One thousand consecutive pancreaticoduodenectomies

Endovascular implantation of iodine-125 seed strand combined and stent placement for locally advanced pancreatic ductal adenocarcinoma with vascular invasion: a prospective single-arm pilot study

Purpose

To investigate the safety and feasibility of endovascular brachytherapy using iodine-125 (¹²⁵I) seed strand for locally advanced pancreatic ductal adenocarcinoma (PDAC) with vascular invasion.

Material and methods

From January 2010 to January 2015, 12 patients diagnosed with locally advanced, inoperable PDAC with splenic or superior mesenteric vein invasion were enrolled in the present study and received endovascular brachytherapy combined with regional intra-arterial infusion chemotherapy. Standardized software was used for dose calculation. Procedure-related and radiation complications were documented and assessed. Overall survival was calculated with the Kaplan-Meier approach.

Results

The technical success rate of ¹²⁵I seed strand implantation and stent placement was 100%. During follow-up with a mean duration of 17.00 ±6.07 months (range, 6~24 months), the mean and median survival times were 12.0 ±2.4 months (95% CI: 7.4~16.6 months) and 10.7 ±1.4 months (95% CI: 8.0~13.5 months), respectively. One month after the treatment, the disease control and objective rates were 83.8% and 58.3%, respectively. The 6-, 12-, and 15-month cumulative survival rates were 66.7%, 47.6%, and 9.5%, respectively.

Conclusions

Endovascular brachytherapy using ¹²⁵I seed strand and stent placement may be a safe and effective treatment option for locally advanced pancreatic duct adenocarcinoma with vascular invasion.

Preoperative CT anthropometric measurements and pancreatic pathology increase risk for postoperative pancreatic fistula in patients following pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is a common complication following pancreaticoduodenectomy (PD). However, risk factors for this complication remain controversial. We conducted a retrospective analysis of 107 patients who underwent PD. POPF was diagnosed in strict accordance with the definition of the 2016 update of pancreatic fistula from the International Study Group on Pancreatic Fistula (ISGPF). Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for POPF. A total of 19 (17.8%) subjects of pancreatic fistula occurred after PD, including 15 (14.1%) with grade B POPF and 4 (3.7%) with grade C POPF. There were 33 (30.8%) patients with biochemical leak. Risk factors for POPF (grade B and C) were larger area of visceral fat (odds ratio [OR], 1.40; p = 0.040) and pathology other than pancreatic adenocarcinoma or pancreatitis (OR, 12.45; p = 0.017) in the multivariate regression analysis. This result could assist the surgeon to identify patients at a high risk of developing POPF.

What should we trust to define, predict and assess pancreatic fistula after pancreatectomy?

OBJECTIVE

The ISGPF postoperative pancreatic fistula (POPF) definition using amylase drain concentration is widely used. However, the interest of lipase drain concentration, daily drain output and absolute enzyme daily production (concentration x daily drain volume) have been poorly investigated.

MATERIAL AND METHODS

These predictive on postoperative day (POD) 1, 3, 5 and 7 were analyzed in a development cohort, and subsequently tested in an independent validation cohort.

RESULTS

Of the 227 patients of the development cohort, 17% developed a biochemical fistula and 34% a POPF (Grade B/C). Strong correlation was found between amylase/lipase drain concentration at all postoperative days (ρ = 0.90; p = 0.001). Amylase and lipase were both significantly higher in patients with a POPF (p < 0.001) presenting an equivalent under the ROC curve area (0.85 vs 0.84; p = 0.466). Combining POD1 and POD3 threefold enzyme cut-off value increased significantly POPF prediction sensibility (97.4% vs 77.8%) and NPV (97.1% vs 86.3%). These results were also confirmed in the validation cohort of 554 patients. Finally, absolute enzyme daily production and daily drain output were significantly higher in patients with a POPF (p < 0.001) but did not add clinical value when compared to drain enzyme concentration.

CONCLUSION

Lipase is as effective as amylase drain concentration to define POPF. Absolute enzyme daily production or daily drain output do not help to better predict clinically significant POPF occurrence and severity. Lipase and amylase should mainly be used for their negative predictive value to predict the absence of clinically significant POPF and could allow early drain removal and hospital discharge.

Unexpected Para-aortic Lymph Node Metastasis in Pancreatic Ductal Adenocarcinoma: a Contraindication to Resection?

BACKGROUND

Margin-negative resection is the only cure for pancreatic cancer. However, para-aortic lymph node metastasis is considered a contraindication to curative resection in pancreatic cancer. To determine if there are long-term survival differences according to the presence or absence of para-aortic lymph node metastasis in patients undergoing pancreatectomy, we evaluated oncologic outcomes in resected pancreatic cancer with unexpected para-aortic lymph node metastasis confirmed on intraoperative frozen section biopsy.

METHODS

We retrospectively investigated 362 patients with pathologically confirmed pancreatic ductal adenocarcinoma who underwent pancreatectomy between 1996 and 2016.

RESULTS

Patients with a metastatic para-aortic lymph node had the poorest median disease-specific survival [hazard ratio 14, 95% confidence interval 10-19]. However, after chemotherapy, patients with a metastatic para-aortic lymph node had a much higher disease-specific survival rate (para-aortic lymph node+/postoperative chemotherapy- versus para-aortic lymph node+/postoperative chemotherapy+, P = 0.0003, adjusted P = 0.0015). Patients with a metastatic para-aortic lymph node who underwent postoperative chemotherapy had a similar survival benefit to patients with metastatic regional lymph node without para-aortic lymph node metastasis, regardless of postoperative chemotherapy (para-aortic lymph node+/postoperative chemotherapy+ versus regional lymph node+/postoperative chemotherapy-, P = 0.3047, adjusted P > 0.9999; para-aortic lymph node+/postoperative chemotherapy+ versus regional lymph node+/postoperative chemotherapy+, P = 0.0905, adjusted P = 0.4525).

CONCLUSIONS

Unexpected para-aortic lymph node metastasis on frozen section biopsy may no longer be a contraindication to curative resection in "resectable" pancreatic ductal adenocarcinoma, as long as postoperative adjuvant chemotherapy can be administered.

Linked color imaging can improve the visibility of superficial non-ampullary duodenal epithelial tumors

The current study aimed to evaluate the efficacy of linked color imaging (LCI) in improving the visibility of superficial non-ampullary duodenal epithelial tumors (SNADETs). We prospectively evaluated 44 consecutive patients diagnosed with SNADETs. Three trainees and three experts assessed the visibility scores of white light imaging (WLI), LCI, and blue laser imaging-bright (BLI-b) for SNADETs, which ranged from 1 (not detectable without repeated cautious examination) to 4 (excellent visibility). In addition, the L* a* b* color values and color differences (ΔE*) were evaluated using the CIELAB color space system. For SNADETs, the visibility scores of LCI (3.53 ± 0.59) were significantly higher than those of WLI and BLI-b (2.66 ± 0.79 and 3.41 ± 0.64, respectively). The color differences (ΔE*) between SNADETs and the adjacent normal duodenal mucosa in LCI mode (19.09 ± 8.33) were significantly higher than those in WLI and BLI-b modes (8.67 ± 4.81 and 12.92 ± 7.95, respectively). In addition, the visibility score of SNADETs and the color differences in LCI mode were significantly higher than those in WLI and BLI-b modes regardless of the presence of milk white mucosa (MWM). LCI has potential benefits, and it is considered a promising clinical modality that can increase the visibility of SNADETs regardless of the presence of MWM.This study was registered at the University Hospital Medical Information Network (UMIN000028840).

Effects of pancreatectomy on nutritional state, pancreatic function, and quality of life over 5 years of follow up

BACKGROUND

To analyze serial changes in nutritional status, pancreatic function, and quality of life (QoL) over 5 years of follow-up after pancreatectomy.

METHODS

Patients undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) between 2007 and 2013 were included. Data on relative body weight (RBW); triceps skinfold thickness (TSFT); body mass index (BMI); serum protein, albumin, transferrin, fasting blood glucose, postprandial 2-h glucose, and stool elastase levels; and QoL questionnaire scores were collected serially for 5 years.

