were identified enrolling 3739 patients of whom 1860 patients underwent LSPDP and the remaining 1879 patients had LDPS. The patients in the LSPDP and LDPS groups were of comparable age (p = 0.73), gender (p = 0.59), and BMI (p = 0.07). However, the patient in the LDPS group had larger tumour size (p = 0.0004) and more malignant lesions (p = 0.02). LSPDP was associated with significantly lower POPF (OR:0.65, p = 0.02), blood loss (MD:-28.30, p = 0.001), and conversion to open (OR:0.48, p < 0.0001) compared to LDPS. Moreover, it was associated with significantly shorter procedure time (MD: -22.06, p = 0.0009) and length of hospital stay (MD: -0.75, p = 0.005). However, no significant differences were identified in overall perioperative (OR:0.89, p = 0.25) or infectious (OR:0.67, p = 0.05) complications between two groups.

CONCLUSIONS

LSPDP seems to be associated with lower POPF, bleeding and conversion to open compared to LDPS in patients with small-sized benign tumours. Moreover, it may be quicker and reduce hospital stay. Nevertheless, such advantages are of doubtful merit about large-sized or malignant tumours. The available evidence is subject to confounding by indication.

The Revised R Status is an Independent Predictor of Postresection Survival in Pancreatic Cancer After Neoadjuvant Treatment

OBJECTIVE

To investigate the oncological outcomes of patients with pancreatic ductal adenocarcinoma (PDAC) who had an R 0 or R 1 resection based on the revised R status (1 mm) after neoadjuvant therapy (NAT).

BACKGROUND

The revised R status is an independent prognostic factor in upfront-resected PDAC; however, the significance of 1 mm margin clearance after NAT remains controversial.

METHODS

Patients undergoing pancreatectomy after NAT for PDAC were identified from 2 prospectively maintained databases. Clinicopathological and survival data were analyzed. The primary outcomes were overall survival (OS), recurrence-free survival (RFS), and pattern of recurrence in association with R 0 >1 mm and R 1 ≤1 mm resections.

RESULTS

Three hundred fifty-seven patients with PDAC were included after NAT and subsequent pancreatic resection. Two hundred eight patients (58.3%) received FOLFIRINOX, 41 patients (11.5%) received gemcitabine-based regimens, and 299 individuals (83.8%) received additional radiotherapy. R 0 resections were achieved in 272 patients (76.2%) and 85 patients (23.8%) had R 1 resections. Median OS after R 0 was 41.0 months, compared with 20.6 months after R 1 resection ( P = 0.002), and even longer after additional adjuvant chemotherapy ( R 0 44.8 vs R1 20.1 months; P = 0.0032). Median RFS in the R 0 subgroup was 17.5 months versus 9.4 months in the R 1 subgroup ( P < 0.0001). R status was confirmed as an independent predictor for OS ( R 1 hazard ratio: 1.56, 95% CI: 1.07-2.26) and RFS ( R 1 hazard ratio: 1.52; 95% CI: 1.14-2.0). In addition, R 1 resections were significantly associated with local but not distant recurrence ( P < 0.0005).

CONCLUSIONS

The revised R status is an independent predictor of postresection survival and local recurrence in PDAC after NAT. Achieving R 0 resection with a margin of at least 1 mm should be a primary goal in the surgical treatment of PDAC after NAT.

Preoperative evaluating early recurrence in resectable pancreatic ductal adenocarcinoma by using CT radiomics

OBJECTIVE

To investigate the feasibility of a radiomics model based on contrast-enhanced CT for preoperatively predicting early recurrence after curative resection in patients with resectable pancreatic ductal adenocarcinoma (PDAC).

METHODS

One hundred and eighty-six patients with resectable PDAC who underwent curative resection were included and allocated to training set (131 patients) and validation set (55 patients). Radiomics features were extracted from arterial phase and portal venous phase images. The Mann-Whitney U test and least absolute shrinkage and selection operator (LASSO) regression were used for feature selection and radiomics signature construction. The radiomics model based on radiomics signature and clinical features was developed by the multivariate logistic regression analysis. Performance of the radiomics model was investigated by the area under the receiver operating characteristic (ROC) curve.

RESULTS

The radiomics signature, consisting of three arterial phase and three venous phase features, showed optimal prediction performance for early recurrence in both training (AUC = 0.73) and validation sets (AUC = 0.66). Multivariate logistic analysis identified the radiomics signature (OR, 2.58; 95% CI 2.36-3.17; p = 0.002) and clinical stage (OR, 1.60; 95% CI 1.15-2.30; p = 0.007) as independent predictors. The AUC values for risk evaluation of early recurrence using the radiomics model incorporating clinical stage were 0.80 (training set) and 0.75 (validation set).

CONCLUSION

The radiomics-based model integrating with clinical stage can predict early recurrence after upfront surgery in patients with resectable PDAC.

Value of markers of systemic inflammation for the prediction of postoperative progression in patients with pancreatic neuroendocrine tumors

Background

Non-invasive prognostic predictors for rare pancreatic neuroendocrine tumors (PNETs) are lacking. We aimed to approach the prognostic value of preoperative systemic inflammatory markers in patients with PNETs.

Methods

The clinical data of 174 patients with PNETs undergoing surgical treatment were retrospectively analyzed to explore the correlation of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), and platelet to white blood cell ratio (PWR) with clinicopathological parameters and the progression of tumor after the operation. The optimal cutoff values for predictors and the area under the curve (AUC) of the receiver operating characteristic (ROC) were estimated. Univariate and multivariate Cox proportional hazards models were used to assess the relation between NLR, LMR, PLR, and progression-free survival (PFS), examined by the Kaplan-Meier and log-rank tests.

Results

The scores of the NLR (P = 0.039) and PLR (P = 0.011) in the progression group were significantly higher than those in the progression-free group, and the LMR was significantly lower than those in the progression-free group (P = 0.001). The best cutoff values of NLR, LMR, and PLR before operation were 2.28, 4.36, and 120.91. The proportions of tumor progression in the high NLR group (P = 0.007) and high PLR group (P = 0.013) obviously increased, and the proportion of tumor development in the low LMR group was higher than that in the high LMR group (P < 0.001). The K-M survival curve showed that the progression-free survival rate was lower in the high NLR group (P = 0.004), the low LMR group (P < 0.001), and the high PLR group (P = 0.018). The results of the multivariate Cox proportional hazards model suggested that preoperative LMR (HR = 3.128, 95% CI: 1.107~8.836, P = 0.031) was an independent predictor of PFS.

Conclusion

The markers of systemic inflammation, especially LMR, can predict the postoperative progression of PNETs.

