Effect of passive versus active abdominal drainage on wound infection after pancreatectomy: A meta-analysis

Following pancreatic resection, there may be a variety of complications, including wound infection, haemorrhage, and abdominal infection. The placement of drainage channels during operation may decrease the chances of postoperative complications. However, what kind of drainage can decrease the rate of postoperative complications is still a matter of debate. The purpose of this research is to evaluate the efficacy of both active and passive drainage for post-operation wound complications. From the beginning of the database until November 2023, EMBASE, the Cochrane Library and the Pubmed database have been searched. The two authors collected 2524 related studies from 3 data bases for importation into Endnote software, and 8 finished trials were screened against the exclusion criteria. Passive drainage can decrease the incidence of superficial wound infection in postoperative patients with pancreas operation (Odds Ratio [OR], 1.30; 95% CI, 1.06-1.60 p = 0.01); No statistically significant difference was found in the incidence of deep infections among the two groups (OR, 1.51; 95% CI, 0.68-3.36 p = 0.31); No statistical significance was found for the rate of haemorrhage after active drainage on the pancreas compared with that of passive drainage (OR, 0.72; 95% CI, 0.29-1.77 p = 0.47); No statistically significant difference was found in the rate of death after operation for patients who had received a pancreas operation in active or passive drainage (OR, 0.90; 95% CI, 0.57-1.42 p = 0.65); On the basis of existing evidence, the use of passive abdominal drainage reduces postoperative surface wound infections in patients. But there were no statistically significant differences in the risk of severe complications, haemorrhage after surgery, or mortality. However, because of the limited sample size of this meta-analysis, it is necessary to have more high-quality research with a large sample size to confirm the findings.

Blood loss during HPB procedures

INTRODUCTION

During the last decades, simultaneously with the development of surgical technique, modern equipment and perioperative management, there has been a significant improvement in postoperative outcome. Despite this, infectious complications and perioperative bleeding remain the leading causes of postoperative morbidity and mortality in HPB surgery.

METHODS

We conducted a retrospective study over a three-year period in 256 patients who underwent surgery of the pancreas, liver, gallbladder, or bile ducts. We monitored perioperative blood loss, the number of administered transfusions, the type and severity of postoperative complications, the number of reoperations and the number of readmissions.

RESULTS

The average blood loss was 457 ml. We administered transfusions to 39 patients (17%). We confirmed the hypothesis that the presence of blood loss statistically significantly increases the development of deep intra-abdominal infections (p=0.0188). Morbidity increases with increasing blood loss (p=0.0168). We confirmed a statistically significant difference in the blood loss between the groups with and without complications (p=0.001). Postoperative 30-day mortality was less than 1% (n=2). There were 15 (6%) reoperated patients, seven for acute bleeding and eight for infectious complications. The length of hospital stay was statistically significantly longer in patients who received transfusions - erythrocytes (p=0.023), and plasma (p=0.011). We readmitted 12 patients, three patients died during rehospitalization (the 90-day mortality rate was 2%, n=5). A total of 59% patients in our group were classified as ASA III.

CONCLUSION

With increasing blood loss, morbidity (development of intra-abdominal infections) increases significantly, but despite this, overall post- operative mortality remains low. Early postoperative bleeding is the cause of more than half of reoperations. The length of hospitalization increases significantly with the number of transfusions administered.

Preoperative nutritional support in patients undergoing pancreatic surgery affects PREPARE score accuracy

Background

This study aimed to validate the accuracy of the Preoperative Pancreatic Resection (PREPARE) risk score in pancreatic resection patients.

Patients and methods

This prospective study included 216 patients who underwent pancreatic resection between January 2015 and December 2018. All patients in our cohort with weight loss or lack of appetite received dietary advice and preoperative oral nutritional supplementation (600 kcal/day). Demographic, clinicopathological, operative, and postoperative data were collected prospectively. The PREPARE score and the predicted risk of major complications were computed for each patient. Differences in major postoperative complications were analyzed using a multivariate Cox proportional hazards regression model. The predicted and observed risks of major complications were tested using the C-statistic.

Results

The study included 216 patients [117 men (54.2%)] with a median age of 65.0 (30.0-83.0) years. The majority of patients were classified as American Society of Anesthesiologists (ASA)' Physical Status score II (N = 164/216; 75.9%) and as "low risk" PREPARE score (N = 185/216; 85.6%) before the surgery. Only 4 (1.9%) patients were malnourished, with albumin levels of less than 3.5 g/dl. The most common type of pancreatic resection was a pylorus-preserving pancreaticoduodenectomy (N = 122/216; 56.5%). Major morbidity and 30-day mortality rates were 11.1% and 1.9%, respectively. The type of surgical procedure (hazard ratio [HR]: 3.849; 95% confidence interval [CI]: 1.208-12.264) and ASA score (HR: 3.089; 95% CI: 1.067-8.947) were significantly associated with the incidence of major postoperative complications in multivariate analysis. The receiver operating characteristic curve was 0.657 for incremental values and 0.559 for risk categories, indicating a weak predictive model.

Conclusion

The results of the present study suggest that the PREPARE risk score has low accuracy in predicting the risk of major complications in patients with consistent preoperative nutritional support. This limits the use of PREPARE risk score in future preoperative clinical routines.

Cachexia index as a prognostic predictor after resection of pancreatic ductal adenocarcinoma

Aim

This study was performed to investigate the relationship between the preoperative cachexia index (CXI) and long-term outcomes in patients who have undergone radical resection of pancreatic ductal adenocarcinoma (PDAC).

Methods

In total, 144 patients who underwent pancreatic resection for treatment of PDAC were retrospectively analyzed. The relationship between the CXI and the patients' long-term outcomes after PDAC resection was investigated. The CXI was calculated based on the preoperative skeletal muscle index, serum albumin level, and neutrophil-to-lymphocyte ratio. After propensity-score matching, we compared clinicopathological features and outcomes.

Results

The multivariate analysis showed that lymph node metastasis (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.16-3.23; P = 0.0118), R1 resection (HR, 57.20; 95% CI, 9.39-348.30; P < 0.0001), and a low CXI (HR, 2.10; 95% CI, 1.27-3.46; P = 0.0038) were independent and significant predictors of disease-free survival (DFS) after PDAC resection. Moreover, a low CXI (HR, 3.14; 95% CI, 1.71-5.75; P = 0.0002) was an independent and significant predictor of overall survival (OS) after PDAC resection. After propensity-score matching, the low CXI group had a significantly worse prognosis than the high CXI group for both DFS and OS.

Conclusion

The CXI can be a useful prognostic factor for DFS and OS after pancreatic resection for treatment of PDAC.

Supervised Home-Based Exercise Prehabilitation in Unfit Patients Scheduled for Pancreatic Surgery: Protocol for a Multicenter Feasibility Study

BACKGROUND

Morbidity rates in pancreatic surgery are high, and frail patients with low aerobic capacity are especially at risk of complications and require prophylactic interventions. Previous studies of small patient cohorts receiving intra-abdominal surgery have shown that an exercise prehabilitation program increases aerobic capacity, leading to better treatment outcomes.

OBJECTIVE

In this study, we aim to assess the feasibility of a home-based exercise prehabilitation program in unfit patients scheduled for pancreatic surgery on a larger scale.

METHODS

In this multicenter study, adult patients scheduled for elective pancreatic surgery with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min or a VO2 at peak exercise ≤18 mL/kg/min will be recruited. A total of 30 patients will be included in the 4-week, home-based, partly supervised exercise prehabilitation program. The program comprises 25-minute high-intensity interval training on an advanced cycle ergometer 3 times a week. Training intensity will be based on steep ramp test performance (ie, a short-term maximal exercise test on a cycle ergometer), aiming to improve aerobic capacity. Twice a week, patients will perform functional task exercises to improve muscle function and functional mobility. A steep ramp test will be repeated weekly, and training intensity will be adjusted accordingly. Next to assessing the feasibility (participation rate, reasons for nonparticipation, adherence, dropout rate, reasons for dropout, adverse events, and patient and therapist appreciation) of this program, individual patients' responses to prehabilitation on aerobic capacity, functional mobility, body composition, quality of life, and immune system factors will be evaluated.

RESULTS

Recruitment for this study began in January 2022 and is expected to be completed in the summer of 2023.