RESULTS

Two hundred and seventeen patients were enrolled, but 79 patients completed the 5-year follow-up. RBW, BMI, and TSFT continued to decrease postoperatively but increased after 6 months. Transferrin, albumin, and protein levels recovered to the preoperative level after 3 months. Multivariate analysis revealed that a BMI >25 kg/m² , DP, and adjuvant therapy had a significant impact on endocrine pancreatic insufficiency. Although steatorrhea and diarrhea were mainly resolved by 12 months, the stool elastase level decreased after PD and was not restored. The mean scores for all QoL questionnaires improved above the preoperative value at 12 months.

CONCLUSIONS

Patients undergoing pancreatectomy can return to their daily lives after 12 months. However, those with risk factors associated with pancreatic function and QoL need more careful follow-up and supportive management.

SRPX2 boosts pancreatic cancer chemoresistance by activating PI3K/AKT axis

Background and aim

This investigation was aimed at disclosing whether SRPX2 affected pancreatic cancer (PC) chemoresistance by regulating PI3K/Akt/mTOR signaling.

Methods

Totally 243 PC patients were recruited, and they were incorporated into partial remission (PR) group, stable disease (SD) group and progressive disease (PD) group in accordance with their chemotherapeutic response. PC cell lines (i.e. AsPC1, Capan2, VFPAC-1, HPAC, PANC-1, BxPC-3 and SW1990) and human pancreatic ductal epithelial cell lines (hTERT-HPNE) were also collected.

Results

PC patients of SD + PD group were associated with higher post-chemotherapeutic SRPX2 level than PR group, and their post-chemotherapeutic SRPX2 level was above the pretherapeutic SRPX2 level (P < 0.05). PR population showed lower SRPX2 level after chemotherapy than before chemotherapy (P < 0.05). Besides high serum SRPX2 level and SRPX2 level change before and after chemotherapy were independent predictors of poor PC prognosis. Additionally, si-SRPX2 enhanced chemosensitivity of PC cell lines, and expressions of p-PI3K, p-AKT and p-mTOR were suppressed by si-SRPX2 (P < 0.05). IGF-1 treatment could changeover the impact of si-SRPX2 on proliferation, migration, invasion and chemoresistance of PC cells (P < 0.05).

Conclusion

The SRPX2-PI3K/AKT/mTOR axis could play a role in modifying progression and chemoresistance of PC cells, which might help to improve PC prognosis.

Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis

Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.

Novel Technique for Single-Layer Pancreatojejunostomy is Not Inferior to Modified Blumgart Anastomosis in Robotic Pancreatoduodenectomy: Results of a Randomized Controlled Trial

BACKGROUND

A novel technique of single-layer continuous suturing (SCS) for pancreaticojejunostomy (PJ) during robotic pancreaticoduodenectomy (RPD), a technically straightforward procedure, has been shown to produce promising results in a previous study. The present RCT aims to show that SCS during RPD does not increase the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) when compared with modified Blumgart anastomosis (MBA).

PATIENTS AND METHODS

Between January 2019 and September 2019, consecutive patients (ASA score ≤ 2) who underwent RPD were enrolled and randomized to the SCS or the MBA group. The primary endpoint was the rate of CR-POPF. A noninferiority margin of 10% was chosen.

RESULTS

Of the 186 patients, 4 were excluded because PJ was not performed. The remaining 182 patients were randomized to the SCS group (n = 89) or MBA group (n = 93). CR-POPF rate was not inferior in the SCS group [SCS: 6.7%, MBA: 11.8%; 95% confidence interval (- 0.76, - 0.06), P = 0.0002]. PJ duration was significantly lower in the SCS group (P < 0.01). No significant differences were found between the two groups in operative time, estimated blood loss, postoperative hospital stay, or rates of conversion to laparotomy, morbidity, reoperation, or mortality. On subgroup analysis of patients with a soft pancreas and small main pancreatic duct, SCS significantly reduced the duration of PJ.

CONCLUSIONS

This study showed that SCS was not inferior to MBA in terms of the CR-POPF rate during RPD. Registration number: ChiCTR1800020086 ( www.Chictr.org.cn ).

147 Pancreatoduodenectomies: a Single Center's Perspective into the Epidemiology and Surgical Outcomes of Periampullary and Pancreatic Cancers in South India

BACKGROUND

Pancreatoduodenectomy (PD) is the only curative procedure for resectable periampullary cancers. This study aims to survey the various outcome variables of the procedure at our institute, which is in the early process of evolving into a high-volume center for PDs.

METHODS

Data of patients, who underwent PDs, was collected retrospectively from January 2010 to December 2017 and prospectively from January 2018 to December 2019. Various preoperative, intraoperative, and histopathological parameters were compared with the outcome variables-morbidity and mortality rates.

RESULTS

A total of 147 patients underwent PDs over the last decade. From January 2010 to December 2014 (period A), 29 patients underwent PD, while 118 patients underwent PD from January 2015 to December 2019 (period B). Clinically relevant (CR) delayed gastric emptying (44.8% vs 23.7%), CR post-pancreatectomy hemorrhage (37.9% vs 18.6%), and blood loss (850 ml (400-5300 ml) vs 600 ml (150-2500 ml)) improved in period B with no improvement in CR postoperative pancreatic fistula (20.7% vs 28.8%). The rates of SSI (63.6%), pulmonary complications (29.9%), and mean postoperative stay (19.87 ± 11.59 days) were found to be higher than most of the major centers. Mortality rates decreased significantly from 27.6% in period A to 10.2% in period B (p = 0.029). Median overall survival was 30 months (95% CI 20.76-39.23 months) CONCLUSION: Over the last decade, there has been a significant improvement in the mortality rate, but morbidity remains high and must be looked into as the department enters the new decade as a young high-volume center.

Benefits of the multiplanar and volumetric analyses of pancreatic cancer using computed tomography

Although pancreatic cancer tumors are irregularly shaped in terms of their three-dimensional (3D) structure, when T staging by imaging results, generally only the axial plane is used to measure the largest tumor diameter. We investigated the size of pancreatic cancer tumors using multi-plane and 3D reconstructed computed tomography (CT) images and investigated their clinical usefulness. Patients who underwent surgery for pancreatic adenocarcinoma were included. We measured the largest diameter of each pancreatic tumor in the axial, coronal, and sagittal planes of CT images. In addition, maximal diameter and cancer volume were measured from 3D images that were constructed using a semi-automated software system. Final data were compared with pathologic examination and the effect of each value on prognosis was analyzed. A total of 183 patients were analyzed. The maximal diameters measured on the axial, coronal, and sagittal planes were 2.9 ± 1.1, 3.2 ± 0.9, and 3.2 ± 1.0 cm, respectively, which were significantly smaller than pathologic results (3.4 ± 1.4 cm, all p<0.05 by paired t-test). The longest diameter among them (3.4 ± 1.1 cm) was nearly similar to the pathologic diameter. Cancer volume measured on 3D images demonstrated a higher area under the receptor operating characteristic curve [0.714, (95% confidence interval: 0.640-0.788)] for predicting early death compared to any unidimensional CT diameters measured. The longest pancreatic tumor diameter measured on multiplanar CT images was most accurate when compared to its corresponding pathologic diameter. Tumor volume had a stronger correlation with overall survival than tumor diameter.

Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery

BACKGROUND

The refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery.

METHODS

The institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used.

RESULTS

Perioperative outcomes of 32 Jehovah's Witnesses patients were included. Median age was 67 years (range, 31-77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100-1000) and 470 min (range, 290-595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7-15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1-14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8-54) with no patient requiring transfusion or re-operation and no 90-day mortality.

CONCLUSIONS

A multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.

C-reactive protein is superior to white blood cell count for early detection of complications after pancreatoduodenectomy: a retrospective multicenter cohort study

BACKGROUND

Early detection of major complications after pancreatoduodenectomy could improve patient management and decrease the "failure-to-rescue" rate. In this retrospective cohort study, we aimed to compare the value of C-reactive protein (CRP) and white blood cell count (WBC) in the early detection of complications after pancreatoduodenectomy.