Development of a radiomics-based model to predict occult liver metastases of pancreatic ductal adenocarcinoma: a multicenter study

BACKGROUND

Undetectable occult liver metastases block the long-term survival of pancreatic ductal adenocarcinoma (PDAC). This study aimed to develop a radiomics-based model to predict occult liver metastases and assess its prognostic capacity for survival.

MATERIALS AND METHODS

Patients who underwent surgical resection and were pathologically proven with PDAC were recruited retrospectively from five tertiary hospitals between January 2015 and December 2020. Radiomics features were extracted from tumors, and the radiomics-based model was developed in the training cohort using LASSO-logistic regression. The model's performance was assessed in the internal and external validation cohorts using the area under the receiver operating curve (AUC). Subsequently, the association of the model's risk stratification with progression-free survival (PFS) and overall survival (OS) was then statistically examined using Cox regression analysis and the log-rank test.

RESULTS

A total of 438 patients [mean (SD) age, 62.0 (10.0) years; 255 (58.2%) male] were divided into the training cohort ( n =235), internal validation cohort ( n =100), and external validation cohort ( n =103). The radiomics-based model yielded an AUC of 0.73 (95% CI: 0.66-0.80), 0.72 (95% CI: 0.62-0.80), and 0.71 (95% CI: 0.61-0.80) in the training, internal validation, and external validation cohorts, respectively, which were higher than the preoperative clinical model. The model's risk stratification was an independent predictor of PFS (all P <0.05) and OS (all P <0.05). Furthermore, patients in the high-risk group stratified by the model consistently had a significantly shorter PFS and OS at each TNM stage (all P <0.05).

CONCLUSION

The proposed radiomics-based model provided a promising tool to predict occult liver metastases and had a great significance in prognosis.

Laparoscopic partial pancreatectomy of the left limb using a harmonic scalpel in nine cats

OBJECTIVE

To describe a laparoscopic technique and outcome for partial pancreatectomy in cats.

STUDY DESIGN

Prospective cohort study.

ANIMALS

Nine cats.

METHODS

Laparoscopic pancreatectomy was performed using a single incision laparoscopic surgery port and an additional 5.5 mm port. The left pancreatic limb was dissected, sealed and divided at the level of the splenic vein insertion to the portal vein using a harmonic device. Surgical time and complications were recorded. The weight and length of the resected pancreatic limb was recorded. Pre- and postoperative trypsin-like immunoreactivity (TLI), pancreatic lipase immunoreactivity (PLI), and hemoglobin A1C were documented.

RESULTS

Laparoscopic partial pancreatectomy was performed successfully in all cats. One grade 1 intraoperative complication occurred (1/9; 11%) resulting in minor hemorrhage from a caudal splenic vein branch. A grade 2 postoperative complication occurred within 3 days after surgery in one cat (1/9; 11%), involving localized, sterile peritonitis in the region of the pancreatic angle. Signs resolved with conservative management. No cats exhibited signs of pancreatitis postoperatively. Long-term, mean TLI decreased by 37% ± 38% (p = .03) following partial pancreatectomy, while PLI and A1C were unchanged. All cats were alive and clinically well at last follow-up 250 to 446 days following surgery.

CONCLUSIONS

Laparoscopic partial pancreatectomy using a harmonic device is effective in cats, and offers a minimally-invasive alternative to open surgical pancreatectomy techniques. Laparoscopic pancreatectomy of the left limb results in adequate exocrine and endocrine function in the long-term.

Long-term quality of life is better after laparoscopic compared to open pancreatoduodenectomy

BACKGROUND

Three randomized controlled trials have reported improved functional recovery after Laparoscopic pancreatoduodenectomy (LPD), as compared to open pancreatoduodenectomy (OPD). Long-term results regarding quality of life (QoL) are lacking. The aim of this study was to compare long-term QoL of LPD versus OPD.

METHODS AND PATIENTS

A monocentric retrospective cross-sectional study was performed among patients < 75 years old who underwent LPD or OPD for a benign or premalignant pathology in a high-volume center (2011-2021). An electronic three-part questionnaire was sent to eligible patients, including two diseases specific QoL questionnaires (the European Organization for Research and Treatment in Cancer Quality of Life Questionnaire for cancer (QLQ-C30) and a pancreatic cancer module (PAN26) and a body image questionnaire. Patient demographics and postoperative data were collected and compared between LPD and OPD.

RESULTS

Among 948 patients who underwent PD (137 LPD, 811 OPD), 170 were eligible and 111 responded (58 LPD and 53 OPD). LPD versus OPD showed no difference in mean age (51 vs. 55 years, p = 0.199) and female gender (40% vs. 45%, p = 0.631), but LPD showed lower BMI (24 vs 26; p = 0.028) and higher preoperative pancreatitis (29% vs 13%; p = 0.041). The postoperative outcome showed similar Clavien-Dindo ≥ III morbidity (19% vs. 23%; p = 0.343) and length of stay (24 vs. 21 days, p = 0.963). After a similar median follow-up (3 vs. 3 years; p = 0.122), LPD vs OPD patients reported higher QoL (QLQ-C30: 49.6 vs 56.3; p = 0.07), better pancreas specific health status score (PAN20: 50.5 vs 55.5; p = 0.002), physical functioning (p = 0.002), and activities limitations (p = 0.02). Scar scores were better after LPD regarding esthetics (p = 0.001), satisfaction (p = 0.04), chronic pain at rest (p = 0.036), moving (p = 0.011) or in daily activities (p = 0.02). There was no difference in digestive symptoms (p = 0.995).

CONCLUSION

This monocentric study found improved long-term QoL in patients undergoing LPD, as compared to OPD, for benign and premalignant diseases. These results could be considered when choosing the surgical approach in these patients.

The Broad Spectrum of Paediatric Pancreatic Disease: A Single-center 26-years Retrospective Review

BACKGROUND

Paediatric pancreatic pathology and its management is rarely described. We present our experience.

METHODS

A retrospective case-note review of all patients with pancreatic disease from 1995 to 2021 was completed. Data are quoted as median (range).