CONCLUSIONS

Results of this study will provide important clinical and scientific knowledge on the feasibility of a partly supervised home-based exercise prehabilitation program in a vulnerable patient population. This might ease the path to implementing prehabilitation programs in unfit patients undergoing complex abdominal surgery, such as pancreatic surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05496777; https://classic.clinicaltrials.gov/ct2/show/NCT05496777.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46526.

Enhancing surgical planning of distal splenopancreatectomy through 3D printed models: a case report

The complex anatomy of the peripancreatic region was a challenge to many surgeons in the past. Up until recently, the only way to prepare and plan a surgery was through the use of traditional 2D images, obtained via computed tomography or magnetic resonance imaging. Recently, the advantages in the field of 3D printing (also called additive manufacturing, or rapid prototyping) allowed the creation of replicas of the patient's anatomy which is to be used for preoperative planning and visual reference. We present the case of a 46-y.o. patient with a distal pancreatic lesion requiring a distal splenopancreatectomy, who benefited from the use of 3D printing technology. No intraoperative or postoperative complications were encountered, while the created model was used to plan and perform the needed resection.

Impact of Aspirin Intake on Postoperative Survival after Primary Pancreatic Resection of Pancreatic Ductal Adenocarcinoma-A Single-Center Evaluation

(1) Background: The intake of aspirin (ASS) has been demonstrated to have a relevant impact on the pathogenesis, incidence and outcome in different solid gastrointestinal tumors. However, data on the effect of ASS on the short-term outcome and the long-term survival in patients with pancreatic carcinoma are still limited. (2) Methods: A total of 213 patients who underwent primary resection of PDAC at the University Hospital of Erlangen from January 2000 to December 2018 were included in this retrospective single-center study in total. Patients were stratified according to the aspirin intake into three groups: continuous aspirin intake (cASS), perioperatively interrupted aspirin intake (iASS) and no aspirin intake (no ASS) at the timepoint of surgery. The postoperative outcome as well as long-term survival were compared between the groups. (3) Results: There were no differences regarding postoperative morbidity (iASS: 54% vs. cASS: 53% vs. no ASS: 64%, p = 0.448) and in-hospital mortality (iASS: 4% vs. cASS: 10% vs. no ASS: 3%, p = 0.198) between the groups. The overall survival (OS) and disease-free survival (DFS) did not differ in the groups when comparing the ASS-intake status (OS: iASS 17.8 months vs. cASS 19.6 months vs. no ASS 21.6 months, p = 0.489; DFS: iASS 14.0 months vs. cASS 18.3 months vs. no ASS 14.7 months, p = 0.957). Multivariate analysis revealed that age (hazard ratio (HR) 2.2, p < 0.001), lymph node-positive status (HR 2.0, p < 0.001), R status 1 or 2 (HR 2.8, p < 0.001) and differentiation with a grading of 3 (HR 1.7, p = 0.005) were significant independent prognostic factors regarding the OS. Moreover, age (HR 1.5, p = 0.040), lymph node-positive status (HR 1.8, p = 0.002) and high-grade (G3) carcinomas (HR 1.5, p = 0.037) could be identified as independent prognostic parameters for DFS. (4) Conclusions: In patients undergoing primary surgery for curative resection of pancreatic carcinoma, the perioperative intake of ASS had no significant impact on postoperative outcome, overall and disease-free survival.

Distal Bile Duct Cancer: Radical (R0 > 1 mm) Resection Achieves Favorable Survival

OBJECTIVE

Evaluation of the outcome after resection for distal bile duct cancer (DBC) with focus on the impact of microscopic histopathological resection status R0 (>1 mm) versus R1 (≤1 mm) vs R1 (direct).

SUMMARY BACKGROUND DATA

DBC is a rare disease for which oncologic resection offers the only chance of cure.

METHODS

Prospectively collected data of consecutive patients undergoing pancreaticoduodenectomy for DBC were analyzed. Histopathological resection status was classified according to the Leeds protocol for pancreatic ductal adeno carcinoma (PDAC) (PDAC; R0 >1 mm margin clearance vs R1 ≤1 mm vs R1 direct margin involvement).

RESULTS

A total of 196 patients underwent pancreaticoduodenectomy for DBC. Microscopic complete tumor clearance (R0>1 mm) was achieved in 113 patients (58%). Median overall survival (OS) of the entire cohort was 37 months (5- and 10-year OS rate: 40% and 31%, respectively). After R0 resection, median OS increased to 78 months with a 5-year OS rate of 52%. Negative prognostic factors were age >70 years ( P < 0.0001, hazard ratio (HR) 2.48), intraoperative blood loss >1000 mL ( P = 0.0009, HR 1.99), pN1 and pN2 status ( P = 0.0052 and P = 0.0006, HR 2.14 and 2.62, respectively) and American Society of Anesthesiologists score >II ( P = 0.0259, HR 1.61).

CONCLUSIONS

This is the largest European single-center study of surgical treatment for DBC and the first to investigate the prognostic impact of the revised PDAC resection status definition in DBC. The results show that this definition is valid in DBC and that "true" R0 resection (>1 mm) is a key factor for excellent survival. In contrast to PDAC, there was no survival difference between R1 (≤1 mm) and R1 (direct).

Hepatopancreaticobiliary Surgical Outcomes at a Community Hospital

There is a national trend towards regionalizing complex hepatopancreaticobiliary (HPB) surgeries to high-volume institutions. Due to geographic and socioeconomic constraints, however, many patients in the United States continue to undergo HPB surgery at local community hospitals. This study evaluated complex HPB surgeries performed by a single surgeon at a low-volume community hospital from May 2007 to June 2021. A retrospective review of medical records (n=163) was done to collect data on patient demographics and outcomes. Surgical outcomes of HPB procedures were compared to published data from high-volume centers. Overall mortality within 30 days of the procedure was 1% (n=1). Using Clavien-Dindo classification, the major complication rate was 10%, including 8% grade III and 2% grade IV complications. Reoperation (2%) and readmission (3%) were rare in this population. Median length of stay was 7 days and median estimated blood loss was 500 milliliters. Surgical outcomes from the community hospital were comparable to high-volume centers. For pancreatic cancer patients treated at the community hospital, Kaplan-Meier curves revealed comparable 5-year survival time to national data. Complex HPB procedures can be safely performed at a low-volume hospital in Hawai'i with outcomes comparable to large tertiary centers.

CXCR4-CXCL12-CXCR7 and PD-1/PD-L1 in Pancreatic Cancer: CXCL12 Predicts Survival of Radically Resected Patients

Pancreatic ductal adenocarcinoma (PDAC) is currently the most deadly cancer. Although characterized by 5-20% of neoplastic cells in the highly fibrotic stroma, immunotherapy is not a valid option in PDAC treatment. As CXCR4-CXCL12 regulates tumor invasion and T-cell access and PD-1/PD-L1 controls immune tolerance, 76 PDACs were evaluated for CXCR4-CXCL12-CXCR7 and PD-1/PD-L1 in the epithelial and stromal component. Neoplastic CXCR4 and CXCL12 discriminated PDACs for recurrence-free survival (RFS), while CXCL12 and CXCR7 discriminated patients for cancer-specific survival (CSS). Interestingly, among patients with radical resection (R0), high tumor CXCR4 clustered patients with worse RFS, high CXCL12 identified poor prognostic patients for both RFS and CSS, while stromal lymphocytic-monocytic PD-L1 associated with improved RFS and CSS. PD-1 was only sporadically expressed (<1%) in focal lymphocyte infiltrate and does not impact prognosis. In multivariate analysis, tumoral CXCL12, perineural invasion, and AJCC lymph node status were independent prognostic factors for RFS; tumoral CXCL12, AJCC Stage, and vascular invasion were independent prognostic factors for CSS. CXCL12's poor prognostic meaning was confirmed in an additional perspective-independent 13 fine-needle aspiration cytology advanced stage-PDACs. Thus, CXCR4-CXCL12 evaluation in PDAC identifies prognostic categories and could orient therapeutic approaches.