METHODS

We assessed pancreatoduodenectomies between January 2012 and December 2017. Major complications were defined as grade III or higher according to the Clavien-Dindo classification. Postoperative pancreatic fistula (POPF) was a secondary endpoint. ROC-curve and logistic regression analysis were performed for CRP and WBC. Results were validated in an external cohort.

RESULTS

In the development cohort (n = 285), 103 (36.1%) patients experienced a major complication. CRP was superior to WBC in detecting major complications on postoperative day (POD) 3 (AUC:0.74 vs. 0.54, P < 0.001) and POD 5 (AUC:0.77 vs. 0.68, P = 0.031), however not on POD 7 (AUC:0.77 vs. 0.76, P = 0.773). These results were confirmed in multivariable analysis and in the validation cohort (n = 202). CRP was also superior to WBC in detecting POPF on POD 3 (AUC: 0.78 vs. 0.54, P < 0.001) and POD 5 (AUC: 0.83 vs. 0.71, P < 0.001).

CONCLUSION

CRP appears to be superior to WBC in the early detection of major complications and POPF after pancreatoduodenectomy.

Implementation of a standardized approach to borderline resectable pancreatic cancer in a multisite community oncology program

Background

Treatment paradigms for borderline resectable pancreatic cancer are evolving with increasing use of neoadjuvant chemotherapy and neoadjuvant chemoradiation. Variations in the definition of borderline resectable pancreatic cancer and neoadjuvant approaches have made standardizing care for borderline resectable pancreatic cancer difficult. We report an effort to standardize management of borderline resectable pancreatic cancer throughout Sanford Health, a large community oncology network.

Methods

Starting in October 2013, cases of pancreatic adenocarcinoma without known metastatic disease were categorized as borderline resectable pancreatic cancer if they met ≥ 1 of the following criteria: (1) abutment of superior mesenteric, common hepatic, or celiac arteries with < 180° involvement, (2) venous involvement deemed potentially suitable for reconstruction, and/or (3) biopsy-proven lymph node involvement. Patients with borderline resectable pancreatic cancer were treated with neoadjuvant chemotherapy followed by reimaging and surgery if venous involvement had improved; if disease remained borderline resectable, patients underwent neoadjuvant chemoradiation and surgical exploration as long as reimaging did not reveal evidence of progressive disease.

Results

Forty-three patients from October 2013 to April 2017 were diagnosed with borderline resectable pancreatic cancer. Twelve of 42 (29%) patients proceeded to surgical exploration directly after neoadjuvant chemotherapy; 23 (55%) received neoadjuvant chemoradiation. Overall, 28/43 (65%) underwent exploration with 19 (44%) able to undergo resection. Of those, 14/19 (74%) attained R0 resection and 11/19 (58%) were pathologic N0. No pretreatment or treatment variables were associated with resection rates; resection was the only variable associated with survival.

Conclusion

This report demonstrates the feasibility of implementing a standardized approach to borderline resectable pancreatic cancer across multiple sites over a wide geographic area. Adherence to protocol therapies was good and surgical outcomes are similar to many reported series.

The impact of individual surgeon on the likelihood of minimal invasive surgery among Medicare beneficiaries undergoing pancreatic resection

BACKGROUND

The objective of the current study was to evaluate the impact of the individual surgeon on the use of minimally invasive pancreatic resection.

METHODS

The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent pancreatic resection between 2013 and 2017. The impact of patient- and procedure-related factors on the likelihood of minimally invasive pancreatic resection was investigated.

RESULTS

A total of 12,652 (85.4%) patients underwent open pancreatic resection, whereas minimally invasive pancreatic resection was performed in 2,155 (14.6%) patients. Unadjusted rates of minimally invasive pancreatic resection ranged from 0% in the bottom volume tertile to 35.3% in the top tertile. Although patients with emergency admission were less likely to undergo minimally invasive pancreatic resection (odds ratio = 0.43, 95% confidence interval 0.32-0.58), patients operated on more recently had a higher chance of minimally invasive pancreatic resection (year 2017; odds ratio = 1.51, 95% confidence interval 1.28-1.79). On multivariable analysis, there was over a 3-fold variation in the odds that a patient underwent minimally invasive versus open pancreatic resection based on the individual surgeon (median odds ratio = 3.27, 95% confidence interval 2.98-3.56). Patients who underwent pancreatectomy by a low-volume, minimally invasive pancreatic resection surgeon had higher odds of 90-day mortality after surgery (odds ratio = 1.33, 95% confidence interval: 1.16-1.59), as well as higher observed/expected mortality compared with individuals treated by high-volume surgeons.

CONCLUSION

The likelihood of undergoing minimally invasive pancreatic resection among Medicare beneficiaries was markedly influenced by the individual treating surgeon rather than patient- or procedure-level factors.

A Phase 1 Dose Escalation Study of Neoadjuvant SBRT Plus Elective Nodal Radiation with Concurrent Capecitabine for Resectable Pancreatic Cancer

PURPOSE

The role of neoadjuvant radiation for resectable pancreatic adenocarcinoma is controversial. We performed a prospective dose-escalation study of neoadjuvant stereotactic body radiation therapy (SBRT) with concurrent capecitabine and elective nodal irradiation (ENI) followed by surgical resection to explore the toxicity and feasibility of this approach.

METHODS AND MATERIALS

Patients with biopsy proven, resectable cancers of the pancreatic head were enrolled. A 4 + 4 dose-escalation design was employed delivering 5 fractions of 5 to 7 Gy to primary tumor with concurrent capecitabine. The maximum tolerated dose level was expanded for an additional 4 patients. Patients at all dose levels were treated with ENI delivering 25 Gy in 5 fractions. Dose-limiting toxicity was defined as any grade ≥3 nonhematologic toxicity (National Cancer Institute Common Terminology Criteria for Adverse Events v4.0) attributable to chemoradiation occurring within 90 days of SBRT.

RESULTS

A total of 17 patients were enrolled with 16 patients evaluable and 13 patients ultimately proceeding to surgery. The most common toxicity was nausea (56%). There were no dose-limiting toxicities, and SBRT was maximally dose escalated to 35 Gy in 5 fractions for 8 patients. All patients completing surgery had R0 resections. Seven patients (54%) had moderate treatment effect identified in pathologic specimens. Three patients (23%) developed locoregional recurrences, with 2 (15%) partially included within the treated volume.

CONCLUSIONS

SBRT was safely dose escalated to 35 Gy in 5 fractions along with concurrent capecitabine and ENI. This regimen will be used in a future expansion cohort.

Immunonutrition in Patients with Pancreatic Cancer Undergoing Surgical Intervention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Immunonutrition is administered to improve the outcome of patients with pancreatic cancer undergoing surgery. However, its effect and mechanism of action remain unclear. Therefore, we conducted this systematic review and meta-analysis to assess its effects on postoperative outcome and the immune system. Randomized controlled trials (RCTs) were identified and data extracted by two reviewers independently from electronic databases from their inception to 31 October 2019. The result was expressed as the risk ratio (RR) for categorical variables and mean difference (MD) for continuous variables with 95% confidence intervals (CIs). Six RCTs published from 1999 and 2016, with a total of 368 patients, were included. The results revealed that immunonutrition significantly decreased the rate of infectious complications (RR = 0.47, 95% CI (0.23, 0.94), p = 0.03) and the length of hospital stay (MD = -1.90, 95% CI (-3.78, -0.02), p = 0.05) by modulating the immune system, especially in preoperative group in subgroup analysis. We therefore recommend that patients with pancreatic cancer undergoing surgery could take the advantage of immunonutrition, especially in the preoperative period.

A phase II study of liposomal irinotecan with 5-fluorouracil, leucovorin and oxaliplatin in patients with resectable pancreatic cancer: the nITRO trial

BACKGROUND

Up-front surgery followed by postoperative chemotherapy remains the standard paradigm for the treatment of patients with resectable pancreatic cancer. However, the risk for positive surgical margins, the poor recovery after surgery that often impairs postoperative treatment, and the common metastatic relapse limit the overall clinical outcomes achieved with this strategy. Polychemotherapeutic combinations are valid options for postoperative treatment in patients with good performance status. liposomal irinotecan (Nal-IRI) is a novel nanoliposome formulation of irinotecan that accumulates in tumor-associated macrophages improving the therapeutic index of irinotecan and has been approved for the treatment of patients with metastatic pancreatic cancer after progression under gemcitabine-based therapy. Thus, it remains of the outmost urgency to investigate introduction of the most novel agents, such as nal-IRI, in perioperative approaches aimed at increasing the long-term effectiveness of surgery.