RESULTS

Two hundred and twelve patients were identified with 75.9% presenting with pancreatitis. Referrals for pancreatitis increased during the study period and affected a wide age range (2 months-15.6 years). Acute pancreatitis (n = 118) (age 10.6 (0.18-16.3) years). The most common causes were idiopathic (n = 60, 50.8%) and biliary (n = 28, 23.8%). About 10% required treatment for complications or underlying biliary causes. Recurrent pancreatitis (n = 14) (11.6 (0.3-14.3) years). The most common cause was hereditary pancreatitis (n = 6, 42.9%). One patient required endoscopic drainage of pseudocyst. Chronic pancreatitis (n = 29) (16 (0.38-15.5) years). The underlying diagnosis was idiopathic (n = 14, 48.4%) or hereditary pancreatitis (n = 10, 34.5%). 13 patients required active management, including pancreaticojejunostomies (n = 5). Blunt Trauma (n = 34) was managed conservatively in 24 (70.5%). 6 patients required open surgery, but 4 were managed by either endoscopy or interventional radiology. Pancreatic tumours (n = 13) presented at 11.2 (2.3-16) years. Pathology included pancreaticoblastomas (n = 3), solid pseudopapillary tumours (n = 3), neuroendocrine tumours (n = 2), acinar cell cystadenoma (n = 1), intraductal papillary mucinous neoplasm (n = 1), pancreatic insulinoma (n = 1), pancreatic ductal adenocarcinoma (n = 1), and embryonal rhabdomyosarcoma (n = 1). OTHERS (N = 4): Pancreatic cyst (n = 3) and annular pancreas (n = 1).

CONCLUSION

Paediatric pancreatic disease spans a wide spectrum of both benign and malignant disease and benefits from access to specialist medical, surgical, endoscopic, and interventional radiology expertise. Referrals for paediatric pancreatitis are increasing, but aetiology is different to that seen in adults.

LEVEL OF EVIDENCE

IV.

The Molecular Twin artificial-intelligence platform integrates multi-omic data to predict outcomes for pancreatic adenocarcinoma patients

Contemporary analyses focused on a limited number of clinical and molecular biomarkers have been unable to accurately predict clinical outcomes in pancreatic ductal adenocarcinoma. Here we describe a precision medicine platform known as the Molecular Twin consisting of advanced machine-learning models and use it to analyze a dataset of 6,363 clinical and multi-omic molecular features from patients with resected pancreatic ductal adenocarcinoma to accurately predict disease survival (DS). We show that a full multi-omic model predicts DS with the highest accuracy and that plasma protein is the top single-omic predictor of DS. A parsimonious model learning only 589 multi-omic features demonstrated similar predictive performance as the full multi-omic model. Our platform enables discovery of parsimonious biomarker panels and performance assessment of outcome prediction models learning from resource-intensive panels. This approach has considerable potential to impact clinical care and democratize precision cancer medicine worldwide.

Robotic versus open pancreatoduodenectomy in patients with pancreatic duct adenocarcinoma after the learning curve: a propensity score-matched analysis

BACKGROUND

Studies have demonstrated that the learning curve plays an important role in robotic pancreatoduodenectomy (RPD). Although improved short-term outcomes of RPD after the learning curve have been reported compared to open pancreatoduodenectomy (OPD), there is a lack of long-term survival analyses.

METHODS

Patients who underwent curative intended RPD and OPD for pancreatic duct adenocarcinoma (PDAC) between January 2017 and June 2020 were retrospectively reviewed. A 1:2 propensity score matching (PSM) analysis was performed to balance the baseline characteristics between the RPD and OPD groups.

RESULTS

Of the 548 patients (108 RPD and 440 OPD), 103 RPD patients were matched with 206 OPD patients after PSM. There were 194 (62.8%) men and 115 (37.2%) women, with a median age of 64 (58-69) years. The median overall survival (OS) in the RPD group was 33.2 months compared with 25.7 months in the OPD group (p = 0.058, log-rank). The median disease-free survival (DFS) following RPD was longer than the OPD (18.5 vs. 14.0 months, p = 0.011, log-rank). The RPD group has a lower incidence of local recurrence compared the OPD group (36.9% vs. 51.2%, p = 0.071). Multivariate Cox analysis demonstrated that RPD was independently associated with improved OS (HR 0.70, 95% CI 0.52-0.94, p = 0.019) and DFS (HR 0.66, 95% CI 0.50-0.88, p = 0.005).

CONCLUSION

After the learning curve, RPD had improved oncologic outcomes in PDAC patients compared to OPD. Future prospective randomized clinical trials will be required to validate these findings.

[Short-term outcomes of the TRIANGLE operation after neoadjuvant chemotherapy in locally advanced pancreatic cancer]

Objective: To investigate the safety and efficacy of the TRIANGLE operation after neoadjuvant chemotherapy in locally advanced pancreatic cancer(LAPC). Methods: This study is a retrospective case series analysis. Between January 2020 and December 2022, a total of 103 patients were diagnosed as LAPC who underwent neoadjuvant chemotherapy at the Pancreas Center, the First Affiliated Hospital of Nanjing Medical University. Among them, 26 patients (25.2%) underwent the TRIANGLE operation. There were 15 males and 11 females,with a age of (59±7) years (range: 49 to 74 years). The pre-treatment serum CA19-9(M(IQR)) was 248.8(391.6)U/ml (range: 0 to 1 428 U/ml),and the serum carcinoembryonic antigen was 4.1(3.8)μg/L(range: 1.4 to 13.4 μg/L). The neoadjuvant chemotherapy regimens included: mFOLFIRINOX regimen in 6 cases(23.1%), GnP regimen in 14 cases(53.8%), and mFOLFIRINOX+GnP regimen in 6 cases(23.1%). The follow-up duration extended until June 2023 or until the occurrence of the patient's death or loss to follow-up. The Kaplan-Meier method was employed to estimate the 1-year and 3-year overall survival rates. Results: After neoadjuvant chemotherapy,CA19-9 levels decreased by 92.3(40.1)%(range:2.1% to 97.7%). Evaluation of the response to treatment revealed 13 cases(50.0%) of stable disease,11 cases(42.3%) of partial response,and 2 cases(7.7%) of complete response. The surgical operation consisted of 12 cases(46.2%) of pancreaticoduodenectomy,12 cases(46.2%) of distal pancreatectomy,and 2 cases(7.7%) of total pancreatectomy. Margin determination was based on the "standardised pathology protocol" and the "1 mm" principle. No R2 and R1(direct) resections were observed,while the R0 resection rate was 61.5%(16/26), and the R1(1 mm) resection rate was 38.5%(10/26).The R1(1 mm) resection rates for the anterior margin,posterior margin,transected margin,portal vein groove margin,and uncinate margin were 23.1%(6/26),19.2%(5/26),12.5%(3/24),2/14, and 1/12, respectively. The overall postoperative complication rate was 57.8%(15/26),with major complications including grade B/C pancreatic fistula 25.0%(6/24,excluding 2 cases of total pancreatectomy),delayed gastric emptying in 23.1%(6/26),wound complications 11.5%(3/26),postoperative hemorrhage 7.7%(2/26), chylous fistula 7.7%(2/26) and bile fistula 3.8%(1/26). No reoperation was performed during the perioperative period(<90 days). One patient died on the 32nd day postoperatively due to a ruptured pseudoaneurysm. A total of 25 patients were followed up,with a follow-up time of 21(24)months(range: 8 to 42 months). During the follow-up period,8 cases(32.0%) died due to tumor recurrence and metastasis,while 17 patients(68.0%) remained alive,including 11 cases of disease-free survival,5 cases of distant metastasis,and 1 case of local recurrence. The overall survival rates at 1- and 3-year after the initiation of neoadjuvant chemotherapy were 95.8% and 58.9%, respectively. The overall survival rates at 1- and 3-year after surgery were 77.7% and 57.8%, respectively. Conclusion: Performing pancreatoduodenectomy according to the Heidelberg triangle protocol in LAPC patients after neoadjuvant chemotherapy might increase the R0 resection rate without increasing perioperative mortality or the incidence of major postoperative complications.

