Twelve Hundred Consecutive Pancreato-Duodenectomies from Single Centre: Impact of Centre of Excellence on Pancreatic Cancer Surgery Across India

Surgical Outcomes and Survival in Pancreatic and Periampullary Cancers: A Single Centre Experience

Pancreatic cancer is an aggressive malignancy with many cases diagnosed at locally advanced stages making pancreaticoduodenectomy a technically challenging surgery with significant mortality and morbidity. This study analyses the surgical outcomes and survival after surgery for pancreatic cancers from a single centre in south India. This is a retrospective analysis of pancreatic and periampullary cancer patients who were treated in our institute between January 2014 and November 2022 (n = 71). The median age at diagnosis was 55 years. In about 2/3rd of cases, tumour was located in periampullary region and 62 out of 71 patients underwent curative resection. The most common histopathological diagnosis was adenocarcinoma (87%). Nodal metastasis were detected in 13% of specimens. The predominant morbidity was delayed gastric emptying (DGE 12.7%) and clinically relevant postoperative pancreatic fistula (CR-POPF 11%) with a combined overall morbidity of 35.2% and 30-day mortality of 7.3%. Pre-op nutritional status had a strong association with postoperative morbidity. The median time of survival was 20 months, with a median follow-up of 22 months. Age less than 60 years (P value = 0.0264) and receiving all 6 or more cycles of chemo were significantly associated with improved survival (P value = 0.0297). Lower-stage cancers (T1, T2, and N0) were associated with better survival. The patient characteristics, histological factors, and perioperative outcomes were similar to the reports from other Indian studies. The 3-year survival rate was 30%. There was an increasing trend of survival in patients with age less than 60 years and in patients who received 6 or more cycles of chemotherapy.

Complexity and Experience Grading to Guide Patient Selection for Minimally Invasive Pancreatoduodenectomy: An International Study Group for Pancreatic Surgery (ISGPS) Consensus

OBJECTIVE

To develop a universally accepted complexity and experience grading system to guide the safe implementation of robotic and laparoscopic minimally invasive pancreatoduodenectomy (MIPD).

BACKGROUND

Despite the perceived advantages of MIPD, its global adoption has been slow due to the inherent complexity of the procedure and challenges to acquiring surgical experience. Its wider adoption must be undertaken with an emphasis on appropriate patient selection according to adequate surgeon and center experience.

METHODS

The International Study Group for Pancreatic Surgery (ISGPS) developed a complexity and experience grading system to guide patient selection for MIPD based on an evidence-based review and a series of discussions.

RESULTS

The ISGPS complexity and experience grading system for MIPD is subclassified into patient-related risk factors and provider experience-related variables. The patient-related risk factors include anatomic (main pancreatic and common bile duct diameters), tumor-specific (vascular contact), and conditional (obesity and previous complicated upper abdominal surgery/disease) factors, all incorporated in an A-B-C classification, graded as no, a single, and multiple risk factors. The surgeon and center experience-related variables include surgeon total MIPD experience (cutoffs 40 and 80) and center annual MIPD volume (cutoffs 10 and 30), all also incorporated in an A-B-C classification.

CONCLUSIONS

This ISGPS complexity and experience grading system for robotic and laparoscopic MIPD may enable surgeons to optimally select patients after duly considering specific risk factors known to influence the complexity of the procedure. This grading system will likely allow for a thoughtful and stepwise implementation of MIPD and facilitate a fair comparison of outcomes between centers and countries.

Long-term outcomes after resection of extra-ampullary duodenal adenocarcinomas: single-center experience

BACKGROUND

Extra-ampullary duodenal adenocarcinoma is a rare neoplasm. The data on long-term outcomes after curative resection are limited, and the role of systemic chemotherapy is not defined in these tumors. This study aimed to investigate the prognostic factors and survival of patients with resected primary duodenal cancers.

METHODS

A retrospective analysis of patients with resected primary duodenal adenocarcinoma was conducted between January 2010 and December 2023.