METHODS

The nITRO trial is a phase II, single-arm, open-label study to assess the safety and the activity of nal-IRI with fluorouracil/leucovorin (5-FU/LV) and oxaliplatin in the perioperative treatment of patients with resectable pancreatic cancer. The primary tumor must be resectable with no involvement of the major arteries and no involvement or <180° interface between tumor and vessel wall of the major veins. A total of 72 patients will be enrolled to receive a perioperative treatment of three cycles before and three cycles after surgical resection with nal-IRI 50 mg/m2, oxaliplatin 60 mg/m2, leucovorin 200 mg/m2, and 5-fluorouracil 2400 mg/m2, days 1 and 15 of a 28-day cycle. The primary objective is to improve from 40% to 55% the proportion of patients achieving R0 resection after preoperative treatment.

DISCUSSION

The nITRO trial will contribute to strengthen the clinical evidence supporting perioperative strategies in resectable pancreatic cancer patients. Moreover, this study represents a unique opportunity for translational analyses aimed to identify novel immune-related prognostic and predictive factors in this setting.

TRIAL REGISTRATION

Clinicaltrial.gov: NCT03528785. Trial registration data: 1 January 2018Protocol number: CRC 2017_01EudraCT Number: 2017-000345-46.

Three Thousand Consecutive Pancreaticoduodenectomies in a Tertiary Cancer Center: A Retrospective Observational Study

(1) Aim: To evaluate clinicopathological features and postoperative outcomes including survival in patients who underwent pancreaticoduodenectomy (PD) for periampullary diseases. (2) Methods: We retrospectively reviewed 3078 cases of PD performed in our center for 25 years. Periampullary diseases were divided into benign and malignancy groups. All cases were also classified by location. The time of 25 years was divided to different periods (5 years per period) to compare outcomes. Overall survival was compared between subdivided periods. (3) Results: Hospitalization became significantly shorter from 28.0 days in the 1st period to 13.8 days in the 5th period. Overall complication rate was significantly increased since the 3rd period. The rate without postoperative pancreatic fistula (POPF) was high at 98.7% in the 1st period. This might be because drain amylase on the 3rd day after PD was not routinely checked in the past. Thus, POPF was not detected. In survival analysis of adenocarcinoma of pancreas, bile duct, and ampulla, overall survival was found to be improved significantly in recent years. (4) Conclusions: Our study revealed that outcomes were improved with increasing number of PDs performed. Although POPF and overall complications showed increases more recently, those were detected and managed, resulting in shorter hospitalization and improved outcomes.

Precision Oncology in Surgery

Objective:

We aimed to define preoperative clinical and molecular characteristics that would allow better patient selection for operative resection.

Background:

Although we use molecular selection methods for systemic targeted therapies, these principles are not applied to surgical oncology. Improving patient selection is of vital importance for the operative treatment of pancreatic cancer (pancreatic ductal adenocarcinoma). Although surgery is the only chance of long-term survival, 80% still succumb to the disease and approximately 30% die within 1 year, often sooner than those that have unresected local disease.

Method:

In 3 independent pancreatic ductal adenocarcinoma cohorts (total participants = 1184) the relationship between aberrant expression of prometastatic proteins S100A2 and S100A4 and survival was assessed. A preoperative nomogram based on clinical variables available before surgery and expression of these proteins was constructed and compared to traditional measures, and a postoperative nomogram.

Results:

High expression of either S100A2 or S100A4 was independent poor prognostic factors in a training cohort of 518 participants. These results were validated in 2 independent patient cohorts (Glasgow, n = 198; Germany, n = 468). Aberrant biomarker expression stratified the cohorts into 3 distinct prognostic groups. A preoperative nomogram incorporating S100A2 and S100A4 expression predicted survival and nomograms derived using postoperative clinicopathological variables.

Conclusions:

Of those patients with a poor preoperative nomogram score, approximately 50% of patients died within a year of resection. Nomograms have the potential to improve selection for surgery and neoadjuvant therapy, avoiding surgery in aggressive disease, and justifying more extensive resections in biologically favorable disease.

[Indications for Surgical Therapy in Chronic Pancreatitis]

Chronic pancreatitis is a recurrent disease with repeating exacerbations of inflammation of the pancreatic gland - associated with belt-like back pain. Without treatment, recurrent chronic pancreatitis leads to development of opioid-dependent pain. The chronic pancreatitis leads to recurrent hospital stays for the affected patient and socioeconomic challenges. In progress it can lead to local complications of chronic pancreatitis, such as formation of pseudocysts, biliary duct obstruction, duodenal obstruction or portal hypertension. The aim of this article is a detailed description of the indication for surgical therapy in chronic pancreatitis. The underlying analysis was a systematic literature research and evaluation, the formulation of key questions according to the PICO system and the evaluation of indications and key statements and questions, as implemented in a three level Delphi process among the members of the pancreas research group and the indications for the surgery group of the German Society of General and Visceral Surgery (DGAV). Surgical resection of the inflammatory pancreatic head pseudotumour, after initial conservative therapy, is a highly efficient therapy for the control of pain and the avoidance of complications in chronic pancreatitis. For this purpose, well evaluated surgical strategies are available. Delay in surgical therapy can lead to chronic pain, kachexia and malnutrition and increase complications of surgical therapy.

The modern trauma pancreaticoduodenectomy for penetrating trauma: a propensity-matched analysis

Trauma pancreaticoduodenectomy (TP) remains a challenging operation with morbidity and mortality rates as high as 80% and 50%. Many trauma surgeons consider it surgical dogma to avoid performing a TP during the index operation for patients with severe pancreatic or duodenal injuries. However, there is no modern analysis evaluating this belief. Therefore, we hypothesized no difference in risk of mortality between patients with severe pancreatic or duodenal injury undergoing a TP for penetrating trauma to propensity-matched controls undergoing laparotomy without TP. The Trauma Quality Improvement Program (2010–2016) was queried for adults with severe penetrating pancreatic or duodenal injuries undergoing laparotomy. A 1:2 propensity-matching including demographics/comorbidities, injury severity score, vitals on admission, Glasgow Coma Scale and concomitant injuries for laparotomy with or without TP was performed. Risk of mortality was reported using a univariable logistic regression model. Of 2182 patients with severe pancreatic or duodenal injuries undergoing laparotomy, 54 (2.5%) underwent TP and 2128 (97.5%) underwent laparotomy without TP. There were no differences in propensity-matching characteristics. Patients undergoing TP had a similar mortality rate (20.0% vs. 28.7%, p = 0.302) but a longer length of stay (LOS) (27.5 vs. 16.5 days, p = 0.017). The TP group had a similar associated risk of mortality (OR = 0.62, p = 0.302) but higher risk of major complications (OR 3.44, CI 1.35–17.47, p = 0.015). In appropriately selected penetrating trauma patients with severe pancreatic/duodenal injuries, TP is associated with a similar risk of mortality compared to laparotomy without TP. However, TP patients did have an increased associated risk of major complications and longer LOS.

Readmission and Resource Use After Robotic-Assisted versus Open Pancreaticoduodenectomy: 2010-2017

BACKGROUND

Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD).

MATERIALS AND METHODS

We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index + readmission) length of stay, costs, and mortality.

RESULTS

Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P = 0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P = 0.98). Disposition with home health care (AOR: 1.1, P < 0.001) or to a skilled nursing facility (AOR: 1.5, P < 0.001) was significantly associated with increased 30-day readmission.

CONCLUSIONS

Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.

Adjuvant chemotherapy in pancreatic cancer: state of the art and future perspectives

PURPOSE OF REVIEW

The modalities of management of resectable pancreatic ductal adenocarcinoma (PDAC) have evolved in recent years with new practice guidelines on adjuvant chemotherapy and results of randomized phase III trials. The aim of this review is to describe the state of the art in this setting and to highlight future possible perspectives.