Predictors and benefits of multiagent chemotherapy for pancreatic adenocarcinoma: Timing matters

INTRODUCTION

Adjuvant (A) multiagent chemotherapy (MC) is the standard of care for patients with pancreatic adenocarcinoma (PDAC). Tolerating MC following a morbid operation may be difficult, thus neoadjuvant (NA) treatment is preferable. This study examined how the timing of chemotherapy was related to the regimen given and ultimately the overall survival (OS).

METHODS

The National Cancer Database was queried from 2006 to 2017 for nonmetastatic PDAC patients who underwent surgical resection and received MC or single-agent chemotherapy (SC) pre- or postresection. Predictors of receiving MC were determined using multivariable logistic regression. Five-year OS was evaluated using the Kaplan-Meier and Cox proportional hazards model.

RESULTS

A total of 12,440 patients (NA SC, n = 663; NA MC, n = 2313; A SC, n = 6152; A MC, n = 3312) were included. MC utilization increased from 2006-2010 to 2011-2017 (33.1%-49.7%; odds ratio [OR]: 0.59; p < 0.001). Younger age, fewer comorbidities, higher clinical stage, and larger tumor size were all associated with receipt of MC (all p < 0.001), but NA treatment was the greatest predictor (OR 5.18; 95% confidence interval [CI]: 4.63-5.80; p < 0.001). MC was associated with increased median 5-year OS (26.0 vs. 23.9 months; hazard ratio [HR]: 0.92; 95% CI: 0.88-0.96) and NA MC was associated with the highest survival (28.2 months) compared to NA SC (23.3 months), A SC (24.0 months), and A MC (24.6 months; p < 0.001).

CONCLUSION

Use and timing of MC contribute to OS in PDAC with an improved 5-year OS compared to SC. The greatest predictor of receiving MC was being given as NA therapy and the greatest survival benefit was the NA MC subgroup. Randomized studies evaluating the timing of effective MC in PDAC are needed.

Accessibility to ERCP-performing hospitals among patients with pancreatic cancer living in SEER regions

BACKGROUND AND AIMS

The two most common interventions used to treat painless jaundice from pancreatic cancer are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD). Our study aimed to characterize the geographic distribution of ERCP-performing hospitals among patients with pancreatic cancer in the United States and the association between geographic accessibility to ERCP-performing hospitals and biliary interventions patients receive.

METHODS

This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database for pancreatic cancer from 2005 to 2013. Multilevel models were used to examine the association between accessibility to ERCP hospitals within a 30- and 45-min drive from the patient's residential ZIP Code and the receipt of ERCP treatment. A two-step floating catchment area model was used to calculate the measure of accessibility based on the distribution across SEER regions.

RESULTS

7464 and 782 patients underwent ERCP and PTBD, respectively, over the study period. There were 808 hospitals in which 8246 patients diagnosed with pancreatic cancer in SEER regions from 2005 to 2013 received a procedure. Patients with high accessibility within both 30- and 45-min drive to an ERCP-performing hospital were more likely to receive an ERCP (30-min adjusted odds ratio [aOR]: 1.53, 95% confidence interval [CI]: 1.17-2.01; 45-min aOR: 1.31, 95% CI: 1.01-1.70). Furthermore, in the adjusted model, Black patients (vs. White) and patients with stage IV disease were less likely to receive ERCP than PTBD.

CONCLUSIONS

Patients with pancreatic cancer and high accessibility to an ERCP-performing hospital were more likely to receive ERCP. Disparities in the receipt of ERCP persisted for Black patients regardless of their access to ERCP-performing hospitals.

Machine Learning of Histopathological Images Predicts Recurrences of Resected Pancreatic Ductal Adenocarcinoma With Adjuvant Treatment

OBJECTIVES

Pancreatic ductal adenocarcinoma is an intractable disease with frequent recurrence after resection and adjuvant therapy. The present study aimed to clarify whether artificial intelligence-assisted analysis of histopathological images can predict recurrence in patients with pancreatic ductal adenocarcinoma who underwent resection and adjuvant chemotherapy with tegafur/5-chloro-2,4-dihydroxypyridine/potassium oxonate.

MATERIALS AND METHODS

Eighty-nine patients were enrolled in the study. Machine-learning algorithms were applied to 10-billion-scale pixel data of whole-slide histopathological images to generate key features using multiple deep autoencoders. Areas under the curve were calculated from receiver operating characteristic curves using a support vector machine with key features alone and by combining with clinical data (age and carbohydrate antigen 19-9 and carcinoembryonic antigen levels) for predicting recurrence. Supervised learning with pathological annotations was conducted to determine the significant features for predicting recurrence.

RESULTS

Areas under the curves obtained were 0.73 (95% confidence interval, 0.59-0.87) by the histopathological data analysis and 0.84 (95% confidence interval, 0.73-0.94) by the combinatorial analysis of histopathological data and clinical data. Supervised learning model demonstrated that poor tumor differentiation was significantly associated with recurrence.

CONCLUSIONS

Results indicate that machine learning with the integration of artificial intelligence-driven evaluation of histopathological images and conventional clinical data provides relevant prognostic information for patients with pancreatic ductal adenocarcinoma.

Neoadjuvant Chemotherapy Versus Upfront Surgery for Resectable Pancreatic Adenocarcinoma: An Updated Nationwide Study

OBJECTIVE

The objective of this study was to assess the association of survival with neoadjuvant chemotherapy (NAC) in resectable pancreatic adenocarcinoma (PDAC).

BACKGROUND

The early control of potential micrometastases and patient selection using NAC has been advocated for patients with PDAC. However, the role of NAC for resectable PDAC remains unclear.