RESULTS

A total of 59 patients were included in the study. The median age of patients was 60 years (IQR, 33-79), and 79.7% of patients were males. The second part of the duodenum was the most common location of the tumor in 42 patients (71.2%). Pancreaticoduodenectomy was performed in 57 patients (96.6%), and segmental duodenal resection was performed on 2 patients (3.4%). The median lymph node harvest was 18 (IQR, 2-70). Adjuvant chemotherapy was administered to 39 patients (66.1%). At a median follow-up of 32.00 months (IQR, 3.29-166.74), the 5-year overall survival (OS) and disease-free survival rates were 55.0% and 49.3%, respectively. Regarding prognostic factors, lymph node ratio (LNR; hazard ratio [HR], 2.94; 95% CI, 1.01-8.53), adenocarcinoma subtype (intestinal vs nonintestinal; HR, 4.59; 95% CI, 1.59-13.23), and margin of resection (HR, 44.24; 95% CI, 4.02-486.19) were significant factors for OS.

CONCLUSION

Margin-free surgical resection offers the best chance of cure for operable duodenal adenocarcinoma. The intestinal subtype and low LNR are predictors of better survival, and the role of adjuvant chemotherapy remains debatable until prospective randomized trials are conducted.

Prognostic Impact of Para-Aortic Lymph Node Metastasis in Resected Non-Pancreatic Periampullary Cancers

BACKGROUND

Surgery remains debatable in para-aortic lymph node (PALN, station 16b1) metastasis in non-pancreatic periampullary cancer (NPPAC). This study examined the impact of PALN metastasis on outcomes following pancreaticoduodenectomy (PD) in NPPAC.

METHODS

A retrospective analysis of patients with NPPAC who were explored for PD with PALN dissection was performed. Based on the extent of nodal involvement on final histopathology, they were stratified as node-negative (N0), regional node involved (N+) and metastatic PALN (N16+) and their outcomes were compared.

RESULTS

Between 2011 and 2022, 153/887 PD patients underwent a PALN dissection, revealing N16+ in 42 patients (27.4%), of whom 32 patients underwent resection. The 3-years overall survival (OS) for patients with N16+ was 28% (95% confidence interval [CI] 13-60%), notably lower than the 67% (95% CI 53-83.5%; p = 0.007) for those without PALN metastasis. Stratified by nodal involvement, the median OS for N+ and N16+ patients was similar (28.4 months and 26.2 months, respectively). The N0 subgroup had a significantly longer 3-years OS of 87.5% (95% CI 79-96.7%; p = 0.0051). Interestingly, 10 patients not offered resection following N16+ identified on frozen section had a median survival of only 9 months. The perioperative morbidity and mortality in patients undergoing PD with PALN dissection were similar to standard resections.

CONCLUSION

In a select group of patients with NPPAC, PD in isolated PALN metastasis was associated with improved OS. The survival in this group of patients was comparable with regional node-positive patients and significantly better than palliative treatment alone.

Efficacy of the omental roll-up technique in pancreaticojejunostomy to prevent postoperative pancreatic fistula after pancreaticoduodenectomy

Backgrounds/Aims

Pancreaticoduodenectomy (PD) is being performed more frequently. A pancreaticojejunostomy (PJ) leak is the major determinant of patient outcomes. An omental flap around PJ might improve postoperative outcomes.

Methods

A prospective randomized controlled trial was planned at PGIMER, Chandigarh. Fifty-eight patients meeting the criteria were included in the study. Group A underwent PD with omental roll-up and group B underwent standard PD.

Results

The mean age of patients in group A was 57.1 ± 14.3 years and 51.2 ± 10.7 in group B. Jaundice (p = 0.667), abdominal pain (p = 0.69), and co-morbidities were equal among the groups. The body mass index of patients in group B was higher at 24.3 ± 5.4 kg/m2 (p = 0.03). The common bile duct diameter (12.6 ± 5.3 mm vs. 17.2 ± 10.3 mm, p = 0.13) and the pancreatic duct diameter (4.06 ± 2.01 mm vs. 4.60 ± 2.43 mm, p = 0.91) were comparable. The intraoperative blood loss (mL) was significantly higher in group B (233.33 ± 9.57 vs. 343.33 ± 177.14, p = 0.04). Drain fluid amylase levels on postoperative day (POD) 1 (p = 0.97) and POD3 (p = 0.92) were comparable. The rate of postoperative pancreatic fistula (POPF) grade A (p ≥ 0.99) and grade B (p = 0.54) were comparable. The mean postoperative length of stay among was similar (p = 0.89).