RECENT FINDINGS

Resectable PDAC is the tumor without vascular contact or a limited venous contact without vein irregularity. Several pathologic and biologic robust prognostic factors such as an R0 resection defined by a margin at least 1 mm have been validated. In phase III trials, the doublet gemcitabine-capecitabine provided a statistically significant, albeit modest overall survival benefit, but failed to show an improvement in relapse-free survival. Similarly, gemcitabine plus nab-paclitaxel did not increase disease-free survival. Modified FOLFIRINOX led to improved disease-free survival, overall survival, and metastasis-free survival, with acceptable toxicity. In the future, prognostic and/or predictive biomarkers could lead the optimization of therapeutic strategies and neoadjuvant treatment could become a standard of care in PDAC.

SUMMARY

After curative intent resection, modified FOLFIRINOX is the standard of care in adjuvant in fit patients with PDAC. Others regimens (monotherapy or gemcitabine-based) are an option in unfit patients.

Safety and Effectiveness of Vessel Sealing for Dissection during Pancreaticoduodenectomy

Traditional pancreaticoduodenectomy dissection techniques are tedious and time-consuming. The LigaSure® Vessel Sealing System is an alternative to standard dissection methods. LigaSure® can be used in replace of ligatures, clips, and sutures in most of the pancreaticoduodenectomy procedure. The objective of this study was to examine our experience with LigaSure® in pancreaticoduodenectomies and to show the safety and time-effectiveness. Forty-three pancreaticoduodenectomies were performed by a single surgeon using the LigaSure® device in place of traditional dissection techniques. A retrospective chart review was conducted to evaluate patient management and outcome. Demographics, preoperative, intraoperative, and postoperative data were analyzed. The average patient age was 61 years. Primary pathologic diagnoses were: periampullary carcinoma (56%), chronic pancreatitis (5%), cystic lesion (26%), neuroendocrine tumor (7%), and other (5%). Our patient population demonstrated American Society of Anesthesiologists Class I (2%), Class II (14%), III (75%), and IV (9%). Average operative time was 4:11 hours. The study group required an average of 0.49 ± 1.35 units of blood. Eight patients (19%) received blood transfusion, receiving an average of 2.63 ± 2.13 units. Patients had a median hospital stay of 10 days (range, 5 to 41 days). An oral diet was ordered for most patients by Day 4. Fourteen patients (32.5%) had a complication, including two patients requiring additional surgery for drainage of abscess. There were no postoperative deaths. The use of LigaSure® is a practical and safe alternative to standard dissection techniques. Operative time, blood loss, and complication rate are favorable compared with published series.

Flooring the Major Vessels with Falciform Ligament to Prevent Post-Pancreatectomy Hemorrhage

BACKGROUND

One of the most severe pancreatic surgery complications is post-pancreatectomy hemorrhage (PPH). This study's aim was to evaluate the efficacy of flooring the major vessels with falciform ligament in preventing PPH after pancreatoduodenectomy (PD).

METHODS

This study was a retrospective review of 500 consecutive patients who underwent PD between Jan 2010 and Dec 2019 at Hiroshima University. Morbidities, including postoperative pancreatic fistula (POPF) or PPH and 90-day mortality, were analyzed. The study cohort was divided into two groups based on the time of surgery (2010-2016 and 2017-2019), i.e., before and after implementation of falciform ligament flooring method. The patient characteristics, operative parameters, clinicopathological factors, morbidity, and mortality were compared between the two periods.

RESULTS

Morbidity and mortality rates in the entire cohort were 21% and 1.4%, respectively. The incidence of Grade B/C POPF and PPH was 9.0% and 3.8%, respectively. There was no significant difference between the two periods with respect to Grade B/C POPF, morbidity rate, and mortality rate; however, the rate of Grade B/C PPH significantly decreased from 5.2 to 1.6% p = .027. On multivariate analysis, the absence of the falciform ligament flooring method was an independent PPH risk factor p = .003.

CONCLUSIONS

Falciform ligament flooring method may help decrease the incidence of PPH after PD.

Pancreas-visceral fat CT value ratio and serrated pancreatic contour are strong predictors of postoperative pancreatic fistula after pancreaticojejunostomy

BACKGROUND

Our aim is to elucidate the true preoperative risk factors for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), making it possible to select POPF high-risk patients preoperatively regardless of intraoperative pancreatic consistency judged by the surgeon's hand.

METHODS

Among the 298 patients who underwent PD with pancreaticojejunostomy from 2007 to 2016, 262 patients had preoperative CT configurations that could be precisely evaluated. Risk factor analyses were conducted using various perioperative factors, including preoperative CT findings, such as CT values of the pancreas, pancreas-visceral fat CT value ratio and pancreatic outer contour. Pancreatic outer contour was further divided into smooth- (smooth interlobular) and serrated-type contours (feathery, irregular interlobular) by preoperative CT.

RESULTS

In terms of the incidence of POPF, among the 262 patients, POPF grade B/C was found in 27 (10.3%): grade B in 23 (8.8%) and grade C in 4 (1.5%). According to multivariate analysis, a high pancreas-visceral fat CT value ratio (p = 0.002), serrated-type contour (p = 0.02) and no history of chemoradiotherapy (p = 0.019) were identified as independent risk factors for POPF grade B/C. Even in patients with soft pancreas, the incidence of POPF grade B/C was 0% (0/57) in patients with a pancreas-visceral fat CT value ratio of less than - 0.4 and smooth-type contour, whereas the incidence was markedly high (45.0%, 9/20) in patients with a pancreas-visceral fat CT value ratio of - 0.4 or greater and serrated-type contour, indicating that patients with soft pancreas should be categorized into POPF high-risk and low-risk groups according to preoperative CT scan results.

CONCLUSIONS

The pancreas-visceral fat CT value ratio and serrated-type pancreas are useful markers to preoperatively identify true POPF high-risk groups in patients undergoing PD, regardless of the pancreatic texture judged intraoperatively.

Resection Versus Observation of Small Asymptomatic Nonfunctioning Pancreatic Neuroendocrine Tumors

BACKGROUND

Management of asymptomatic, nonfunctioning small pancreatic neuroendocrine tumors (PNETs) is controversial because of their overall good prognosis, and the morbidity and mortality associated with pancreatic surgery. Our aim was to compare the outcomes of resection with expectant management of patients with small asymptomatic PNETs.

METHODS

Retrospective review of patients with nonfunctioning asymptomatic PNETs < 2 cm that underwent resection or expectant management at the Tel-Aviv Medical Center between 2001 and 2018.

RESULTS

Forty-four patients with small asymptomatic, biopsy-proven low-grade PNETs with a KI67 proliferative index < 3% were observed for a mean of 52.48 months. Gallium⁶⁷DOTATOC-PET scan was completed in 32 patients and demonstrated uptake in the pancreatic tumor in 25 (78%). No patient developed systemic metastases. Two patients underwent resection due to tumor growth, and true tumor enlargement was evidenced in final pathology in one of them. Fifty-five patients underwent immediate resection. Significant complications (Clavien-Dindo grade ≥ 3) developed in 10 patients (18%), mostly due to pancreatic leak, and led to one mortality (1.8%). Pathological evaluation revealed lymphovascular invasion in 1 patient, lymph node metastases in none, and a Ki67 index ≥ 3% in 5. No case of tumor recurrence was diagnosed after mean follow-up of 52.8 months.

CONCLUSIONS

No patients with asymptomatic low-grade small PNETs treated by expectant management were diagnosed with regional or systemic metastases after a 52.8-month follow-up. Local tumor progression rate was 2.1%. Surgery has excellent long-term outcomes, but it harbors significant morbidity and mortality. Observation can be considered for selected patients with asymptomatic, small, low grade PNETs.