METHODS

Patients with clinical T1 and T2 PDAC were identified in the National Cancer Database from 2010 to 2017. Kaplan-Meier estimates, and Cox regression models were used to compare survival. To address immortal time bias, landmark analysis was performed. Interactions between preoperative factors and NAC were investigated in subgroup analyses. A propensity score analysis was performed to compare survival between multiagent NAC and upfront surgery.

RESULTS

In total, 4041 patients were treated with upfront surgery and 1,175 patients were treated with NAC (79.4% multiagent NAC, 20.6% single-agent NAC). Using a landmark time of 6 months after diagnosis, patients treated with multiagent NAC had longer median overall survival compared with upfront surgery and single-agent NAC. (35.8 vs 27.1 vs 27.4 mo). Multiagent NAC was associated with lower mortality rates compared with upfront surgery (adjusted hazard ratio, 0.77; 95% CI, 0.70-0.85), whereas single-agent NAC was not. The association of survival with multiagent NAC were consistent in analyses using the matched data sets. Interaction analysis revealed that the association between multiagent NAC and a lower mortality rate did not significantly differ across age, facility type, tumor location, CA 19-9 levels, and clinical T/N stages.

CONCLUSIONS

The findings suggest that multiagent NAC followed by resection is associated with improved survival compared with upfront surgery.

[Minimally Invasive Resection of Cystic Pancreatic Neoplasia]

Zystische Pankreasneoplasien haben aufgrund ihrer hohen Prävalenz einen relevanten Stellenwert im klinischen Alltag eingenommen. Nur ein kleiner Teil der diagnostizierten Pankreaszysten erfordert eine chirurgische Therapie. Ist eine Resektion indiziert, so hängt die Wahl des passenden Operationsverfahrens von der Art, dem Ausmaß und der Lage der zystischen Pankreasneoplasie ab.

Zystische Pankreasneoplasien: Fall 1: Seitengang-IPMN im Pankreaskopf; Fall 2: muzinös-zystische Neoplasie (MCN) im Pankreasschwanz; Fall 3: solide pseudopapilläre Neoplasie (SPN) im Pankreasschwanz; Fall 4: Mixed-Type-IPMN im Pankreaskorpus.

Minimalinvasive Resektionstechniken bei zystischen Pankreasneoplasien: Fall 1: roboterassistierte Enukleation; Fall 2: laparoskopische Pankreaslinksresektion; Fall 3: roboterassistierte milzerhaltende Pankreasschwanzresektion; Fall 4: roboterassistierte Pankreassegmentresektion.

Die Heterogenität zystischer Pankreasneoplasien erfordert eine individualisierte Wahl des Operationsverfahrens, das bevorzugt minimalinvasiv und organerhaltend durchgeführt werden sollte.

SMAD4 loss predicts worse overall and distant metastasis-free survival in patients with resected pancreatic adenocarcinoma

BACKGROUND

In select patients, pancreatic adenocarcinoma remains a local disease, yet there are no validated biomarkers to predict this behavior and who may benefit from aggressive local treatments. This study sought to determine if SMAD4 (mothers against decapentaplegic homolog 4) messenger RNA-sequencing (RNA-seq) expression is a robust method for predicting overall survival (OS) and distant metastasis-free survival (DMFS) in patients with resected pancreatic adenocarcinoma.

METHODS

Utilizing The Cancer Genome Atlas (TCGA) and the International Cancer Genome Consortium (ICGC), 322 patients with resected stage I-III pancreatic adenocarcinoma were identified. In TCGA, multivariable proportional hazards models were used to determine the association of SMAD4 genomic aberrations and RNA-seq expression with OS and DMFS. In the ICGC, analysis sought to confirm the predictive performance of RNA-seq via multivariable models and receiver operator characteristic curves.

RESULTS

In TCGA, the presence of SMAD4 genomic aberrations was associated with worse OS (hazard ratio [HR], 1.55; 95% CI, 1.00-2.40; p = .048) but not DMFS (HR, 1.33; 95% CI, .87-2.03; p = .19). Low SMAD4 RNA-seq expression was associated with worse OS (HR, 1.83; 95% CI, 1.17-2.86; p = .008) and DMFS (HR, 1.70; 95% CI, 1.14-2.54; p = .009). In the ICGC, increased SMAD4 RNA-seq expression correlated with improved OS (area under the curve [AUC], .92; 95% CI, .86-.94) and DMFS (AUC, .84; 95% CI, .82-.87).

CONCLUSIONS

In patients with resected pancreatic adenocarcinoma, SMAD4 genomic aberrations are associated with worse OS but do not predict for DMFS. Increased SMAD4 RNA-seq expression is associated with improved OS and DMFS in patients with resected pancreatic adenocarcinoma. This reproducible finding suggests SMAD4 RNA-seq expression may be a useful marker to predict metastatic spread.

Neoadjuvant Therapy for Duodenal and Ampullary Adenocarcinoma: A Systematic Review

BACKGROUND

The role of systemic therapy in the management of ampullary (AA) and duodenal adenocarcinoma (DA) remains poorly understood. This study sought to synthesize current evidence supporting the use of neoadjuvant therapy (NAT) in AA and DA.

METHODS

The study searched PubMed, Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCO), and ClinicalTrials.gov databases for observational or randomized studies published between 2002 and 2022 evaluating survival outcomes for patients with non-metastatic AA or DA who received systemic therapy and surgical resection. The data extracted included overall survival, progression-free survival, and pathologic response (PR) rate.

RESULTS

From the 347 abstracts identified in this study, 29 reports were reviewed in full, and 15 were included in the final review. The selected studies published from 2007 to 2022 were retrospective. Eight were single-center studies; five used the National Cancer Database (NCDB); and two were European multicenter/national studies. Overall, no studies identified survival differences between NAT and upfront surgery (with or without adjuvant therapy). Two NCDB studies reported longer survival with NAT/AT than with surgery. Five single-center studies reported a significant portion of NAT patients who achieved PR, and one study identified major PR as an independent predictor of survival. Other outcomes associated with NAT included conversion from unresectable to resectable disease, reduced lymph node positivity, and decreased local recurrence rate.

CONCLUSION

Evidence supporting the use of NAT in AA and DA is weak. No randomized studies exist, and observational data show mixed results. For patients with DA and AA, NAT appears safe, but better evidence is needed to understand the preferred multidisciplinary management of DA and AA periampullary malignancies.

In Neoadjuvant FOLFIRINOX Chemotherapy for Pancreatic Ductal Adenocarcinoma, Which Response is the More Reliable Indicator for Prognosis, Radiologic or Biochemical?