Conclusions

An omental wrap can be performed without increase in complexity of the procedure. However, its utility in preventing POPFs and morbidity remains unclear.

Evolution and improved outcomes in the era of multimodality treatment for extended pancreatectomy

BACKGROUND

The evolution and outcomes of extended pancreatectomies at a single institute over 15 years are presented in this study.

METHODS

A retrospective analysis of the institutional database was performed from 2015 to 2022 (period B). Patients undergoing extended pancreatic resections, as defined by the International Study Group for Pancreatic Surgery, were included. Perioperative and survival outcomes were compared with data from 2007-2015 (period A). Regression analyses were used to identify factors affecting postoperative and long-term survival outcomes.

RESULTS

A total of 197 (16.1%) patients underwent an extended resection in period B compared to 63 (9.2%) in period A. Higher proportions of borderline resectable (5 (18.5%) versus 51 (47.7%), P = 0.011) and locally advanced tumours (1 (3.7%) versus 24 (22.4%), P < 0.001) were resected in period B with more frequent use of neoadjuvant therapy (6 (22.2%) versus 79 (73.8%), P < 0.001). Perioperative mortality (4 (6.0%) versus 12 (6.1%), P = 0.81) and morbidity (23 (36.5%) versus 83 (42.1%), P = 0.57) rates were comparable. The overall survival for patients with pancreatic adenocarcinoma was similar in both periods (17.5 (95% c.i. 6.77 to 28.22) versus 18.3 (95% c.i. 7.91 to 28.68) months, P = 0.958). Resectable, node-positive tumours had a longer disease-free survival (DFS) in period B (5.81 (95% c.i. 1.73 to 9.89) versus 14.03 (95% c.i. 5.7 to 22.35) months, P = 0.018).

CONCLUSION

Increasingly complex pancreatic resections were performed with consistent perioperative outcomes and improved DFS compared to the earlier period. A graduated approach to escalating surgical complexity, multimodality treatment, and judicious patient selection enables the resection of advanced pancreatic tumours.

Centralization of Pancreaticoduodenectomy: A Systematic Review and Spline Regression Analysis to Recommend Minimum Volume for a Specialist Pancreas Service

OBJECTIVE

Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center.

BACKGROUND

The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable.

MATERIALS AND METHODS

Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a "zero-crossing" technique was used, which produced "first and second derivatives" to identify volume thresholds.

RESULTS

Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df 5.154 ( P <0.001) and 8.254 ( P <0.001), respectively. The threshold value for mortality was ~45 PDs/year (model 9.219 ( P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost ( edf =2, P =0.989) and length of stay ( edf =2.04, P =0.099).

CONCLUSIONS

There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year.

Global Perceptions on ERAS® in Pancreatoduodenectomy

BACKGROUND

Uptake of ERAS® pathways for pancreatic surgery have been slow and impacted by low compliance.

OBJECTIVE

To explore global awareness, perceptions and practice of ERAS® peri-pancreatoduodenectomy (PD).

METHODS

A structured, web-based survey (EPSILON) was administered through the ERAS® society and IHPBA membership.

RESULTS

The 140 respondents included predominantly males (86.4%), from Europe (45%), practicing surgery (95%) at academic/teaching hospitals (63.6%) over a period of 10-20 years (38.6%). Most respondents identified themselves as general surgeons (68.6%) with 40.7% reporting an annual PD volume of 20-50 cases, practicing post-PD clinical pathways (37.9%), with 31.4% of respondents auditing their outcomes annually. Reduced medical complications, cost and hospital length of stay, and improved patient satisfaction were perceived benefits of compliance to enhancing-recovery. Multidisciplinary co-ordination was considered the most important factor in the implementation and sustainability of peri-PD ERAS® pathways, while reluctance to change among health care practitioners, difficulties in data collection and audit, lack of administrative support, and recruitment of an ERAS® dedicated nurse were reported to be important barriers.