Impact of Patient Age on Postoperative Short-Term and Long-Term Outcome after Pancreatic Resection of Pancreatic Ductal Adenocarcinoma

(1) Purpose: to evaluate the impact of age on postoperative short-term and long-term outcomes in patients undergoing curative pancreatic resection for PDAC. (2) Methods: This retrospective single-center study comprised 213 patients who had undergone primary resection of PDAC from January 2000 to December 2018 at the University Hospital of Erlangen, Germany. Patients were stratified according the age into two groups: younger (≤70 years) and older (>70 years) patients. Postoperative outcome and long-term survival were compared between the groups. (3) Results: There were no significant differences regarding inhospital morbidity (58% vs. 67%, p = 0.255) or inhospital mortality (2% vs. 7%, p = 0.073) between the two groups. The median overall survival (OS) and disease-free survival (DFS) were significantly shorter in elderly patients (OS: 29.2 vs. 17.1 months, p < 0.001, respectively; DFS: 14.9 vs. 10.4 months, p = 0.034). Multivariate analysis revealed that age was a significant independent prognostic predictor for OS and DFS (HR 2.23, 95% CI 1.58−3.15; p < 0.001 for OS and HR 1.62, 95% CI 1.17−2.24; p = 0.004 for DFS). (4) Conclusion: patient age significantly influenced overall and disease-free survival in patients with PDAC undergoing primary resection in curative intent.

Simultaneous Resection of Pancreatic Neuroendocrine Tumors with Synchronous Liver Metastases: Safety and Oncological Efficacy

Simple Summary

Up to half of all newly diagnosed pancreatic neuroendocrine tumors (PNET) present with liver metastases (LM). The surgical resection of PNETs and LMs can provide complete tumor clearance and improve long-term survival. However, the combination of liver and pancreatic resection simultaneously can theoretically cumulate the morbidity and mortality of two separate operations. In the current study, we analyzed the outcomes of the synchronous surgical resection of PNETs and LMs in 51 patients. There were no differences in the postoperative outcomes in terms of mortality and morbidity according to the type of pancreatic resection. The tumor grade was identified as the sole prognostic factor for survival. The resection of well-differentiated PNETs with LMs was characterized by the longest survival rates (median overall survival 128 months, 5-year overall survival 83%). The optimal sequential surgical strategies for PNETs with LM and the use of neoadjuvant/adjuvant chemotherapy in this category of patients remain to be further investigated.

Abstract

Whether the simultaneous resection of pancreatic neuroendocrine tumors (PNET) with synchronous liver metastases (LM) is safe and oncologically efficacious remains to be debated. We retrospectively reviewed clinical data from patients who underwent the simultaneous resection of PNETs with LMs over the last 25 years. Fifty-one consecutive patients with a median age of 54 years (range 27–80 years) underwent pancreaticoduodenectomy (PD) (n = 16), distal pancreatosplenectomy (DSP) (n = 32) or total pancreatectomy (n = 3) with synchronous LM resection. There were no differences in the postoperative outcomes in term of mortality (p = 0.33) and morbidity (p = 0.76) between PD and DSP. The median overall survival (OS) was 64.78 months (95% CI: 49.7–119.8), and the overall survival rates at 1, 3, and 5 years were 97.9%, 86.2% and 61%, respectively. The OS varied according to the tumor grade (G): G1 (OS 128 months, 5-year OS 83%) vs. G2 (OS 60.5 months, 5-year OS 58%) vs. G3 (OS 49.7 months, 5-year OS 0%) (p = 0.03). Multivariate Cox analysis identified G as the only prognostic factor (HR: 5.56; 95% CI: 0.91–9.60; p = 0.01). Simultaneous PNETS with LMs can be performed safely with acceptable morbidity and mortality at tertiary centers. Well-differentiated PNETs had longer survival and might benefit the most from these extended surgeries.

Effect of malnutrition on the postoperative outcomes of patients undergoing pancreatectomy for pancreatic cancer: Propensity score-matched analysis of 2011-2017 US hospitals

BACKGROUND

Patients with pancreatic cancer suffer from metabolic dysregulation, which can manifest in clinical malnutrition. Because a portion of these patients require cancer-resective surgery, we evaluate the impact of malnutrition in patients undergoing pancreatic resection using a national database.

METHODS

The 2011-2017 National Inpatient Sample was used to isolate cases of pancreatic resection (partial/total pancreatectomy and radical pancreaticoduodenectomy), which were stratified using malnutrition. A 1:1 nearest-neighbor propensity-score matching was applied to match the controls to the malnutrition cohort. End points include mortality, length of stay (LOS), hospitalization costs, and postoperative complications.

RESULTS

Following the match, there were 2108 with malnutrition and an equal number without; from this, those with malnutrition had higher mortality (4.7% vs 3.04%; P = 0.007; odds ratio [OR], 1.57; 95% CI, 1.14-2.17), longer LOS, and higher costs. Regarding complications, malnourished patients had higher bleeding (5.41% vs 2.99%; P < 0.001; OR, 1.86; 95% CI, 1.36-2.54), wound complications (3.75% vs 1.57%; P < 0.001; OR, 2.45; 95% CI, 1.62-3.69), infection (7.83% vs 3.13%; P < 0.001; OR, 2.63; 95% CI, 1.96-3.52), and respiratory failure (7.45% vs 3.56%; P < 0.001; OR, 2.18; 95% CI, 1.65-2.89). In multivariate analyses, those with malnutrition had higher mortality (P = 0.008; adjust OR, 1.55; 95% CI, 1.12-2.14).

CONCLUSION

Those with malnutrition had higher mortality and complications following pancreatic resection; given these findings, it is important that preoperative nutrition therapy is provided to minimize the surgical risks.

Causes of Exocrine Pancreatic Insufficiency Other Than Chronic Pancreatitis

Exocrine pancreatic insufficiency (EPI), an important cause of maldigestion and malnutrition, results from primary pancreatic disease or is secondary to impaired exocrine pancreatic function. Although chronic pancreatitis is the most common cause of EPI, several additional causes exist. These include pancreatic tumors, pancreatic resection procedures, and cystic fibrosis. Other diseases and conditions, such as diabetes mellitus, celiac disease, inflammatory bowel disease, and advanced patient age, have also been shown to be associated with EPI, but the exact etiology of EPI has not been clearly elucidated in these cases. The causes of EPI can be divided into loss of pancreatic parenchyma, inhibition or inactivation of pancreatic secretion, and postcibal pancreatic asynchrony. Pancreatic enzyme replacement therapy (PERT) is indicated for the conditions described above presenting with clinically clear steatorrhea, weight loss, or symptoms related to maldigestion and malabsorption. This review summarizes the current literature concerning those etiologies of EPI less common than chronic pancreatitis, the pathophysiology of the mechanisms of EPI associated with each diagnosis, and treatment recommendations.

Prophylactic Intra-Peritoneal Drainage After Pancreatic Resection: An Updated Meta-Analysis

Introduction

Prophylactic intra-peritoneal drainage has been considered to be an effective measure to reduce postoperative complications after pancreatectomy. However, routinely placed drainage during abdominal surgery may be unnecessary or even harmful to some patients, due to the possibility of increasing complications. And there is still controversy about the prophylactic intra-peritoneal drainage after pancreatectomy. This meta-analysis aimed to analyze the incidence of complications after either pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) in the drain group and no-drain group.

Methods

Data were retrieved from four electronic databases PubMed, EMBASE, the Cochrane Library and Web of Science up to December 2020, including the outcomes of individual treatment after PD and DP, mortality, morbidity, clinically relevant postoperative pancreatic fistula (CR-POPF), bile leak, wound infection, postoperative hemorrhage, delayed gastric emptying (DGE), intra-abdominal abscess, reoperation, intervened radiology (IR), and readmission. Cochrane Collaboration Handbook and the criteria of the Newcastle-Ottawa scale were used to assess the quality of studies included.

Results

We included 15 studies after strict screening. 13 studies with 16,648 patients were analyzed to assess the effect of drain placement on patients with different surgery procedures, and 4 studies with 6,990 patients were analyzed to assess the effect of drain placement on patients with different fistula risk. For patients undergoing PD, the drain group had lower mortality but higher rate of CR-POPF than the no-drain group. For patients undergoing DP, the drain group had higher rates of CR-POPF, wound infection and readmission. There were no significant differences in bile leak, hemorrhage, DGE, intra-abdominal abscess, and IR in either overall or each subgroup. For Low-risk subgroup, the rates of hemorrhage, DGE and morbidity were higher after drainage. For High-risk subgroup, the rate of hemorrhage was higher while the rates of reoperation and morbidity were lower in the drain group.

