REDISCOVER International Guidelines on the Perioperative Care of Surgical Patients With Borderline-resectable and Locally Advanced Pancreatic Cancer

OBJECTIVE

The REDISCOVER consensus conference aimed at developing and validate guidelines on the perioperative care of patients with borderline resectable (BR-) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC).

SUMMARY BACKGROUND DATA

Coupled with improvements in chemotherapy and radiation, the contemporary approach to pancreatic surgery supports resection of BR-PDAC and, to a lesser extent, LA-PDAC. Guidelines outlining the selection and perioperative care for these patients are lacking.

METHODS

The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used to develop the REDISCOVER guidelines and create recommendations. The Delphi approach was used to reach consensus (agreement ≥80%) among experts. Recommendations were approved after a debate and vote among international experts in pancreatic surgery and pancreatic cancer management. A Validation Committee used the AGREE II-GRS tool to assess the methodological quality of the guidelines. Moreover, an independent multidisciplinary advisory group revised the statements to ensure adherence to non-surgical guidelines.

RESULTS

Overall, 34 recommendations were created targeting centralization, training, staging, patient selection for surgery, possibility of surgery in uncommon scenarios, timing of surgery, avoidance of vascular reconstruction, details of vascular resection/reconstruction, arterial divestment, frozen section histology of perivascular tissue, extent of lymphadenectomy, anticoagulation prophylaxis and role of minimally invasive surgery. The level of evidence was however low for 29 of 34 clinical questions. Participants agreed that the most conducive mean to promptly advance our understanding in this field is to establish an international registry addressing this patient population ( https://rediscover.unipi.it/ ).

CONCLUSIONS

The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with BR- and LA-PDAC, and serve as the basis of a new international registry for this patient population.

Postoperative Hyperamylasemia (POH) is an Early Predictor of Pancreatic Fistula Occurrence and Severity after Distal Pancreatectomy: Results from a European Multicentric Study

OBJECTIVES

The aim of this international multicentric study is to characterize postoperative hyperamylasemia (POH) after distal pancreatectomy (DP), with particular focus on its relationship with postoperative pancreatic fistula (POPF) occurrence and severity.

BACKGROUND

The clinical relevance of POH after DP and its relationship with the occurrence and severity of POPF have not been explored yet.

METHODS

All patients undergoing DP for any indication between 2015 and 2021 at three European referral Centers for pancreatic surgery were retrospectively analyzed. Drain fluid amylase (DFA), C-reactive protein (C-RP), and serum amylase were examined from postoperative-day (POD) 1 to 3. Biochemical leak (BL), POPF, POH, and post-pancreatectomy hemorrhage (PPH) were defined and graded according to ISGPS definitions.

RESULTS

In total 1192 patients were included. Overall rates of POH and POPF were 18% (n= 210) and 29% (n= 344), respectively. The presence of DFA ≥2000 U/L on POD 1 (OR=2.11, 95% CI 1.68-2.86), C-RP ≥200 mg/L on POD 3 (OR=2.19, 95% CI 1.68-2.86), and POH (OR=1.58, 95% CI 1.14-2.19) were all independent early predictors of POPF (all P< 0.01). The presence of POH almost doubled the rate of POPF (43% vs. 26%, P<0.001), and higher POPF severity presented also higher POH rates (no POPF= 12%; BL= 19%; B POPF= 24%; C POPF= 52%). Among patients developing POPF, patients with POH had higher rates of PPH (22% vs 9%, P= 0.001), sepsis (24% vs 13%; P=0.011), re-operation (21% vs 8%; P< 0.01), and mortality (3% vs 0.3%; P= 0.025).

CONCLUSIONS

The occurrence of POH is an early predictor of POPF and its severity after DP. The diagnosis of POH might define patients at higher risk for a complicated course, targeting them for prevention / mitigation strategies against pancreas specific complications.

Preoperative predictive factors of laparoscopic distal pancreatectomy difficulty

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is a challenging operation due to technical complexity and tumor-related factors. Aim of this study was to identify preoperative risk factors affecting LDP difficulty.

METHODS

Consecutive patients who underwent LDP between 2015 and 2018 at San Raffaele Hospital and Policlinico S.Orsola-Malpighi Hospital were enrolled retrospectively. Three variables were used to define surgical difficulty: conversion to open, duration of surgery >3rd quartile and intraoperative blood loss >3rd quartile. The presence of ≥1 of these 3 variables was considered as another measure of difficulty.

RESULTS

Overall, 191 patients were included. Conversion to open was required in 25 patients (13%). At multiple regression analysis, tumor proximity to major vessels was the only independent predictor of conversion from laparoscopic to open (p < 0.001). No variables independently predicted an excessive duration of surgery. Male gender (p = 0.033) and increasing parenchymal thickness at resection line (p = 0.018) were independent predictors of excessive blood loss. Increasing parenchymal thickness at resection line (p = 0.014) and tumor proximity to major vessels (p = 0.002) were significant risk factors for the presence of ≥1 outcome of surgical difficulty.

CONCLUSION

Male gender, increasing parenchymal thickness at resection line and tumor proximity to major vessels represent preoperative risk factors of LDP difficulty.

[Apnea during sleep and wakefulness in term newborns]

Apneas in the different sleep states are commonly observed in the full-term healthy newborn infant. Central and short apneas prevail whilst apneas greater than 15 sec. are rare; a marked incidence of short apneas (less than 10 sec.) was observed in active sleep, even though apneas are not exclusive of active sleep. There is a strong inter-individual variability of apnea incidence. Apnea incidence in a state is not positively correlated to apnea incidence in different behavioural states: on the contrary there seems to be an opposite correlation between incidence in AS and QS. Apnea occurrence is positively correlated, in individuals, to the periodic breathing percentage. Apneas number and their duration is markedly lowered already in the second month of life. Periodic breathing must be considered a feature of immaturity. Obstructive apneas are less frequent than central apneas: their survey requires sophisticated technics with the aid of simultaneous recording of several breathing parameters. Relationship between central apneas/ obstructive apneas and mixed apneas is not known. Certainly obstructive and mixed apneas occurrence has been underestimated because of technical difficulties deriving from their survey. The meaning of an incidence of short apneas markedly higher than normal in full-term newborn infants is controversial and not clear, individuals with long apneas and subjects with short apneas in excess have been considered infants at SIDS risk. It is not clear whether periodic breathing and apneas depend on a common pathogenesis; the correlation between high incidence of periodic breathing in postnatal period and SIDS risk is still controversial. Few Authors suggest to treat newborn infants with extended apneas in sleep and considerable percentage of periodic breathing with aminophylline. The relation between gastro-oesophageal reflux and apnea has been recently evidenced. Central apneas and obstructive apneas during breast and bottle feeding have also been documented. Differently from pre-term infant apneas, bradycardia, although not exceptional, is not frequent during apneas in full-term newborn infants.