CONCLUSIONS

The EPSILON survey highlighted global clinician perceptions regarding the benefits of compliance to peri-PD ERAS®, the importance of individual components, perceived facilitators and barriers, to the implementation and sustainability of these pathways.

Role of inflammatory and nutritional markers in predicting complications after pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy is associated with considerable morbidity and mortality rates. Early recognition of patients likely to develop severe postoperative complications will allow the timely commencement of a tailored approach. This study aimed to predict postoperative complications using inflammatory and nutritional markers measured early in the postoperative period.

METHODS

Patients who underwent pancreaticoduodenectomy between June 2019 and November 2020 were included in the study. Postoperative pancreatic fistula, delayed gastric emptying, and postoperative pancreatic hemorrhage were graded according to the International Study Group of Pancreatic Fistula and the International Study Group of Pancreatic Surgery. We also documented other complications such as wound infection, intra-abdominal collection, and nonsurgical complications. Nutritional and inflammatory markers were analyzed on postoperative days 1 and 3. Patients were followed up for 30 days or until discharge, depending on which was longer.

RESULTS

Of the 58 enrolled patients, 51 were included in the study. The incidence of postoperative pancreatic fistula was 51% (clinically relevant postoperative pancreatic fistula 27.4%), delayed gastric emptying was 80.4% (clinically relevant delayed gastric emptying 43%), postoperative pancreatic hemorrhage was 3.9%, intra-abdominal collection was 23.5%, and wound infection was 29.4%. The median drain fluid interlukin-6 levels on postoperative day 1 and postoperative day 3 were significantly higher in patients developing clinically relevant postoperative pancreatic fistula than in those who did not develop clinically relevant postoperative pancreatic fistula on postoperative day 1 (211 [125, 425] fg/dL vs 99 [15, 170] fg/dL, [P = .045]) and on postoperative day 3 (110 [22, 28] fg/dL vs 10 [1.8, 45] fg/dL [P = .002]). Patients who tested negative for urine trypsinogen-2 on postoperative day 3 had a significantly lower probability of developing clinically relevant postoperative pancreatic fistula than those who tested positive (1 vs 24 [P < .001]). A model comprising both drain fluid interlukin-6 and urine trypsinogen-2 on postoperative day 3 definitively ruled out the occurrence of clinically relevant postoperative pancreatic fistula.

CONCLUSION

Drain fluid interlukin-6 and urine trypsinogen-2 on postoperative day 3 ruled out the occurrence of clinically relevant postoperative pancreatic fistula.

Does Preoperative Serum Neutrophil to Lymphocyte Ratio (NLR), Platelet to Lymphocyte Ratio (PLR), and Lymphocyte to Monocyte Ratio (LMR) Predict Prognosis Following Radical Surgery for Pancreatic Adenocarcinomas? Results of a Retrospective Study

BACKGROUND

Pretherapy serum neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and lymphocyte to monocyte ratio (LMR) have been shown to predict prognosis in patients with pancreatic ductal adenocarcinoma (PDAC). However, the published literature is conflicting; hence, we aimed to evaluate their role in predicting survival outcomes in operated patients of PDAC.

METHODS

A retrospective analysis was performed in all operated cases of PDAC who underwent curative resection between 2011 and 2018. The pretherapy NLR, PLR, and LMR were calculated and analyzed with respect to pathological and survival outcomes RESULTS: One hundred thirty-four operated patients were included. The median overall survival for NLR of less than 2, 2.7, and 5 was 30.8, 27.2, and 27.5 months and for NLR of more than 2, 2.7, and 5 was 22.9, 21.6, and 21.5 months, respectively, and was statistically insignificant (p-value-0.32, 0.91, 0.34, respectively). Similarly, the PLR was not significant for a cutoff of 150 (p-value-0.27), and LMR was not significant for a cutoff of 2.8 (p-value-0.13) and 4.8 (p-value-0.11). On univariate analysis age, CA 19-9 levels, perineural invasion, margin positivity, lymph node positivity, and TNM stage were found to have a significant correlation with overall survival. However, on multivariate analysis, only TNM stage was found to be significant.