Conclusions

Intraperitoneal drainage may benefit some patients undergoing PD, especially those with high pancreatic fistula risk. For DP, current evidences suggest that routine drainage might not benefit patients, but no clear conclusions can be drawn because of the study limitations.

Redefining the tail of pancreas based on the islets microarchitecture and inter-islet distance: An immunohistochemical study

ABSTRACT

Researchers divided the pancreas distal to the neck into 2 equal parts as the body and tail region by an arbitrary line. Surgeons considered the part of the pancreas, left to the aorta as the tail region. We performed this study to identify the transition zone of low-density to high-density islet cells for redefining the tail region.We quantified islets area proportion, beta-cell area proportion, and inter-islet distance in 9 Indian-adult-human non-diabetic pancreases from autopsy by using anti-synaptophysin and anti-insulin antibodies. Data were categorized under 3 regions like the proximal body, distal body, and distal part of the pancreas.Islet and beta-cell area proportion are progressively increased from head to tail region of the pancreas with a significant reduction in inter-islet distance and beta-cell percentage distal to the aorta. There is no significant difference in inter-islet distance and beta-cell percentage of the distal part of the body and tail region.Crowding of islets with intermingled microarchitecture begins in the pancreas distal to the aorta, which may be the beginning of the actual tail region. This study will provide insight into the preservation of islets-rich part of the pancreas during pancreatectomy and future prediction of new-onset diabetes.

Impact of Pancreatic Resection on Survival in Locally Advanced Resectable Gastric Cancer

Whether gastric adenocarcinoma (GC) patients with adjacent organ invasion (T4b) benefit from aggressive surgery involving pancreatic resection (PR) remains unclear. This study aimed to clarify the impact of PR on survival in patients with locally advanced resectable GC. Between 1995 and 2017, patients with locally advanced GC undergoing radical-intent gastrectomy with and without PR were enrolled and stratified into four groups: group 1 (G1), pT4b without pancreatic resection (PR); group 2 (G2), pT4b with PR; group 3 (G3), positive duodenal margins without Whipple's operation; and group 4 (G4), cT4b with Whipple's operation. Demographics, clinicopathological features, and outcomes were compared between G1 and G2 and G3 and G4. G2 patients were more likely to have perineural invasion than G1 patients (80.6% vs. 50%, p < 0.001). G4 patients had higher lymph node yield (40.8 vs. 31.3, p = 0.002), lower nodal status (p = 0.029), lower lymph node ratios (0.20 vs. 0.48, p < 0.0001) and higher complication rates (45.2% vs. 26.3%, p = 0.047) than G3 patients. The 5-year disease-free survival (DFS) and overall survival (OS) rates were significantly longer in G1 than in G2 (28.1% vs. 9.3%, p = 0.003; 32% vs. 13%, p = 0.004, respectively). The 5-year survival rates did not differ between G4 and G3 (DFS: 14% vs. 14.4%, p = 0.384; OS: 12.6% vs. 16.4%, p = 0.321, respectively). In conclusion, patients with T4b lesion who underwent PR had poorer survival than those who underwent resection of other adjacent organs. Further Whipple's operation did not improve survival in pT3-pT4 GC with positive duodenal margins.

Precision anatomy for safe approach to pancreatoduodenectomy for both open and minimally invasive procedure: A systematic review

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) has recently gained popularity. Several international meetings focusing on the existing literature on MIPD were held; however, the precise surgical anatomy of the pancreas for the safe use of MIPD has not yet been fully discussed. The aim of this study was to carry out a systematic review of available articles and to show the importance of identifying the anatomical variation in pancreatoduodenectomy.

METHODS

In this review, we described variations in surgical anatomy related to MIPD. A systematic search of PubMed (MEDLINE) was conducted, and the references were identified manually.

RESULTS

The search strategy yielded 272 articles, with 77 retained for analysis. The important anatomy to be considered during MIPD includes the aberrant right hepatic artery, first jejunal vein, first jejunal artery, and dorsal pancreatic artery. Celiac artery stenosis and a circumportal pancreas are also important to recognize.

CONCLUSIONS

We conclude that only certain anatomical variations are associated directly with perioperative outcomes and that identification of these particular variations is important for safe performance of MIPD.

Comparison of Oncological and Surgical Outcomes Between Formal Pancreatic Resections and Parenchyma-Sparing Resections for Small PanNETs (<2 cm): Pancreas2000 Research and Educational Program (Course 9) Study Protocol

Pancreatic neuroendocrine tumors (PanNETs) are rare tumors but incidence is increasing. An increasing number of these tumors are diagnosed incidentally when they are small (<2 cm) and when patients are asymptomatic. The European Neuroendocrine Tumor Society (ENETS) recommends conservative watch and wait policy for these patients. However, best surgical approach (parenchyma-sparing or formal oncological resection) for these small tumors when surgery is indicated is currently unknown. Parenchyma-sparing resections such as enucleation is associated with higher risk of post-operative morbidity compared to formal oncological resections. They are also be associated with potentially inadequate surgical margin clearance and with lack of lymphadenectomy for full pathological staging.

Method: This study is a retrospective study and the aim is to analyze pre-operative clinical predictors of nodal metastases for small PanNETs to identify which patients are at a lower risk of lymph node metastases and are therefore suitable for parenchyma-sparing resection.

Conclusion: The primary endpoint of this study is to determine if pre-operative clinical predictors such as tumor size are associated with lymph node involvement in small PanNETs.

Landscape of Health-Related Quality of Life in Patients With Early-Stage Pancreatic Cancer Receiving Adjuvant or Neoadjuvant Chemotherapy: A Systematic Literature Review

OBJECTIVES

Pancreatic resection is associated with postoperative morbidity and reduced quality of life (QoL). A systematic literature review was conducted to understand the patient-reported outcome measure (PROM) landscape in early-stage pancreatic cancer (PC).

METHODS

Databases/registries (through January 24, 2019) and conference abstracts (2014-2017) were searched. Study quality was assessed using the Newcastle-Ottawa Scale/Cochrane risk-of-bias tool. Searches were for general (resectable PC, adjuvant/neoadjuvant, QoL) and supplemental studies (resectable PC, European Organisation for Research and Treatment of Cancer QoL Questionnaire [QLQ] - Pancreatic Cancer [PAN26]).

RESULTS

Of 750 studies identified, 39 (general, 22; supplemental, 17) were eligible: 32 used QLQ Core 30 (C30) and/or QLQ-PAN26, and 15 used other PROMs. Baseline QLQ-C30 global health status/QoL scores in early-stage PC were similar to all-stage PC reference values but lower than all-stage-all-cancer values. The QoL declined after surgery, recovered to baseline in 3 to 6 months, and then generally stabilized. A minimally important difference (MID) of 10 was commonly used for QLQ-C30 but was not established for QLQ-PAN26.

CONCLUSIONS

In early-stage PC, QLQ-C30 and QLQ-PAN26 are the most commonly used PROMs. Baseline QLQ-C30 global health status/QoL scores suggested a high humanistic burden. Immediately after surgery, QoL declined but seemed stable over the longer term. The QLQ-C30 MID may elucidate the clinical impact of treatment on QoL; MID for QLQ-PAN26 needs to be established.

Pancreatic Enzyme Replacement Therapy in Pancreatic Cancer.Cancers (Basel). 2020;12. [PMID: 31979186 DOI: 10.3390/cancers12020275]

Pancreatic cancer is an aggressive malignancy and the seventh leading cause of global cancer deaths in industrialised countries. More than 80% of patients suffer from significant weight loss at diagnosis and over time tend to develop severe cachexia. A major cause of weight loss is malnutrition. Patients may experience pancreatic exocrine insufficiency (PEI) before diagnosis, during nonsurgical treatment, and/or following surgery. PEI is difficult to diagnose because testing is cumbersome. Consequently, PEI is often detected clinically, especially in non-specialised centres, and treated empirically. In this position paper, we review the current literature on nutritional support and pancreatic enzyme replacement therapy (PERT) in patients with operable and non-operable pancreatic cancer. To increase awareness on the importance of PERT in pancreatic patients, we provide recommendations based on literature evidence, and when data were lacking, based on our own clinical experience.