Imaging and Management of Pancreatic Cancer

Pancreatic cancer is an aggressive disease with rising incidence and high mortality despite advances in imaging and therapeutic options. Surgical resection is currently the only curative treatment, with expanding roles for adjuvant and neoadjuvant chemoradiation. Accurate detection, staging, and post-treatment monitoring of pancreatic cancer are critical to improving survival and imaging plays a central role in the multidisciplinary approach to this disease. This article will provide a broad overview of the imaging and management of pancreatic cancer with a focus on diagnosis and staging, operative and nonoperative treatments, and post-therapeutic appearances after surgery and chemoradiation therapy.

Extended Experience with a Dynamic, Data-Driven Selective Drain Management Protocol in Pancreaticoduodenectomy: Progressive Risk Stratification for Better Practice

BACKGROUND

Intraoperative drain use for pancreaticoduodenectomy has been practiced in an unconditional, binary manner (placement/no placement). Alternatively, dynamic drain management has been introduced, incorporating the Fistula Risk Score (FRS) and drain fluid amylase (DFA) analysis, to mitigate clinically relevant postoperative pancreatic fistula (CR-POPF).

STUDY DESIGN

An extended experience with dynamic drain management was used at a single institution for 400 consecutive pancreaticoduodenectomies (2014 to 2019). This protocol consists of the following: drains omitted for negligible/low-risk FRS (0 to 2) and drains placed for moderate/high-risk FRS (3 to 10) with early (postoperative day [POD] 3) removal if POD1 DFA ≤5,000 U/L. Adherence to this protocol was prospectively annotated and outcomes were retrospectively analyzed.

RESULTS

The overall CR-POPF rate was 8.7%, with none occurring in the negligible/low-risk cases. Moderate/high-risk patients manifested an 11.9% CR-POPF rate (n = 35 of 293), which was lower on-protocol (9.5% vs 21%; p = 0.014). After drain placement, POD1 DFA ≥5,000 U/L was a better predictor of CR-POPF than FRS (odds ratio 14.7; 95% CI, 4.3 to 50.3). For POD1 DFA ≤5,000 U/L, early drain removal was associated with fewer CR-POPFs (2.8% vs 23.5%; p < 0.001), and substantiated by multivariable analysis (odds ratio 0.09; 95% CI, 0.03 to 0.28). Surgeon adherence was inversely related to CR-POPF rate (R = 0.846).

CONCLUSIONS

This extended experience validates a dynamic drain management protocol, providing a model for better drain management and individualized patient care after pancreaticoduodenectomy. This study confirms that drains can be safely omitted from negligible/low-risk patients, and moderate/high-risk patients benefit from early drain removal.

Pancreas Cystic Lesions

This article outlines the principles behind the management of pancreatic cystic lesions. We outline what the general surgeon needs to know in managing and triaging these patients. It is our feeling that the general surgeon is often the first line of evaluation of these complex patients and a working knowledge of the different types of cysts is critical to safe care of the patient.

Comparative Effectiveness of Pylorus-Preserving Versus Standard Pancreaticoduodenectomy in Clinical Practice

OBJECTIVES

We compared risk-adjusted short- and long-term outcomes between standard pancreaticoduodenectomy (SPD) and a pylorus-preserving pancreaticoduodenectomy (PPPD).

METHODS

The National Cancer Database was queried for the years 2004 to 2014 to identify patients with adenocarcinoma of the pancreatic head undergoing SPD and PPD. Margin status, lymph node yield, length of stay (LOS), 30- and 90-day mortality, and overall survival were compared.

RESULTS

A total of 11,172 patients were identified, of whom 9332 (83.5%) underwent SPD and 1840 (16.5%) PPPD. There was no difference in patient age, sex, stage, tumor grade, radiation treatment, and chemotherapy treatment between the 2 groups. Total number of regional lymph nodes was examined, and surgical margin status and overall survival were also comparable. However, patients undergoing PPPD had a shorter LOS (11.3 vs 12.3 days, P < 0.001), lower 30-day mortality (2.5% vs 3.7%, P = 0.02), and 90-day mortality (5.5% vs 6.9%, P = 0.03). On multivariate analyses, patients undergoing SPD were at higher risk for 30-day mortality compared with PPPD (odds ratio, 1.51; 95% confidence interval, 1.07-2.13).

CONCLUSIONS

Standard pancreaticoduodenectomy and PPPD are oncologically equivalent, yet PPPD is associated with a reduction in postoperative mortality and shorter LOS.

Failure to rescue after major abdominal surgery: The role of hospital safety net burden

BACKGROUND

We aimed to examine whether safety-net burden is a significant predictor of failure-to-rescue (FTR) after major abdominal surgery controlling for patient and hospital characteristics, including surgical volume.

METHODS

Data were extracted from the 2007-2011 Nationwide Inpatient Sample. FTR was defined as mortality among patients experiencing major postoperative complications. Differences in rates of complications, mortality, and FTR across quartiles of safety-net burden were assessed with univariate analyses. Multilevel regression models were constructed to estimate the association between FTR and safety-net burden.

RESULTS

Among 238,645 patients, the incidence of perioperative complications, in-hospital mortality, and FTR were 33.7%, 4.4%, and 11.8%, respectively. All the outcomes significantly increased across the quartiles of safety-net burden. In the multilevel regression analyses, safety-net burden was a significant predictor of FTR after adjustment for patient and hospital characteristics, including hospital volume.

CONCLUSION

Increasing hospital safety-net burden is associated with higher odds of FTR for major abdominal surgery.

How I do it: Endoscopic diagnosis for superficial non-ampullary duodenal epithelial tumors

There are no reports on detailed endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors (SNADET) except for relatively small case series. Herein, we conducted a prospective observational study to investigate the relationship between endoscopic findings and histopathological diagnosis of SNADET. A total of 163 SNADET diagnosed using magnified endoscopic examination with image-enhanced endoscopy (IEE-ME) were prospectively registered in this study. We investigated location, size, macroscopic type, color, and IEE-ME findings including surface structure (closed- or open-loop) and presence of white opaque substance (WOS) in SNADET. We analyzed association between these findings and histopathological diagnosis of SNADET based on the Vienna classification (VCL) using logistic regression analysis. In univariate analysis, lesion size, superficial structure, and WOS deposition showed statistical significance, and the oral side of the lesion location showed statistical tendency for association with VCL C4/5. In multivariate analysis, lesion size (odds ratio [OR], 2.92; 95% CI, 1.94-4.39; P < 0.05) and negative WOS (OR, 5.59; 95% CI, 1.72-18.1; P < 0.05) were significantly associated with VCL C4/5 lesions. Superficial structures with a closed-loop pattern on the surface showed statistical tendency for predicting VCL C4/5 lesions (OR, 2.15; 95% CI, 0.86-5.37; P = 0.10). Based on these findings, we concluded that negative WOS by IEE-ME and lesion size were independent predictors of VCL C4/5 SNADET. These factors may help us to understand of pathophysiology of SNADET and to select appropriate therapeutic strategies.

Predictive factors for postoperative pancreatitis after pancreaticoduodenectomy: A single-center retrospective analysis of 1465 patients

BACKGROUND

Postoperative acute pancreatitis (POAP) after pancreaticoduodenectomy (PD) has been recently recognized as an independent complication that is associated with undesirable postoperative outcomes and often precedes other complications, yet predictive factors attributable to POAP after PD remain elusive.

METHODS

The data from 1465 consecutive patients who underwent laparotomy or minimally invasive robotic PD from March 2010 to December 2018 were retrospectively reviewed. POAP was defined as an elevation of the serum amylase levels above the institution's normal upper limit (100 U/L) on postoperative day (POD) 1. Univariate and multivariate analyses were performed to investigate the predictive factors for POAP after PD and the association between POAP and clinically relevant postoperative pancreatic fistulas (CR-POPFs).

RESULTS

Among the 1465 patients, 411 (28%) underwent minimally invasive robotic surgeries, and the overall POAP and CR-POPFs rates were 770 (53%) and 277 (19%), respectively. The female sex (OR 1.76), a normal bilirubin level (OR 1.55), the robotic surgery (OR 1.36), a main pancreatic duct (MPD) ≤3 mm (OR 5.69) and a high-risk nonadenocarcinoma pathology (cystic disease: OR 4.33; pNETs: OR 4.34; others: OR 2.74) were considered independent risk factors for POAP. A nondilated MPD was a predominant predictor for POAP, with 72.2% sensitivity and 71.8% specificity. POAP was also an independent predictive factor for CR-POPFs (OR 3.48).