CONCLUSION

The NLR, PLR, and LMR do not correlate with overall survival in operated patients with PDAC in this study. A combination of inflammatory markers or their dynamic testing might probably achieve prognostic significance.

Patient volume and clinical outcome after pancreatic cancer resection: A contemporary systematic review and meta-analysis

BACKGROUND

Pancreatic cancer remains a highly fatal disease with a 5-year overall survival of less than 10%. In seeking to improve clinical outcomes, there is ongoing debate about the weight that should be given to patient volume in centralization models. The aim of this systematic review is to examine the relationship between patient volume and clinical outcome after pancreatic resection for cancer in the contemporary literature.

METHODS

The Google Scholar, PubMed, and Cochrane Library databases were systematically searched from February 2015 until June 2021 for articles reporting patient volume and outcomes after pancreatic cancer resection.

RESULTS

There were 46 eligible studies over a 6-year period comprising 526,344 patients. The median defined annual patient volume thresholds varied: low-volume 0 (range 0-9), medium-volume 9 (range 3-29), high-volume 19 (range 9-97), and very-high-volume 28 (range 17-60) patients. The latter 2 were associated with a significantly lower 30-day mortality (P < .001), 90-day mortality (P < .001), overall postoperative morbidity (P = .005), failure to rescue rate (P = .006), and R0 resection rate (P = .008) compared with very-low/low-volume hospitals. Centralization was associated with lower 30-day mortality in 3 out of 5 studies, while postoperative morbidity was similar in 4 out of 4 studies. Median survival was longer in patients traveling greater distance for pancreatic resection in 2 out of 3 studies. Median and 5-year survival did not differ between urban and rural settings.

CONCLUSION

The contemporary literature confirms a strong relationship between patient volume and clinical outcome for pancreatic cancer resection despite expected bias toward more complex surgery in high-volume centers. These outcomes include lower mortality, morbidity, failure-to-rescue, and positive resection margin rates.

Neoadjuvant therapy in borderline resectable pancreatic cancer: Outcomes in the era of changing practices and evolving evidence

BACKGROUND

Neoadjuvant therapy (NAT) is increasingly being used in the management of borderline resectable pancreatic cancer (BRPC). We compared the outcomes of patients with BRPC treated either with upfront surgery (UPS) or NAT to assess whether increased use of NAT has helped improve perioperative and long-term outcomes.

METHODS

Prospectively maintained database of 201 consecutive patients with BRPC treated at Tata Memorial Center, India, from 2007-2019 was analyzed.

RESULTS

NAT was offered to 148 patients and 53 were planned for UPS. Progression on NAT was seen in 47 (31.8%) patients. Resection was performed in 103 patients (51.24%). The resection rate was significantly lower after NAT as compared with upfront explorations (42.56% vs 75.47%, P = .00) however, R0 resection rate after NAT was significantly better (74.6% vs 42.5%, P = .001). NAT group showed a significant decrease in the pT stage (P = .004), node positivity (60%-31.7%, P = .005%), and perineural invasion (70%-41.6% P = .026). There was no significant difference in the median overall survival (OS) of patients offered NAT versus UPS on an intention-to-treat basis (15 vs 18 months P = .431). However, OS (22 vs 19 months, P = .205) and disease-free survival (DFS) (16 vs 11 months, P = .135) were higher for resected patients in the NAT group and OS was significantly superior in patients completing the course of treatment (34 vs 22 months, P = .010) CONCLUSION: The progression rate with NAT in patients with BPRC was 31.8%. NAT was associated with significant pathologic downstaging, improvement in R0 resection rate, and survival in resected patients.