Antimicrobial Stewardship Reduces Surgical Site Infection Rate, as well as Number and Severity of Pancreatic Fistulae after Pancreatoduodenectomy

Background: Surgical site infections (SSIs) remain a major source of morbidity after pancreatoduodenectomy (PD). We noted a higher than anticipated incidence of SSI in our patients undergoing PD, and after an internal audit and detailed analysis of the microflora of SSIs, as well as a multidisciplinary discussion, the local prophylactic antibiotic policy was changed based on sensitivities to the bacteria isolated from post-operative infections. The hypothesis was that a targeted change in antibiotic prophylaxis would reduce the rate of SSIs. The aim of the current study was to analyze the results of a change in prescribing policy on SSI rates, and in addition, on the occurrence and severity of post-operative pancreatic fistulae (POPF) because this complication is often linked to the presence of an organ/space SSI. Methods: After implementing a change of prophylaxis policy from cefalexin to ceftriaxone and metronidazole, and educating staff and residents, a prospectively maintained departmental database was used to identify consecutive patients undergoing PD pre- and post-institution of policy change. Incidence data relating to SSIs and POPF were obtained from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data set and the details of culture results and organism sensitivity extracted from the electronic medical record, as were details on the severity of fistulae, and verified by the senior author. Results: The pre- and post-implementation cohorts consisted of 111 and 216 patients, respectively, and were matched in terms of all demographic features. After the change in the antibiotic prophylaxis policy, there was a reduction in the overall SSI rate (26.4% vs. 14.8%; p = 0.01) and the organ/space SSI rate (OS-SSI; 15.3% vs. 8.6%; p = 0.03). There were also reductions in the POPF rate (38.2% vs. 19%; p = 0.002) and in the clinically relevant POPF (CR-POPF; 23.4% vs. 6.0%; p = 0.001). The rate of Clostridium difficile infections also decreased (8.1% vs.1.9%; p = 0.006) as did the median length of hospital stay (7 vs. 6 days; p = 0.003). After excluding patients with a penicillin allergy (n = 24) from the post-implementation cohort, cases compliant (158/192) and non-compliant (34/192) to the new antibiotic policy were compared. The overall SSI (26.4% vs. 10.7%; p = 0.025), OS-SSI (17.6% vs. 5.1%; p = 0.021), overall POPF (32.4 vs. 14.6; p = 0.023); CR-POPF (10.8% vs. 5.5%; p = 0.047) and Clostridium difficile (8.8% vs. 1.3%; p = 0.040) were all lower in the compliant patient cohort. Conclusions: A change in antibiotic prophylaxis prior to PD based on the local microflora, resulted in reductions in SSI, POPF, and Clostridium difficile rates.

Preoperative C-reactive protein to albumin ratio is a predictor of survival after pancreatic resection for pancreatic ductal adenocarcinoma

AIM

Systemic inflammation and nutritional status are associated with clinical outcomes of cancer patients. We investigated the prognostic value of preoperative C-reactive protein to albumin ratio (CAR) in patients with pancreatic ductal adenocarcinoma (PDA) after pancreatic resection.

METHODS

One-hundred and thirty-six PDA patients who underwent pancreatic resection between January 2005 and June 2017 were retrospectively enrolled. Preoperative inflammation-based scores including CAR, modified Glasgow prognostic score (mGPS), neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, lymphocyte to monocyte ratio (LMR) and prognostic nutritional index (PNI) were evaluated as potential predictor of overall survival (OS) using Cox regression models. An optimal cutoff value for the continuous variable was estimated by receiver-operating characteristic (ROC) analysis.

RESULTS

Patients were categorized by CAR using a cutoff value of 0.09. High CAR was associated with advanced stage, increased mGPS and decreased LMR and PNI, but not with other factors such as tumor location, preoperative biliary drainage or preoperative chemotherapy. In univariate analysis, patients with high CAR had poor OS compared with those with low CAR (P = 0.01). Multivariate analysis indicated that high CAR was an independent predictor of poor OS (P = 0.03) in addition to advanced stage and residual tumors. The predictive ability of CAR evaluated by area under the ROC curve was consistently higher than that of other inflammation-based factors.

CONCLUSION

Preoperative CAR was an independent and superior predictor of survival after pancreatic resection in patients with PDA. [Correction added on 17 January 2019, after first online publication: In Conclusion, "in" has been corrected to "independent" for clarity.].

An updated systematic review and meta-analysis of the use of octreotide for the prevention of postoperative complications after pancreatic resection

BACKGROUND

The use of octreotide prophylaxis following pancreatic surgery is controversial. We aimed to evaluate the effectiveness of octreotide for the prevention of postoperative complications after pancreatic surgery through this systematic review and meta-analysis.

METHODS

Literature databases (including the MEDLINE, EMBASE, and Cochrane databases) were searched systematically for relevant articles. Only randomized controlled trials (RCTs) were eligible for inclusion in our research. We extracted the basic information regarding the patients, intervention procedures, and all complications after pancreatic surgery and then performed the meta-analysis.

RESULTS

Thirteen RCTs involving 2006 patients were identified. There were no differences between the octreotide group and the placebo group with regard to pancreatic fistulas (PFs) (relative risk [RR] = 0.79, 95% confidence interval [CI] = 0.62-0.99, P = .05), clinically significant PFs (RR = 1.01, 95% CI = 0.68-1.50, P = .95), mortality (RR = 1.21, 95% CI = 0.78-1.88, P = .40), biliary leakage (RR 0.84, 95% CI = 0.39-1.82, P = .66), delayed gastric emptying (RR = 0.83, 95% CI = 0.54-1.27, P = .39), abdominal infection (RR = 1.00, 95% CI = 0.66-1.52, P = 1.00), bleeding (RR = 1.16, 95% CI = 0.78-1.72, P = .46), pulmonary complications (RR = 0.73, 95% CI = 0.45-1.18, P = .20), overall complications (RR = 0.80, 95% CI = 0.64-1.01, P = .06), and reoperation rates (RR = 1.18, 95% CI = 0.77-1.81, P = .45). In the high-risk group, octreotide was no more effective at reducing PF formation than placebo (RR = 0.81, 95% CI = 0.67-1.00, P = .05). In addition, octreotide had no influence on the incidence of PF (RR = 0.38, 95% CI = 0.14-1.05, P = .06) after distal pancreatic resection and local pancreatic resection.

CONCLUSION

The present best evidence suggests that prophylactic use of octreotide has no effect on reducing complications after pancreatic resection.

Bleeding complications after pancreatic surgery: interventional radiology management

Surgical intervention in the pancreas region is complex and carries the risk of complications, also of vascular nature. Bleeding after pancreatic surgery is rare but characterized by high mortality. This review reports epidemiology, classification, diagnosis and treatment strategies of hemorrhage occurring after pancreatic surgery, focusing on the techniques, roles and outcomes of interventional radiology (IR) in this setting. We then describe the roles and techniques of IR in the treatment of other less common types of vascular complications after pancreatic surgery, such as portal vein (PV) stenosis, portal hypertension and bleeding of varices.

Outcomes associated with robotic approach to pancreatic resections

Minimally invasive techniques have improved post-operative outcomes, however, the majority of pancreatic surgery, known for its complexity, is still performed via open approaches. The development of robotics has improved dexterity which may allow for application in more complex surgeries. We queried a prospectively maintained robotic database to identify patients who underwent robotic pancreatic resection by a single surgeon between 2012 and 2016. Patient demographics and operative outcomes were compared using Mann-Whitney U, Kruskal Wallis and Pearson's Chi-square test as appropriate. We identified 119 patients; 65 Whipples [Robotic Whipple (RW)], 43 distal pancreatectomies, 4 total pancreatectomies, 6 pancreatic enucleations, and 1 robotic cyst gastrostomy with a median age of 71 [24-91], median body mass index (BMI) of 27.6 (16.8-40.2), and American society of anesthesiologists (ASA) of 3. The median estimated blood loss (EBL) was 125 [25-800] and loss of heterozygosity (LOH) 6 [1-34]. Mean operative time for RW decreased after 15 cases (578 vs. 457 minutes, P<0.004). Conversions to open occurred in 5 (4.2%) patients. In total of 117 (98.3%) patients underwent R0 resections and the median lymph node (LN) harvest was 16 [0-37]. The 30 and 90 days mortality was 1 (0.8%). Major complications (Clavien-Dindo grade 3-5) were seen in 16 (13.4%) cases (20.3%) but decreased steadily as volume increased (case 30). Pancreatic leaks occurred in 14 (11.8%): A, 8 (6.7%); B, 4 (3.4%); and C, 2 (1.7%). Robotic assisted approaches to pancreatic resections is feasible. However, it takes approximately 15 cases before a decrease in operative time and 30 cases before major complications are decreased. These trends in complications are associated with surgeon experience and volume are critical to consider in robotic pancreatic surgery.