BACKGROUND

In this era of increasing neoadjuvant chemotherapy, methods for evaluating responses to neoadjuvant chemotherapy are still diverse among institutions. Additionally, the efficacy of adjuvant chemotherapy for patients undergoing neoadjuvant chemotherapy remains unclear. Therefore, this retrospective study was performed to evaluate the effectiveness of methods for assessing response to neoadjuvant chemotherapy and the need for adjuvant chemotherapy in treating patients with non-metastatic pancreatic ductal adenocarcinoma.

METHODS

The study identified 150 patients who underwent neoadjuvant FOLFIRINOX chemotherapy followed by curative-intent pancreatectomy. The patients were stratified by biochemical response based on the normalization of carbohydrate antigen 19-9 and by radiologic response based on size change at imaging.

RESULTS

The patients were classified into the following three groups based on their response to neoadjuvant chemotherapy and prognosis: biochemical responders (BR+), radiology-only responders (BR-/RR+), and non-responders (BR-/RR-). The 3-year overall survival rate was higher for BR+ (71.0%) than for BR-/RR+ (53.6%) or BR-/RR- (33.1%) (P < 0.001). Response to neoadjuvant chemotherapy also was identified as a significant risk factor for recurrence in a comparison between BR-/RR+ and BR+ (hazard ratio [HR], 2.15; 95% confidence interval [CI] 1.19-3.88; P = 0.011) and BR-/RR- (HR, 3.82; 95% CI 2.41-6.08; P < 0.001). Additionally, regardless of the response to neoadjuvant chemotherapy, patients who completed adjuvant chemotherapy had a significantly higher 3-year overall survival rate than those who did not.

CONCLUSIONS

This response evaluation criterion for neoadjuvant chemotherapy is feasible and can significantly predict prognosis. Additionally, completion of adjuvant chemotherapy could be helpful to patients who undergo neoadjuvant chemotherapy regardless of their response to neoadjuvant chemotherapy.

The timing of recurrence after endoscopic papillectomy

BACKGROUND

Endoscopic papillectomy (EP) offers a safe and effective method for resection of ampullary adenomas. Data regarding the long-term resolution of adenoma following EP are limited. The aim of this study therefore was to examine the timing of recurrence after EP of ampullary adenomas.

METHODS

This was a single-center retrospective study including patients who received EP for ampullary adenomas from 8/2000 to 1/2018. Patients with confirmed complete eradication of adenoma were included in the recurrence analysis with recurrence defined as finding adenomatous histology after 1 negative surveillance endoscopy. Kaplan-Meier estimates were calculated to determine recurrence rates.

RESULTS

Of the 165 patients who underwent EP, 136 patients (mean age 61.9, 51.5% female) had adenomatous histology with a mean lesion size of 21.2 mm. A total of 124 (91.2%) achieved complete eradication with a follow-up of 345.8 person-years. Recurrence occurred in 20 (16.1%) patients at a mean of 3.2 (± 3) years (range 0.5-9.75 years) for a recurrence rate of 5.8 (95% CI 3.6-8.8) per 100 person-years. Nine (45%) recurrences occurred after the 1st 2 years of surveillance. Recurrence rate did not differ by baseline pathology [low-grade dysplasia: 5.2 (95% CI 3.0-9.0), high-grade dysplasia: 6.9 (95% CI 2.3-15.5), adenocarcinoma: 7.7 (95% CI 0.9-25.1)].

CONCLUSION

Recurrence remains a significant concern after EP. Given the timing of recurrence, long surveillance periods may be necessary. Larger multicenter studies are needed, however, to determine appropriate surveillance intervals.

Tumor vascularity on contrast-enhanced computed tomography as a predictive marker of metastatic potential for small nonfunctioning pancreatic neuroendocrine tumors

BACKGROUND

Although surgical resection is generally suggested for nonfunctioning pancreatic neuroendocrine tumors, observation can be proposed for carefully selected patients with small tumors. However, the indications for observation remain unclear.

METHODS

This retrospective study included 77 patients with nonfunctioning pancreatic neuroendocrine tumors, including small tumors (≤2.0 cm, n = 41), who received pancreatectomy. The ratio of the mean computed tomography value of a tumor in the late arterial/equilibrium phase (computed tomography a/e ratio) was used to evaluate tumor vascularity. Pathologic examinations of small tumors were conducted. The associations among the computed tomography a/e ratio, pathologic findings, and survival outcomes were investigated.

RESULTS

Small tumors were pathologically categorized by the degree of fibrosis as follows: medullary (n = 20), intermediate (n = 11), and fibrotic (n = 10). The fibrotic type had significantly lower computed tomography a/e ratios than the medullary type (median, 1.42 vs 2.03, P < .001). The median number of vessels with microscopic venous invasion was significantly higher in the fibrotic type than in the medullary type (4.5 vs 0.0, P < .001). The cutoff value of the computed tomography a/e ratio for predicting microscopic venous invasion was determined to be 1.54 by the receiver operating characteristic curve (area under the curve, 0.832; sensitivity, 80.0%; specificity, 83.9%; accuracy, 82.9%). Microscopic venous invasion was an independent prognostic factor for relapse-free survival in overall patients (hazard ratio 5.18, P = .017).

CONCLUSION

The computed tomography a/e ratio may be a useful predictor of the metastatic potential of nonfunctioning pancreatic neuroendocrine tumors and may help decide the indications of observation for small nonfunctioning pancreatic neuroendocrine tumors.

Conditional Relative Survival of Exocrine Pancreatic Cancer: A Population-Based Study

BACKGROUND

Adjusted prognostic information is important for treatment decisions, especially in elderly patients or survivors of exocrine pancreatic cancer (EPC). This study aims to investigate conditional relative survival (CS) rates and conditional probabilities of death in patients with EPC.

METHODS

Data of 77,975 individuals diagnosed with EPC between 1999 and 2019 were obtained from the Korea Central Cancer Registry. CS was analyzed across strata including histology groups (ductal adenocarcinoma excluding cystic or mucinous [group I, PDAC] and ductal adenocarcinoma specified as mucinous or cystic adenocarcinoma [group II]), and age.

RESULTS

For PDAC, the overall 5-year relative survival (RS) rate at diagnosis, 3-year CS of 2-year survivors, and 5-year CS of 5-year survivors were 8.5%, 50.1%, and 77.6%, respectively. Overall conditional probabilities of death were 85.2% (≥ 80 years), 73.5% (70-79 years), and 62.0% (60-69 years) in year 1 after diagnosis. Among patients with localized or regional stage who underwent surgery, conditional probabilities of death of ≥ 80, 70-79, and 60-69 years were 37.7%, 32.5%, and 22.6% in the first year, and 26.6%, 27.2%, and 26.0% in year 2 after diagnosis.