Organ preserving pancreatic resections offer better long-term conservation of pancreatic function at the expense of high perioperative major morbidity: a fair trade-off for benign or low malignant potential pancreatic neoplasms-a single-center experience

BACKGROUND

Standard pancreatic resections (SPRs) might have long-term deleterious effects on pancreatic function, without added oncological advantage in low malignant potential (LMP) or benign neoplasms. This study aimed to evaluate outcomes following organ-preserving pancreatic resections (OPPARs) and SPRs.

METHOD

Post hoc analysis of patients undergoing OPPAR or SPR for benign or LMP pancreatic tumors from January 2011 to January 2020 at Tata Memorial Hospital, Mumbai.

RESULTS

Thirty-six and 114 patients were identified in OPPAR and SPR groups respectively. The overall morbidity (58.3% vs 43.9%, p-0.129) was comparable. Major morbidity (41.7% vs 21.9%, p-0.020), post-operative pancreatic fistula (POPF) (63.9% vs 35.1%, p-0.002), and clinically relevant POPF (41.7% vs 20.2%, p-0.010) were significantly higher with OPPAR. Post-operative endocrine insufficiency (14.9% vs 11.1%, p-0.567), exocrine insufficiency (19.3% vs 0%, p-0.004), and requirement of long-term pancreatic enzyme replacement (17.5% vs 0%, p-0.007) were higher in SPRs. Comparing left-sided and right-sided resections in the entire cohort, incidence of endocrine insufficiency was 17.1% vs 11.2% (p-0.299) and that of exocrine insufficiency was 8.6% vs 20% (p-0.048) respectively.

CONCLUSION

OPPAR is associated with high post-operative major morbidity and pancreatic fistula rate but offers long-term benefit due to better preservation of pancreatic function than SPR. The incidence of exocrine insufficiency is higher in right sided as compared to left-sided pancreatic resections.

Surgical Feasibility, Determinants, and Overall Efficacy of Neoadjuvant 177Lu-DOTATATE PRRT for Locally Advanced Unresectable Gastroenteropancreatic Neuroendocrine Tumors

We assessed 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) in the neoadjuvant setting in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs). We also evaluated the variables associated with resectability of the primary tumor after PRRT. Methods: This study included 57 GEP-NET patients who had a primary tumor that was unresectable (because of vascular involvement as defined using the pancreatic ductal adenocarcinoma criteria of the National Comprehensive Cancer Network) and who underwent 177Lu-DOTATATE therapy without any prior surgery. They were categorized into 2 groups: 23 patients without liver metastases (group 1) and 34 patients with potentially resectable liver metastases (group 2). 177Lu-DOTATATE was administered with mixed amino acid-based renal protection at a dose of 7.4 GBq (200 mCi) per cycle. Surgical resectability was evaluated using triphasic contrast-enhanced abdominal CT imaging at 3 different time points during the PRRT course. Four broad categories of overall PRRT response were evaluated. The Kaplan-Meier product-limit method was used to calculate progression-free survival (PFS) and overall survival (OS). Associations between variables and a resectable primary tumor after PRRT were analyzed using the χ2 test, with a P value of less than 0.05 considered statistically significant. Results: After 177Lu-DOTATATE therapy, the unresectable primary tumor became resectable in 15 of 57 (26.3%) patients (7 patients in group 1 and 8 patients in group 2). A complete or partial response to PRRT was seen in 48 patients (84%), 23 patients (40%), 18 patients (31%), and 23 patients (40%) using symptomatic, biochemical, molecular imaging, and anatomic imaging criteria, respectively. Estimated rates of PFS were 95% and 90% at 2 y in groups 1 and 2, respectively. The 2-y OS of the 2 groups combined was 92.1%. The rate at which the primary tumor was resectable after PRRT was significantly higher in patients who had duodenal neuroendocrine tumors, patients who had GEP-NETs with no regional lymph node involvement, patients for whom the primary tumor was smaller than 5 cm, patients for whom liver metastases were no larger than 1.5 cm, patients for whom there were no more than 3 liver metastases, and patients for whom 18F-FDG uptake in the primary tumor had an SUVmax of less than 5. Conclusion: In a moderate fraction of GEP-NET patients, with or without liver metastases, whose primary tumor was unresectable because of vascular involvement, the primary tumor converted from unresectable to resectable after 177Lu-DOTATATE therapy, signifying that neoadjuvant PRRT can be considered in such patients. The effective control of symptoms, favorable morphologic and functional imaging response, and durable PFS and OS that we observed after 177Lu-DOTATATE PRRT may lead to less morbidity and mortality in these patients.