Predictive value of drain pancreatic amylase concentration for postoperative pancreatic fistula on postoperative day 1 after pancreatic resection: An updated meta-analysis

BACKGROUND

Postoperative pancreatic fistula (POPF) is a potentially fatal complication following pancreaticoduodenectomy. Early prediction and exclusion of POPF may be highly advantageous to enhance patient outcomes, and accelerate recovery. In this meta-analysis, we sought to assess the prediction of drain pancreatic amylase concentration on postoperative day 1 (DPA1) for POPF.

METHODS

By searching online databases up to April 2018, all researches mentioned DPA1 for detecting POPF were analyzed. STATA 12.0 was used to analyze pooled predictive parameters.

RESULTS

Seventeen studies were finally analyzed including 4676 patients in total. The pooled sensitivity and specificity of DPA1 were respectively 0.85 (95% CI: 0.71, 0.93), 0.80 (95% CI: 0.74, 0.85) to predict overall POPF, and 0.70 (95% CI: 0.53, 0.82), 0.88 (95% CI: 0.86, 0.90) to predict CR-POPF. If pretest probability was 50%, corresponding post-test (+) were respectively 81%, 86% for overall POPF and CR-POPF when DPA1 was above cutoffs, while the post-test (-) were respectively 16%, 26% when DPA1 was under cutoffs. In subgroup analysis, sensitivities of cutoff >5000 group, 1000< cutoff <5000 group, and cutoff <1000 group were respectively 0.65 (0.43-0.82), 0.82 (0.71-0.89), 0.87 (0.78-0.92); and specificities were respectively 0.88 (0.83-0.92), 0.83 (0.77-0.88), 0.71 (0.62-0.79). Positive LR was 5.5 (3.4-8.8), 4.8 (3.4-6.7), and 3.0 (2.3-4.0) respectively. Negative LR was 0.40 (0.22-0.72), 0.22 (0.13-0.37), and 0.19 (0.11-0.32) respectively.

CONCLUSION

DPA1, which has good sensitivity and specificity, is useful for predicting overall POPF and CR-POPF, according to the present studies. Meanwhile, it should be cautious to apply because there is a wide range in cutoffs between different studies.

Oncologic outcomes after robot-assisted versus laparoscopic distal pancreatectomy: Analysis of the National Cancer Database

BACKGROUND

How the oncologic outcomes after robotic distal pancreatectomy (RDP) compare to those after laparoscopic distal pancreatectomy (LDP) remains unknown.

METHODS

Using the National Cancer Database (NCDB), we analyzed all patients undergoing LDP or RDP for resectable pancreatic adenocarcinoma over a 4-year period (2010-2013).

RESULTS

Of the 704 eligible patients, 605 (86%) underwent LDP and 99 (14%) underwent RDP. The median follow-up for patients was 25 months. There were no differences in the two groups with respect to sociodemographic, clinicopathologic, or treatment characteristics. On comparing LDP versus RDP, there was no difference in the margin-positive rate (15% vs 16%; P = 0.84); lymph nodes examined (12 vs 11; P = 0.67); overall survival (hazard ratio [HR], 1.1, 95% confidence intervals [CI], 0.7 to 1.7; 28 vs 25 months; P = 0.71); hospital stay (6 vs 5 days; P = 0.14); time to chemotherapy (50 vs 52 days; P = 0.65); 30-day readmission (9.4% vs 9.1%; P = 0.92); and mortality (1% vs 0%; P = 0.28). Patients undergoing LDP had a significantly higher conversion rate to open or minimally invasive pancreatic cancer resections compared with RDP (27% vs 10%; P < 0.001).

CONCLUSION

The early national experience with RDP demonstrates similar oncologic outcomes to LDP, with a significantly lower conversion rate.

Factors leading to pancreatic resection in patients with pancreatic cancer: a national perspective

Background

Resection is the only option for potential cure in pancreatic cancer. Patients admitted for resection may have the procedure deferred during their hospitalization. We aim to identify factors that lead pancreatic cancer patients to undergo resection.

Methods

An analysis utilizing the Nationwide Inpatient Sample (NIS) database, 2003-2009. Study population included adults (≥18 years) with pancreatic cancer who underwent either pancreatic resection or other interventions. Surgeon volume classified based on the median into low and high-volume surgeon.

Results

Eleven thousand three hundred and sixty-five patients were included; 68.0% underwent pancreatic resection, while 32.0% had other interventions. The majority of patients resected were <60 years old, female, with higher annual household income (P<0.05 for all). Patients with Medicaid coverage and comorbidity scores ≥2 were least likely to undergo pancreatic resection. Resection was more likely for high-volume surgeons, high-volume hospitals and teaching hospitals (P<0.05 for all). Those managed by high-volume surgeons were at a lower risk of postoperative complications, lower mortality, shorter hospital stay, and lower healthcare costs (P<0.05 for all).

Conclusions

Patients' insurance type and economic status are significantly associated with their ability to achieve pancreatic resection. Surgeon experience and hospital volumes were also significantly associated with pancreatic resection, clinical and economic outcomes.

Efficacy of the prophylactic use of octreotide for the prevention of complications after pancreatic resection: An updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The use of octreotide prophylaxis in the prevention of complications after pancreatic resection remains controversial. The aim of this systematic review and meta-analysis was to evaluate the efficacy of octreotide prophylactic treatment to prevent complications after pancreatic resection.

METHODS

Five databases (PubMed, Medline, SinoMed, Embase, and Cochrane Library) were searched for eligible studies from 1980 to November 2016 with the limitation of human subjects and randomized controlled trials (RCTs). Data were extracted independently and were analyzed using RevMan statistical software version 5.3 (Cochrane Collaboration, http://tech.cochrane.org/revman/download). Weighted mean differences (WMDs), risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration risk of bias tool was used to assess the risk of bias.

RESULTS

Twelve RCTs comprising 1902 patients were identified as eligible. The methodological quality of the trials ranged from low to moderate. A pooled analysis of effectiveness based on the data from each study revealed that octreotide could significantly reduce the rate of pancreatic fistula (PF) after pancreatic resection (RR = 0.75, 95% CI = 0.57-0.98, P = .04). The same findings were discovered in multicenter and European subgroups with a subgroup analysis; no obvious differences were noted in American, Asian, and single-center subgroup analyses. An equal effect was observed between the use or non-use of octreotide groups regarding mortality (RR = 1.24, 95% CI = 0.77-2.02, P = .38). Octreotide had no advantages in regards to mortality improvement. The total numbers of complications associated with the use or non-use of octreotide were similar (RR = 0.77, 95% CI = 0.58-1.03, P = .08). Among the high-risk group, octreotide was more effective in reducing complications (RR = 0.61, 95% CI = 0.46-0.82, P = .0009). Compared with the patients who did not receive prophylactic treatment, the patients who underwent pancreatic resection benefited from octreotide because it had better efficacy in preventing fluid collection and postoperative pancreatitis.

CONCLUSION

The prophylactic use of octreotide is suitable for preventing postoperative complications, especially PF and fluid collection as well as postoperative pancreatitis. However, no obvious differences were noted regarding mortality. In view of the clinical heterogeneity and varying definitions of PF, whether these conclusions are broadly applicable should be further determined in future studies.

Preoperative Platelet-to-Albumin Ratio Predicts Prognosis of Patients with Pancreatic Ductal Adenocarcinoma After Pancreatic Resection

BACKGROUND

The aim of this study was to evaluate a novel prognostic value of preoperative platelet-to-albumin ratio (PAR) in patients resected for pancreatic cancer.