CONCLUSION

A nondilated MPD, a high-risk pathology, the female sex, a normal bilirubin level and the robotic surgery were independent predictive factors for POAP after PD. Prevention and early treatment strategy changes can be made based on these preoperative predictive factors.

The risk of not receiving adjuvant chemotherapy after resection of pancreatic ductal adenocarcinoma: a nationwide analysis

BACKGROUND

The relation between type of postoperative complication and not receiving chemotherapy after resection of pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim was to investigate which patient factors and postoperative complications were associated with not receiving adjuvant chemotherapy.

METHODS

Patients who underwent resection (2014-2017) for PDAC were identified from the nationwide mandatory Dutch Pancreatic Cancer Audit. The association between patient-, tumor-, center-, treatment characteristics, and the risk of not receiving adjuvant chemotherapy was analyzed with multivariable logistic regression.

RESULTS

Overall, of 1306 patients, 24% (n = 312) developed postoperative Clavien Dindo ≥3 complications. In-hospital mortality was 3.5% (n = 46). Some 433 patients (33%) did not receive adjuvant chemotherapy. Independent predictors (all p < 0.050) for not receiving adjuvant chemotherapy were older age (odds ratio (OR) 0.96), higher ECOG performance status (OR 0.57), postoperative complications (OR 0.32), especially grade B/C pancreatic fistula (OR 0.51) and post-pancreatectomy hemorrhage (OR 0.36), poor tumor differentiation grade (OR 0.62), and annual center volume of <40 pancreatoduodenectomies (OR 0.51).

CONCLUSIONS

This study demonstrated that a third of patients do not receive chemotherapy after resection of PDAC. Next to higher age, worse performance status and lower annual surgical volume, this is mostly related to surgical complications, especially postoperative pancreatic fistula and post-pancreatectomy hemorrhage.

The Impact of Sarcopenia on Postoperative Course following Pancreatoduodenectomy: Single-Center Experience of 110 Consecutive Cases

BACKGROUND

Despite that mortality following pancreatoduodenectomy (PD) has gradually dropped during the past few decades, the incidence of postoperative complications remains high, ranging from 30-60%. Many studies have been focused on identification of perioperative risk factors for morbidity, and in recent years, sarcopenia has been pointed out as a valid predictor of postoperative complication.

MATERIALS AND METHODS

Perioperative data from 110 consecutive patients who underwent PD were retrieved, and the presence of sarcopenia was assessed by the measurement of Hounsfield unit average calculation on preoperative CT scans. Postoperative complications were graded according to Clavien-Dindo classification, and the morbidity burden was assessed by comprehensive complication index (CCI) calculation.

RESULTS

Sarcopenia was associated with advanced age (72 vs. 66 years; p = 0.014) and lower preoperative albumin levels (3.5 vs. 3.7 g/dL; p = 0.010); it represented an independent risk factor for clinically relevant complications (relative risk: 1.71; p = 0.015) and was related to a higher rate of Grade C postoperative pancreatic fistula (50.0 vs. 11.4%; p = 0.005) and a higher CCI (47.6 vs. 29.6; p = 0.001).

CONCLUSIONS

Sarcopenia represents a valid indicator of increased morbidity risk and may play a central role in preoperative risk stratification, allowing the selection of patients who may benefit from prehabilitation programs.

[Morphometry of adipose tissue for prediction of the outcomes of total pancreatectomy with pancreatic islets autotransplantation in patients with chronic pancreatitis]

OBJECTIVE

To compare different clinical and morphometric features of patients undergoing TPAIT for prediction of postoperative outcomes.

MATERIAL AND METHODS

A retrospective review enrolled patients who underwent TPAIT for the period from January 2007 to October 2017. Morphometric parameters were analyzed using preoperative CT scans and patients were grouped to examine association of these characteristics with postoperative morbidity. Sarcopenia was defined as the presence of a TPA in the lowest sex-specific quartile. The impact of sarcopenia on pancreatic islet features, perioperative blood transfusion, ICU- and hospital-stay, complications, repeated admission within 90 days and islet function was assessed.

RESULTS

A total of 34 patients were included in this study (12 males and 24 females). At the time of diagnosis, mean age of patients was 43.1 years. Mean body mass index (BMI) in sarcopenic patients was 24.9 kg/m2, mean BMI in those without sarcopenia - 24.8 kg/m2 (p=1.00). Various surgical complications were observed in 11 patients (32.3%). Patients with sarcopenia experienced more complications (83.3%) compared with patients without sarcopenia (50%). However, differences were not significant (p=0.31). Islet characteristics (islet numbers, purity), readmission, ICU- and hospital-stay, incidence of blood transfusion and islet function were also similar in both groups.

CONCLUSION

Sarcopenia is not a predictor of postoperative complications and islet cell function in chronic pancreatitis patients following TPAIT.

Long-term outcomes of endoscopic resection for non-ampullary duodenal epithelial tumors: A single-center experience

BACKGROUND/AIMS

The malignant potential of non-ampullary duodenal epithelial tumors (NADETs) is lower compared to that of other gastrointestinal epithelial tumors, but it should not be overlooked. Recently, endoscopic resection (ER) has been proposed as an alternative treatment option for NADETs. Therefore, we aimed to analyze the clinical outcomes of ER of NADETs and determine the factors associated with an incomplete resection.

MATERIALS AND METHODS

We conducted a retrospective observational study of 54 patients (56 lesions) with NADETs, who underwent ER in the period between October 2006 and March 2016, and analyzed the therapeutic outcomes and procedure-related adverse events.

RESULTS

Endoscopic mucosal resection (EMR) was performed on 41 lesions, and endoscopic submucosal dissection (ESD) was performed on 15 lesions. The en bloc and complete resection rates were 82% (46/56) and 54% (30/56), respectively. Multivariate logistic regression analyses determined that the resection method (EMR: odds ratio 4.356, 95% confidence interval 1.021-18.585, p=0.047) was independently associated with incomplete resection. The procedure-related bleeding and perforation rates were 4% and 5%, respectively. Recurrence of tumor occurred in one of 44 patients during the median follow-up period of 25 months (range: 6-89 months).

CONCLUSION

ER is an effective, safe, and feasible treatment option for NADETs. However, the incomplete resection rate increases when EMR is performed. Nevertheless, given the longer procedure time and the technical difficulty associated with ESD, and the excellent long-term outcomes associated with EMR, EMR of NADETs is appropriate, especially in patients with dysplastic lesions.

Embedment of the gastroduodenal artery stump into the jejunal serosa: A new technique aiming to prevent post-pancreatectomy hemorrhage

Post-pancreaticoduodenectomy hemorrhage has an estimated incidence of 5% and a mortality rate of 11-38%. Vascular erosion resulting from pancreatic leak and skeletonization of the arterial wall during pancreatic mobilization may be the two possible mechanisms responsible for this complication, which most commonly affects the gastroduodenal artery stump. A novel technique of wrapping up the gastroduodenal artery stump into the jejunal serosa to decrease postoperative hemorrhage is presented.

Influence of bile contamination for patients who undergo pancreaticoduodenectomy after biliary drainage

BACKGROUND

The influence of bile contamination on the infectious complications of patients undergoing pancreaticoduodenectomy (PD) has not been thoroughly evaluated.

AIM

To evaluate the effect of preoperative biliary drainage and bile contamination on the outcomes of patients who undergo PD.

METHODS

The database of 4101 patients who underwent PD was reviewed. Preoperative biliary drainage was performed in 1964 patients (47.9%), and bile contamination was confirmed in 606 patients (14.8%).