Factors influencing local and distant recurrence following resection of periampullary cancer

BACKGROUND

Recurrence of periampullary cancer after pancreatoduodenectomy is common. The aim of this study was to investigate patterns of recurrence, incidence, and factors associated with local and distant recurrences.

METHODS

This retrospective, single-centre study included consecutive patients with periampullary cancer who underwent resection with curative intent from January 2012 to January 2018. Survival, patterns of recurrence, and factors associated with recurrences were analysed.

RESULTS

Median overall survival (OS) and disease-free survival among 398 included patients was 58.4 and 49.5 months respectively. Twenty-three patients (5.8 per cent) developed isolated local recurrences (LR), 50 (12.6 per cent) developed LR along with distant metastasis (DM), and 103 (25.9 per cent) developed isolated DM. Median OS was 40.4 months for patients with isolated LR versus 23 months for those with DM (P < 0.001). Tumour subtype (distal common bile duct (CBD): odds ratio (OR) 6.18, 95 per cent c.i. 2.19 to 17.46) and node-positive status (OR 2.36, 1.26 to 4.43) were independently associated with higher rates of LR. The most common site for isolated LR was along the superior mesenteric artery (12 of 23 patients). Tumour subtype (distal CBD: OR 2.86, 1.09 to 7.52), nodal positivity (OR 2.46, 1.53 to 3.94), and presence of perineural invasion (OR 1.80, 1.02 to 3.18) were independently associated with DM.

CONCLUSION

Isolated LR is associated with better survival than DM and occurs most commonly along the superior mesenteric artery.

Endovascular Hepatic Artery Stents in the Modern Management of Postpancreatectomy Hemorrhage

Background

Postoperative hemorrhage is a potentially lethal complication of pancreatoduodenectomy. This study reports on the use of endovascular hepatic artery stents in the management of postpancreatectomy hemorrhage.

Methods

This is a retrospective analysis of a prospectively maintained, consecutive dataset of 440 patients undergoing pancreatoduodenectomy over 68 months. Data are presented on bleeding events and outcomes, and contextualized by the clinical course of the denominator population. International Study Group of Pancreatic Surgery terminology was used to define postpancreatectomy hemorrhage.

Results

Sixty-seven (15%) had postoperative hemorrhage. Fifty (75%) were male and this gender difference was significant (P = 0.001; 2 proportions test). Postoperative pancreatic fistulas were more frequent in the postoperative hemorrhage group (P = 0.029; 2 proportions test). The median (interquartile range [IQR]) delay between surgery and postoperative hemorrhage was 5 days (2-14 days). Twenty-six (39%) required intervention comprising reoperation alone in 12, embolization alone in 5, and endovascular hepatic artery stent deployment in 5. Four further patients underwent more than 1 intervention with 2 of these having stents. Endovascular stent placement achieved initial hemostasis in 5 of 7 (72%). Follow-up was for a median (IQR) of 199 days (145-400 days) poststent placement. In 2 patients, the stent remained patent at last follow-up. The remaining 5 stents occluded with a median (IQR) period of proven patency of 10 days (8-22 days).

Conclusions

This study shows that in the specific setting of postpancreatoduodenectomy hemorrhage with either a short remnant gastroduodenal artery bleed or a direct bleed from the hepatic artery, where embolization risks occlusion with compromise of liver arterial inflow, endovascular hepatic artery stent is an important hemostatic option but is associated with a high risk of subsequent graft occlusion.