PATIENTS AND METHODS

A total of 107 patients who underwent pancreatic resection for pancreatic cancer were studied. The patients were divided into two groups as PAR ≥46.4×10³ or <46.4×10³ Survival data were analyzed using the log-rank test for univariate analysis and Cox proportional hazards for multivariate analysis.

RESULTS

The PAR was a significant prognostic index on univariate analysis for disease-free survival (DFS) and overall survival (OS). The PAR retained its significance on multivariate analysis for OS (hazard ratio(HR)=2.344, 95% confidence interval(CI)=1.188-4.624, p=0.014) along with tumor differentiation and nodal involvement. PAR was a significant independent prognostic index for poor DFS on multivariate analysis (HR=1.971, 95% CI=1.128-3.444, p=0.017).

CONCLUSION

The preoperative PAR is a novel significant independent prognostic index for DFS and OS in patients after pancreatic resection with curative intent.

Hemorrhage after Major Pancreatic Resection: Incidence, Risk Factors, Management, and Outcome

BACKGROUND AND AIMS

Hemorrhage is a rare but dreaded complication after pancreatic surgery. The aim of this study was to examine the incidence, risk factors, management, and outcome of postpancreatectomy hemorrhage in a tertiary care center.

MATERIALS AND METHODS

A retrospective observational study was conducted on 500 consecutive patients undergoing major pancreatic resections at our institution. Postpancreatectomy hemorrhage was defined according to the International Study Group of Pancreatic Surgery criteria.

RESULTS

A total of 68 patients (13.6%) developed postpancreatectomy hemorrhage. Thirty-four patients (6.8%) had a type A, 15 patients (3.0%) had a type B, and the remaining 19 patients (3.8%) had a type C bleed. Postoperative pancreatic fistula Grades B and C and bile leakage were significantly associated with severe postpancreatectomy hemorrhage on multivariable logistic regression. For patients with postpancreatectomy hemorrhage Grade C, the onset of bleeding was in median 13 days after the index operation, ranging from 1 to 85 days. Twelve patients (63.2%) had sentinel bleeds. Surgery lead to definitive hemostatic control in six of eight patients (75.0%). Angiography was able to localize the bleeding source in 8/10 (80.0%) cases. The success rate of angiographic hemostasis was 8/8. (100.0%). The mortality rate among patients with postpancreatectomy hemorrhage Grade C was 2/19 (10.5%), and both fatalities occurred late as a consequence of eroded vessels in association with pancreaticogastrostomy.

CONCLUSION

Delayed hemorrhage is a serious complication after major pancreatic surgery.Sentinel bleed is an early warning sign. Postoperative pancreatic fistula and bile leakage are important risk factors for severe postpancreatectomy hemorrhage.

Conservative and surgical management of pancreatic trauma in adult patients

BACKGROUND

The management of pancreatic trauma is complex. The aim of this study was to report our experience in the management of pancreatic trauma.

METHODS

All patients hospitalized between 2005 and 2013 for pancreatic trauma were included. Traumatic injuries of the pancreas were classified according to the American Association for Surgery of Trauma (AAST) in five grades. Mortality and morbidity were analyzed.

RESULTS

A total of 30 patients were analyzed (mean age: 38±17 years). Nineteen (63%) patients had a blunt trauma and 12 (40%) had pancreatic injury ≥ grade 3. Fifteen patients underwent exploratory laparotomy and the other 15 patients had nonoperative management (NOM). Four (13%) patients had a partial pancreatectomy [distal pancreatectomy (n=3) and pancreaticoduodenectomy (n=1)]. Overall, in hospital mortality was 20% (n=6). Postoperative mortality was 27% (n=4/15). Mortality of NOM group was 13% (n=2/15) in both cases death was due to severe head injury. Among the patients who underwent NOM, three patients had injury ≥ grade 3, one patient had a stent placement in the pancreatic duct and two patients underwent endoscopic drainage of a pancreatic pseudocyst.

CONCLUSIONS

Operative management of pancreatic trauma leads to a higher mortality. This must not be necessarily related to the pancreas injury alone but also to the associated injuries including liver, spleen and vascular trauma which may cause impaired outcome more than pancreas injury.

Outcome and complications of combined liver and pancreas resections: a retrospective analysis

BACKGROUND

Combined resections of the liver and pancreas are related to high complication and mortality rates. The present study assessed the outcome of these procedures and identified specific risk factors for morbidity and mortality.

METHODS

Between January 2001 and April 2012, 28 combined liver/pancreas resections were performed at our institution. All patients were retrospectively analysed using a database with regards to baseline characteristics, surgical procedures, complications and survival.

RESULTS

Among the pancreatic resections, there were 12 (42.9%) Kausch-Whipple (KW), 9 (32.1%) pylorus-preserving pancreaticoduodenectomy (PPPD), 6 (21.4%) distal pancreatectomies (DP) and 1 (3.6%) total pancreaticoduodenectomy (TPD). In 12 (48.9%) cases, major complications (grade IIIb-V) were observed. Overall survival was 35 months (SD = 40.5) and the 3-year survival rate was 35.7% (1-year survival rate: 50%).

DISCUSSION

Combined resections of the liver and pancreas are associated with high complication rates, especially if major liver resections are performed. Therefore, it is mandatory to do a thorough evaluation of potential patients.

Laparoscopic distal pancreatectomy

After technological advances and increased experiences, more complicated surgeries including distal pancreatectomy can be easily performed with acceptable oncologic results, and decreased mortality and morbidity. Laparoscopic distal pancreatectomy (LDP) has been shown to have several advantages including less blood loss, less hospital stay, less pain. Several studies comparing open distal pancreatectomy (ODP) and LDP resulted that both techniques have similar results according to pancreas fistulas, oncological results, costs and operation indications. Morbidity is very low in high volume centers, for this reason at least ten cases should be performed for the learning curve. Several authors remarked important technical points in LDP in order to perform safe and acceptable LDP in several studies. Here in this review, we aimed to overview the results of previous studies about LDP and discuss the technical points of LDP.

Laparoscopic pancreatic resection-a review

Contrary to many other gastrointestinal operations, minimal access approaches in pancreatic surgery have gained ground slowly. Laparoscopic distal pancreatectomy has gained wide acceptance. It is associated with reduced blood loss and shorter duration of stay (DOS) while oncologic results and morbidity are similar to open surgery. In recent years the number of laparoscopic pancreatoduodenectomies has also increased. While oncological outcome seems comparable to the open approach, operative times are longer while DOS and blood loss are reduced. One added advantage of the laparoscopic approach to pancreatic cancer seems to be that adjuvant treatment can start earlier. Minimal access total pancreatectomy, only reported in small numbers (mostly robot assisted), has also been shown to be feasible and safe. Enucleation (EN) of small pancreatic lesions is the most common tissue sparing resection. Although no reconstruction is necessary, the risk of pancreatic fistula is high, related to excision margins equal or smaller than 2 mm to the main pancreatic duct. Compared to the open approach, laparoscopic EN has shown comparable results in terms of morbidity, pancreatic function and fistula rate, with shorter operation times and faster recovery. Experience in robot assisted pancreatic surgery is increasing. However reports are still small in numbers, lacking randomization and mostly limited to dedicated centers. The learning curve for minimal access pancreatic surgery is steep. Low patient volume leads to longer DOS, higher costs and negatively impacts outcome.

Persisting ratio of total amylase output in drain fluid can predict postoperative clinical pancreatic fistula

BACKGROUND/PURPOSE

A consistent predictor for pancreatic fistula (PF) development in the early period after pancreatic resection is still lacking.

PATIENTS AND METHODS

A total of 54 consecutive patients undergoing pancreatic resection were enrolled between June 2007 and April 2010. Pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) were performed in 38 and 16 patients, respectively. For the purpose of finding an early predictor for PF development, we investigated drain amylase levels (d-Amy, IU/mL), drain output volume (d-Vol, mL/day) and drain amylase output (Amy-V, IU/day) on postoperative days (POD) 1 and 3. Amy-V was calculated as the product of d-Amy and d-Vol, and was expressed as the sum of values obtained from all drains. In addition, the ratio of d-Amy or Amy-V on POD3 to that on POD1 was calculated as the persisting ratio in each patient.