CONCLUSIONS

Half of patients with EPC who survived for 2 years survived for an additional 3 years. However, 5-year PDAC survivors require follow-up as more than 20% do not survive for a further 5 years. Elderly patients should not be excluded from active treatment for localized or regional-stage PDAC, as the CS of elderly patients who are fit enough to undergo surgery is not inferior to that of younger patients.

A systematic review meta-analysis and meta-regression on the implications of an aberrant right hepatic artery in patients undergoing pancreaticoduodenectomy for the treatment of malignant disease

We investigated the outcomes of pancreaticoduodenectomy in the presence of an aberrant right hepatic artery (aRHA). We systematically reviewed Medline, Scopus, and Web of Science until April 2023 for studies comparing pancreaticoduodenectomy outcomes with and without aRHA. Endpoints included postoperative mortality, R0 resection margins, pancreatic fistulae, hemorrhage, biliary leak/fistulae, delayed gastric emptying, operative duration, and blood loss. Eight retrospective studies involving 1514 patients were included. The risk ratio (RR) for postoperative mortality and odds ratio (OR) for R0 resection between the aRHA and normal anatomy groups were 1.37 (95%CI:0.74-256) (I2=0%, P=0.99) and 1.03 (95%CI:0.67-1.59) (I2=10%, P=0.35). Besides a longer operative duration in the aRHA group, mean difference (MD) 54.64 (95% CI: 8.51-100.77) (I2=94%, P<0.01), there were no significant differences in secondary endpoints. Meta-regression revealed a significant association between aRHA reconstruction and postoperative mortality (β=0.0179, P<0.01). This review displayed non-statistically significant differences in terms of surgical and oncological outcomes between patients with aRHA and patients with normal hepatic artery anatomy undergoing pancreaticoduodenectomy. However, the observed trend of increased postoperative mortality in patients with aRHA, combined with extended surgical duration and the link between aRHA reconstruction and postoperative mortality, prevents drawing definitive conclusions. Further research through high-quality studies is warranted.

Impact of preoperative endoscopic procedures on adverse event rates after surgical resection for main-duct and mixed-type intraductal papillary mucinous neoplasms (IPMNs)

BACKGROUND

Main-duct (MD-) and mixed-type (MT-) IPMNs harbor an increased risk of pancreatic cancer and warrant surgical resection. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are important in the diagnosis of IPMNs. The aim of this study was to investigate whether endoscopic procedures manipulating the MD impact postoperative adverse events in patients with MD- and MT-IPMNs.

METHODS

We performed a retrospective study of 369 patients who underwent resections for MD- or MT-IPMN at two tertiary centers (2000-2019). Multivariable logistic regression analyses were performed for postoperative adverse events to compare the risks between intervention (ERCP, EUS-FNA with branch duct (BD) aspirated, EUS-FNA with MD aspirated from the duct directly or cyst/mass arising from MD) versus no-intervention group.

RESULTS

33.1 % of patients had a preoperative ERCP and 69.4 % had EUS-FNA. Postoperative adverse events included: 30-day readmission (12.7 %), delayed gastric emptying (13.8 %), pancreatic fistula (10.3 %), abdominal abscess (5.7 %), cardiopulmonary adverse events (11.4 %), and mortality (1.4 %). The model was adjusted for potential confounders. There were no significant differences between the ERCP and no-ERCP groups for specific adverse events. Compared to no-EUS-FNA groups, groups of EUS-FNA with BD aspiration and EUS-FNA with MD aspiration from the main pancreatic duct directly or cyst/mass arising from MD did not show a significant increase in specific adverse events.

CONCLUSIONS

Postoperative adverse events were not significantly increased among patients who had ERCP or EUS-FNA before surgical resection for MD- or MT-IPMNs. Endoscopic procedures directly sampling the MD can be safely pursued for diagnostic purposes in selected cases.

Survival and surgical outcomes of robotic versus open pancreatoduodenectomy for ampullary cancer: A propensity score-matching comparison

BACKGROUND/OBJECTIVE

Robotic pancreaticoduodenectomy in ampullary cancer has never been studied. This study aimed to clarify the feasibility and justification of robotic pancreaticoduodenectomy in ampullary cancer in terms of surgical risks, and oncologic and survival outcomes.

METHODS

A propensity score-matching comparison of robotic and open pancreaticoduodenectomy based on seven factors commonly used to predict the survival outcomes in ampullary cancer patients.

RESULTS

A total of 147 patients were enrolled, of which 101 and 46 underwent robotic and open pancreaticoduodenectomies, respectively. After propensity score-matching with a 2:1 ratio, 88 and 44 patients in the robotic and open pancreaticoduodenectomy groups were included. The operation time was of no significant difference after matching. The median intraoperative blood loss was much less in those who underwent robotic pancreaticoduodenectomy, both before (median, 120 vs. 320 c.c. P < 0.001) and after (100 vs. 335 mL P < 0.001) score-matching. There were no significant differences in terms of surgical risks, including surgical mortality, surgical morbidity, Clavien-Dindo severity classification, postoperative pancreatic fistula, delayed gastric emptying, post-pancreatectomy hemorrhage, chyle leak, bile leak, and wound infection, both before or after score-matching. The survival outcomes were also similar between the two groups, regardless of matching.

CONCLUSIONS

Robotic pancreaticoduodenectomy for ampullary cancer is not only technically feasible and safe without increasing surgical risks, but also oncologically justifiable without compromising surgical radicality and survival outcomes.

Impact on Survival of Early Versus Late Initiation of Adjuvant Chemotherapy After Pancreatic Adenocarcinoma Surgery: A Target Trial Emulation

BACKGROUND

We examined the impact of early (0-4 weeks after discharge) versus late (> 4-8 weeks after discharge) initiation of adjuvant chemotherapy on pancreatic adenocarcinoma survival.

METHODS

We used Danish population-based healthcare registries to emulate a hypothetical target trial using the clone-censor-weight approach. All eligible patients were cloned with one clone assigned to 'early initiation' and one clone assigned to 'late initiation'. Clones were censored when the assigned treatment was no longer compatible with the actual treatment. Informative censoring was addressed using inverse probability of censoring weighting.

RESULTS

We included 1491 patients in a hypothetical target trial, of whom 32.3% initiated chemotherapy within 0-4 weeks and 38.3% between > 4 and 8 weeks after discharge for pancreatic adenocarcinoma surgery; 206 (13.8%) initiated chemotherapy after > 8 weeks, and 232 (15.6%) did not initiate chemotherapy. Median overall survival was 30.4 and 29.9 months in late and early initiators, respectively. The absolute differences in OS, comparing late with early initiators, were 3.2% (95% confidence interval [CI] - 1.5%, 7.9%), - 0.7% (95% CI - 7.2%, 5.8%), and 3.2% (95% CI - 2.8%, 9.3%) at 1, 3, and 5 years, respectively. Late initiators had a higher increase in albumin levels as well as higher pretreatment albumin values.