Centralisation of Pancreatoduodenectomy in India: Where Do We Stand?

BACKGROUND

The volume-outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact.

METHOD

A systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded.

RESULTS

A total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10-25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing <10, 10-25 and ≥26 cases/year, respectively. Operative mortality also improved with increasing number of cases/year (5.1% vs. 6.6% vs. 3.2%, respectively).

CONCLUSION

With increasing volume of cases per year, trend towards improved PD outcomes is observed. To optimise the use of healthcare facilities, it would be pragmatic to consider building an organised referral system for complex surgeries to deliver unsurpassed patient care with maximum utilisation of the available healthcare infrastructure.

Combined Bile Duct and Pancreatic Duct Injuries during Distal Gastrectomy for Obstructing Peptic Ulcer Disease

A combination of bile and pancreatic duct injuries is very rare. Anomalous ductal anatomy, distorting duodenal fibrosis, and pancreatic atrophy predispose to this untoward complication during performance of distal gastrectomy for benign peptic stricture. The technical challenges posed by this complication and experience gained by managing it are shared.

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.

Emergency Radical Gastrectomy with Pancreatico-duodenectomy for a Recent Onset Perforation of Locally Advanced Gastric Cancer with Pancreatic Head Involvement-Exceptional but a Definite Option

Gastric cancer perforations are rare events with management options ranging from lavage and perforation closure, to resection. Usual aim is to perform a damage control procedure, and very few patients are suitable for a curative resection. We report the first case of emergency gastrectomy with pancreatico-duodenectomy performed in emergency for a perforated stomach cancer with pancreatic head invasion. The patient was a 32-year-old gentleman who presented with a perforated antro-pyloric cancer with infiltration of pancreatic head. Emergency radical gastrectomy with en-bloc pancreatico-duodenectomy was performed with due considerations to the patient and disease factors. He had an uneventful postoperative recovery and remains disease free at 18 months of follow-up after having received adjuvant chemotherapy. Curative resections should be selectively offered in advanced (T4b) gastric cancers in patients without multiple adverse factors. In an emergency situation with perforation peritonitis, if the magnitude of resection is deemed unlikely to add to significant morbidity of the surgery, taking multiple factors into consideration, an R0 resection can offer a large survival benefit in such settings.

Vein resection without reconstruction (VROR) in pancreatoduodenectomy: expanding the surgical spectrum for locally advanced pancreatic tumours

PURPOSE

Pancreatic malignancy with mesenterico-portal venous involvement can be safely managed with en bloc vein resection with comparable survival outcomes. Non-constructible venous encasement is regarded as criteria of unresectability in pancreatic cancer. In long-standing extra-hepatic venous obstruction, hepatopetal blood flow is established by collateralization in the hepatoduodenal and mesenteric region. Their importance in pancreatic malignancies is being recently acknowledged.

METHODS

The records of patients undergoing pancreatoduodenectomies were retrospectively evaluated from 2012 to 2019. Pre and intraoperative records of patients undergoing concomitant vein resection were evaluated for the presence of venous collaterals, and its impact on oncological management was studied.

RESULTS

Over a period of 7 years, 947 pancreatoduodenectomies were performed, of which 56 patients underwent concomitant vein resection. Among these, six patients had significant collaterals due to venous obstruction. They had pancreatic adenocarcinoma (2), neuroendocrine tumour (2) and solid pseudopapillary epithelial neoplasm (2) respectively. All these patients successfully underwent pancreatoduodenectomy with vein resection without vascular reconstruction. Superior mesenteric vein (SMV) was resected in four patients, whereas spleno-portal junction was resected in two patients. Dominant collaterals were preserved in all, without compromising oncological safety. Bowel congestion was checked by tolerability to 20-minute mesenteric venous clamping test. There was no major morbidity or hospital mortality following this surgical approach.

CONCLUSION

We recommend vein resection without reconstruction (VROR) as a novel approach in locally advanced pancreatic tumours (due to non-constructible vein involvement) with significant venous collaterals and emphasize the need to assess venous collateralization pre and intraoperatively.