RESULTS

The incidence of postoperative infectious complications was 37.9% in patients with preoperative biliary drainage and 42.4% in patients with biliary contamination, respectively. Patients with extrahepatic bile duct carcinoma, ampulla of Vater carcinoma, and pancreatic carcinoma had a high frequency of preoperative biliary drainage (82.9%, 54.6%, and 50.8%) and bile contamination (34.3%, 26.2%, and 20.2%). Bile contamination was associated with postoperative pancreatic fistula (POPF) Grade B/C, wound infection, and catheter infection. A multivariate logistic regression analysis revealed that biliary contamination (odds ratio 1.33, P = 0.027) was the independent risk factor for POPF Grade B/C. The three most commonly cultured microorganisms from bile (Enterococcus, Klebsiella, and Enterobacter) were identical to those isolated from organ spaces.

CONCLUSION

In patients undergoing PD, bile contamination is related to postoperative infectious complication including POPF Grade B/C. The management of biliary contamination should be standardised for patients who require preoperative biliary drainage for PD, as the main microorganisms are identical in both organ spaces and bile.

Nationwide trends in incidence, treatment and survival of pancreatic ductal adenocarcinoma

BACKGROUND

In recent years, new treatment options have become available for pancreatic ductal adenocarcinoma (PDAC) including 5-fluorouracil, leucovorin, irinotecan and oxaliplatin. The impact hereof has not been assessed in nationwide cohort studies. This population-based study aimed to investigate nationwide trends in incidence, treatment and survival of PDAC.

MATERIALS AND METHODS

Patients with PDAC (1997-2016) were included from the Netherlands Cancer Registry. Results were categorised by treatment and by period of diagnosis (1997-2000, 2001-2004, 2005-2008, 2009-2012 and 2013-2016). Kaplan-Meier survival analysis was used to calculate overall survival.

RESULTS

In a national cohort of 36,453 patients with PDAC, the incidence increased from 12.1 (1997-2000) to 15.3 (2013-2016) per 100,000 (p < 0.001), whereas median overall survival increased from 3.1 to 3.8 months (p < 0.001). Over time, the resection rate doubled (8.3%-16.6%, p-trend<0.001), more patients received adjuvant chemotherapy (3.0%-56.2%, p-trend<0.001) and 3-year overall survival following resection increased (16.9%-25.4%, p < 0.001). Over time, the proportion of patients with metastatic disease who received palliative chemotherapy increased from 5.3% to 16.1% (p-trend<0.001), whereas 1-year survival improved from 13.3% to 21.2% (p < 0.001). The proportion of patients who only received supportive care decreased from 84% to 61% (p-trend<0.001).

CONCLUSION

The incidence of PDAC increased in the past two decades. Resection rates and use of adjuvant or palliative chemotherapy increased with improved survival in these patients. In all patients with PDAC, however, the survival benefit of 3 weeks is negligible because the majority of patients only received supportive care.

Pancreaticoduodenectomy following surgery for esophageal cancer with gastric tube reconstruction: a case report and literature review

Background

Synchronous and asynchronous multiple cancers have become more pervasive in recent years despite advances in medical technologies. However, there have been only six cases (including the present case) that underwent pancreaticoduodenectomy (PD) for pancreas head cancer following surgery for esophageal cancer. PD for treating pancreas head cancer is extremely challenging; thus, the confirmation of vessel variation and selection of surgical procedures are vital.

Case presentation

The patient was a 78-year-old Japanese male who was synchronously diagnosed with esophageal and cecal cancer 7 years previously at our hospital. He was admitted with densely stained and jaundiced urine and presented no remarkable family medical history. Following various examinations, surgery was performed due to the diagnosis of distal cholangiocarcinoma (pancreatic head cancer). Since the tumor was located far from the gastroduodenal artery (GDA) and no significant lymph node metastases could be found, subtotal stomach-preserving PD was performed instead of the resection of GDA with the right gastroepiploic artery (RGEA) for gastric tube blood flow preservation. The common hepatic artery (CHA) and GDA were confirmed, and RGEA diverged from GDA was identified. Subsequently, their respective tapings were preserved. The right gastric artery (RGA) was identified, taped, and preserved considering the gastric tube blood flow. The inflow area of the right gastroepiploic vein (RGEV) through gastric colic vein trunk in the superior mesenteric vein was exposed and preserved as the outflow of gastric tube blood flow. PD was completed without any complications on the shade of the gastric tube.

Conclusions

This case report describes successfully preserved gastric blood flow without the resection of GDA, RGEA, RGEV, or RGA. To preserve the gastric tube, GDA inflow, RGEA, RGA, and RGEV outflow should be preserved if possible. When performing PD after tube reconstruction, it is essential to confirm the relative positions of the blood vessel, blood flow, and tumor through three-dimensional computed tomography angiography before surgery and to consider the balance between the invasiveness and optimal curability of the surgery.

Age comorbidity scores as risk factors for 90-day mortality in patients with a pancreatic head adenocarcinoma receiving a pancreaticoduodenectomy: A National Population-Based Study

Background

To estimate easily assessed preoperative factors for predicting 90‐day mortality in patients with a pancreatic head adenocarcinoma (PHA) receiving a pancreaticoduodenectomy.

Methods

We analyzed data from the Taiwan Cancer Registry Database of patients with a PHA who received a pancreaticoduodenectomy. Basic demographic characteristics, including gender and age, were categorized. The selection of preoperative comorbidities was based on the preoperative American Society of Anesthesiologists score and Charlson comorbidity index.

Results

We enrolled 8490 patients with a PHA who received a pancreaticoduodenectomy without distant metastasis. Currently, a pancreaticoduodenectomy for a PHA achieves an overall 90‐day mortality rate of 8.39%. Univariate and multivariate Cox regression analyses indicated that an older age (65‐74 and ≥75 years) and specific comorbidities (chronic obstructive pulmonary disease, chronic kidney disease, dementia, and sepsis) were significant independent prognostic factors for predicting 90‐day mortality after a pancreaticoduodenectomy. After adjustment, the adjusted hazard ratios (aHRs) (95% confidence intervals [CIs]) of subjects with middle and high comorbidity scores for 90‐day mortality in 65 to 74‐year‐old patients were 1.36 (1.05‐1.75) and 2.25 (1.03‐4.90), respectively, compared to subjects with low comorbidity scores. The aHRs (95% CIs) of subjects with middle and high comorbidity scores for 90‐day mortality in ≥75‐year‐old patients were 1.35 (1.07‐1.78) and 2.07 (1.19‐3.62), respectively, compared to those with low comorbidity scores.

Conclusions

Elderly patients with a PHA and moderate or high comorbidity scores have an increased risk of 90‐day mortality after a pancreaticoduodenectomy.

Clinical outcomes of endoscopic resection for non-ampullary duodenal laterally spreading tumors

BACKGROUND AND AIMS

Non-ampullary duodenal laterally spreading tumors (NAD-LSTs) mimic the morphological features and natural history of colorectal LSTs, even achieving a large size but lacking invasive behavior; thus, they are suited for endoscopic resection (ER). At present, the endoscopic therapeutic approach in NAD-LSTs has not been clearly established. The aim of this study was to evaluate the efficacy and safety of ER for NAD-LSTs and to evaluate the risk factors for delayed perforation after ER of NAD-LSTs.

PATIENTS AND METHODS

A total of 54 patients with 54 NAD-LSTs treated with ER at the Chinese PLA General Hospital between January 2007 and January 2018 were retrospectively analyzed. Data on patient demographic, clinicopathological characteristics of the lesions, outcomes of ER, and results of follow-up endoscopies were collected.

RESULTS

The mean (SD) lesion size was 26.9 mm (8.5). Endoscopic mucosal resection (EMR) was performed in 21 lesions, and endoscopic submucosal dissection (ESD) was performed in 33 lesions. R0 resection was achieved in 93.9% of the ESD group and 38.1% of the EMR group (p = 0.000). Delayed bleeding was noted in two patients. Delayed perforation was identified in four patients. The incidence of delayed perforation showed a significant association with post-ampullary tumor location (p = 0.030). Follow-up endoscopy was performed in all cases with a mean (SD) period of 22.1 months (8.2), and local recurrence was identified in four cases after piecemeal EMR.

CONCLUSIONS

ER of NAD-LSTs is a feasible and less invasive treatment. However, ER of NAD-LSTs is associated with serious adverse events such as delayed perforation, especially in patients with lesions located distal to Vater's ampulla.