CONCLUSIONS

Postponement of adjuvant chemotherapy up to 8 weeks after discharge from pancreatic adenocarcinoma surgery is safe and may allow more patients to receive adjuvant therapy due to better recovery.

Preoperative CT histogram analysis to predict the expression of Ki-67 in solid pseudopapillary tumours of the pancreas

AIM

To explore the value of preoperative computed tomography (CT) histogram features in predicting the expression status of Ki-67 in patients with solid pseudopapillary pancreatic tumours (SPTP).

MATERIALS AND METHODS

This retrospective study analysed venous phase CT images of 39 patients with SPTP confirmed at surgery and histopathology and measured using the Ki-67 proliferation index from November 2015 to February 2022. According to the Ki-67 proliferation index, they were divided into high expression (Ki-67 ≥ 4%) and low expression (Ki-67 < 4%) groups. The histogram features of quantitative parameters were extracted using MaZda software, and the quantitative parameters of CT histograms were compared between groups. The receiver operating characteristic (ROC) curves of the patients were plotted according to the parameters, with statistically significant differences. The area under the curve (AUC), sensitivity, and specificity were calculated, and the effectiveness of the histogram parameters in predicting Ki-67 expression was analysed and evaluated.

RESULTS

In total, 27 SPTP patients were enrolled, including 11 with high expression of Ki-67 and 16 with low expression. Comparative analysis of the Ki-67 high- and low-expression groups revealed a statistically significant in necrosis and variance (p<0.05). ROC curve analysis showed that the AUC of necrosis and variance predicting Ki-67 expression status were 0.753 and 0.841, the sensitivities were 81.8% and 81.3%, and the specificities were 68.7% and 81.8%, respectively.

CONCLUSION

Preoperative CT histogram features help predict Ki-67 expression status in patients with SPTP.

Implementation of robotic pancreaticoduodenectomy at a community tertiary care hospital utilizing a comprehensive curriculum

BACKGROUND

We evaluated the outcomes of a robotic pancreaticoduodenectomy (RPD) program implemented at a community tertiary care hospital.

METHODS

A retrospective review of 65 RPD cases compared surgical outcomes and performance to benchmark data.

RESULTS

Postoperative complications occurred in 31% (20) of patients vs. ≤73% (variance -42), with grade IV complications in 3% (2) vs. ≤5% (variance -2). Postoperative pancreatic fistula type B frequency was 12% (8) vs. ≤15% (variance -3). One 90-day mortality occurred (1.5% vs. 1.6%). Failure to rescue rate was 7% vs. ≤9% (variance -2), and R1 resection rate was 2% vs. ≤39% (variance -37). There was a downward trend of operative time (rho ​= ​-0.600, P ​< ​0.001), with a learning curve of 27 cases. Median hospital length of stay was 6 days vs. ≤15 days (variance -9).

CONCLUSION

Our comprehensive RPD training program resulted in improved operative performance and outcomes commensurate with benchmark thresholds.

Challenge in optimizing robotic pancreaticoduodenectomy including nerve plexus hanging maneuver: a Japanese single center experience of 76 cases

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is technically demanding, and 20-50 cases are required to surpass the learning curve. This study aimed to show our experience of 76 cases from the introduction of RPD and report the changes in surgical results owing to the accumulation of cases and optimization of surgical techniques.

METHODS

A total of 76 patients who underwent RPD between November 2009 and May 2023 at the Fujita Health University Hospital were divided into three groups: competency (n = 23, Nov 2009-Mar 2020), proficiency (n = 31, Apr 2020-Jun 2022), and mastery (n = 22, Jul 2022-May 2023) phases. In the mastery phase, for the education of new surgeons and maintenance of surgical quality, optimization of the procedure, including hanging maneuver with or without stapling transection of the retropancreatic tissue was implemented. The surgical outcomes were compared between the groups.

RESULTS

The mean operation time decreased over time despite of the participation of newly started operators in mastery phase [competency: 921.5 min (IQR 775-996 min) vs. proficiency: 802.8 min (IQR 715-887 min) vs. mastery: 609.2 min (IQR 514-699 min), p < 0.001]. Additionally, Clavien-Dindo ≥ grade IIIa complications decreased from 52.2% in competency phase to 35.5% and 9.1% in proficiency and mastery phases, respectively (p = 0.005).

CONCLUSION

Operation time and major complications decreased along the learning curve from the introduction of RPD. In addition, optimization of the procedure, including hanging maneuver of the retropancreatic tissue seemed to be effective in reducing operation time and educating new RPD surgeons.

Technical Strategy for Pancreatic Body Cancers: A Raison d'etre of Distal Pancreatectomy with Portal Resection

BACKGROUND

Advancements in multiagent chemotherapy have expanded the surgical indications for pancreatic cancer. Although pancreaticoduodenectomy (PD) with portal vein resection (PVR) has become widely adopted, distal pancreatectomy (DP) with PVR remains rarely performed because of its technical complexity. This study was designed to assess the feasibility of DP-PVR compared with PD-PVR for pancreatic body cancers, with a focus on PV complications and providing optimal reconstruction techniques when DP-PVR is necessary.

METHODS

A retrospective review was conducted on consecutive pancreatic body cancer patients who underwent pancreatectomy with PVR between 2005 and 2020. An algorithm based on the anatomical relationship between the arteries and PV was used for optimal surgical selection.

RESULTS

Among 119 patients, 32 underwent DP-PVR and 87 underwent PD-PVR. Various reconstruction techniques were employed in DP-PVR cases, including patch reconstruction, graft interposition, and wedge resection. The majority of PD-PVR cases involved end-to-end anastomosis. The length of PVR was shorter in DP-PVR (25 vs. 40 mm; p < 0.001). Although Clavien-Dindo ≥3a was higher in DP-PVR (p = 0.002), inpatient mortality and R0 status were similar. Complete PV occlusion occurred more frequently in DP-PVR than in PD-PVR (21.9% vs. 1.1%; p < 0.001). A cutoff value of 30 mm for PVR length was determined to be predictive of nonrecurrence-related PV occlusion after DP-PVR. The two groups did not differ significantly in recurrence or overall survival.

CONCLUSIONS

DP-PVR had higher occlusion and postoperative complication rates than PD-PVR. These findings support the proposed algorithm and emphasize the importance of meticulous surgical manipulation when DP-PVR is deemed necessary.