RESULTS

The overall incidence of clinical PF (International Study Group on Pancreatic Fistula Grade B and C) was 16.7%, occurring in 13.1% after PD and 25% after DP. All PF occurred in cases with a remnant pancreas of soft texture. There was no significant difference in d-Amy, d-Vol, or Amy-V on POD1 and POD3 between patients with and without clinical PF. The persisting ratio of Amy-V was significantly lower in patients without clinical PF compared to those with clinical PF (p = 0.029). Furthermore, the persisting ratio of Amy-V was significantly lower in patients with Grade A PF compared to those with Grade B PF (p = 0.03).

CONCLUSION

The persisting ratio of drain amylase output is a new significant predictive factor for clinical PF development.

Pancreas Cancer Surgery in Octogenarians - Should We or Should We Not?

BACKGROUND/AIM

In this study we aimed to determine if advanced age represents a risk factor for negative perioperative and long-term outcome in patients undergoing curative surgery ductal pancreatic adenocarcinoma surgery.

PATIENTS AND METHODS

Two-hundred-twenty-one consecutive patients, twelve (6%) patients ≥80 years were included in the study. We assessed perioperative and long-term outcome and independent predictors for in-hospital mortality with Cox regression analysis.

RESULTS

Advanced age was not a predictor for in-hospital mortality (6.3% in non-octogenarian versus 8.3% in octogenarians; p=0.55) nor for morbidity (31% vs. 32%; p=0.69). An ASA score >II was the only predictor for in-hospital mortality (odds ratio (OR)=10.10, 95%CI=1.28-79.60; Hosmer-Lemeshow: p=0.86). No significant difference was observed in one- and five-year survival rates (68 and 58% vs. 16 and 14%; log-rank p=0.61).

CONCLUSION

Advanced age is not a risk factor for negative outcome in curative pancreatic cancer surgery. Therefore, this single curative option should be considered in octogenarians at risk.

Multivisceral Resection in Patients with Advanced Abdominal Tumors

BACKGROUND/AIM

Multivisceral resection for advanced tumors can result in prolonged survival but may also increase the risk of postoperative morbidity and mortality. The primary aim of this study was to investigate whether extensive resections increase the severity of postoperative complications.

MATERIALS AND METHODS

A retrospective study was conducted between 2009 and 2014 at the Linköping University Hospital surgical department. All patients with a confirmed or presumed malignant disease who underwent a non-standardized surgical procedure requiring a multivisceral resection were included. The primary endpoint was 90-day complications according to the Clavien-Dindo score.

RESULTS

Forty-eight patients were included, with an age range of 17-77 years. A median of three organs was resected. The most common diagnoses were neuroendocrine tumor (n = 8), gastric cancer (n = 7), and gastrointestinal stromal tumor (n = 6). One patient died during surgery. Complications ⩾ grade 3b according to Clavien-Dindo score occurred in 10 patients. R0 resection was achieved in 32 patients. No correlation was observed between the number of anastomoses, perioperative blood loss, operative time, and complications. Only postoperative blood transfusion was correlated with severe complications (p = 0.046); however, a tendency toward more complications with an increasing number of resected organs was observed (p = 0.06).

CONCLUSION

Multivisceral resection can result in R0, potentially curing patients with advanced tumors. Here, no correlation between extensive resections and complications was observed. Only postoperative blood transfusion was correlated with severe complications.

A randomized phase II study of S-1 plus oral leucovorin versus S-1 monotherapy in patients with gemcitabine-refractory advanced pancreatic cancer

This is the first phase II trial in which adding oral leucovorin (LV) to S-1 (SL) significantly prolonged progression-free survival (PFS) when compared with S-1 monotherapy (S) in patients with gemcitabine-refractory advanced pancreatic cancer (PC). The significantly better PFS and disease control rate with SL than with S suggest that the antitumor activity of S-1 is enhanced by LV in advanced PC.

Background

We evaluated the efficacy and toxicity of adding oral leucovorin (LV) to S-1 when compared with S-1 monotherapy in patients with gemcitabine-refractory pancreatic cancer (PC).

Patients and methods

Gemcitabine-refractory PC patients were randomly assigned in a 1:1 ratio to receive S-1 at 40, 50, or 60 mg according to body surface area plus LV 25 mg, both given orally twice daily for 1 week, repeated every 2 weeks (SL group), or S-1 monotherapy at the same dose as the SL group for 4 weeks, repeated every 6 weeks (S-1 group). The primary end point was progression-free survival (PFS).

Results

Among 142 patients enrolled, 140 were eligible for efficacy assessment (SL: n = 69 and S-1: n = 71). PFS was significantly longer in the SL group than in the S-1 group [median PFS, 3.8 versus 2.7 months; hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.37–0.85; P = 0.003]). The disease control rate was significantly higher in the SL group than in the S-1 group (91% versus 72%; P = 0.004). Overall survival (OS) was similar in both groups (median OS, 6.3 versus 6.1 months; HR, 0.82; 95% CI, 0.54–1.22; P = 0.463). After adjusting for patient background factors in a multivariate analysis, OS tended to be better in the SL group (HR, 0.71; 95% CI, 0.47–1.07; P = 0.099). Both treatments were well tolerated, although gastrointestinal toxicities were slightly more severe in the SL group.

Conclusion

The addition of LV to S-1 significantly improved PFS in patients with gemcitabine-refractory advanced PC, and a phase III trial has been initiated in a similar setting.

Clinical trials number

Japan Pharmaceutical Information Center: JapicCTI-111554.

Pancreatic Resection as Part of Cytoreductive Surgery in Advanced-stage and Recurrent Epithelial Ovarian Cancer--A Single-center Experience

AIM

To demonstrate the efficacy of pancreatic resection as part of cytoreductive surgery for advanced-stage and recurrent epithelial ovarian cancer.

PATIENTS AND METHODS

Data of patients submitted to cytoreductive surgery for advanced-stage and relapsed epithelial ovarian cancer at the Dan Setlacec Center of Gastrointestinal Disease and Liver Transplantation, Fundeni Clinical Institute, Romania, treated between January 2002 and May 2014 were retrospectively reviewed.

RESULTS

A total of six cases were eligible for the study: one case was submitted to pancreatic resection in the context of primary cytoreduction, four cases were submitted to pancreatic resection during secondary cytoreduction, while the sixth case was submitted to distal pancreatectomy as part of tertiary cytoreduction. The early postoperative course was uneventful in four cases, while the other two developed pancreatic fistulas. In one case, the leak was managed in a conservative manner, while in the second case re-operation was required. Thirty-day mortality was zero. At the time of writing, the patient submitted to pancreatic resection during primary cytoreduction was still alive with disease at 54 months and proposed for secondary cytoreduction. The median overall survival for cases submitted to pancreatic resection in the context of secondary cytoreduction was 36.38 months, while the patient submitted to distal pancreatectomy at the moment of tertiary cytoreduction was dead of disease 10 months after surgery.

CONCLUSION

Pancreatic resections can be safely performed in the context of cytoreductive surgery for advanced-stage and relapsed epithelial ovarian cancer, with acceptable rates of morbidity, therefore benefit in terms of survival might be achieved.

[Pancreatic cancer- a curable disease]

Pancreatic cancer is the seventh most common cancer in Switzerland associated with a dismal prognosis. Its natural course is fatal with a 3-year survival rate below 3%. Advances in diagnostic tools, tumor staging and multimodal treatment strategies resulted in an improved 5-year survival rate of over 20%. Patients presenting with pancreatic cancer significantly benefit from a multi-disciplinary treatment strategy in an experienced hepato-pancreato-biliary center. Following a comprehensive tumor staging, surgical resection associated with adjuvant chemotherapy is still the only curative therapy option. The role of neoadjuvant chemotherapy is currently investigated in clinical trials. Patients presenting with advanced pancreatic cancer not eligible for curative treatment might benefit from inclusion into innovative clinical trials with novel treatment concepts.

Incidence and risk factors of chylous ascites after pancreatic resection

Chylous ascites (CA) is a rare postoperative complication. It also occurs in pancreatic surgery and can influence the patient's prognosis after pancreatic resection. There are few studies focusing on CA following pancreatic resection. We aimed to evaluate the incidence and risk factors of CA following pancreatic resection. Patients who underwent pancreatic resection from the year 2007 to 2013 were retrospectively reviewed. The diagnosis of CA was based on the presence of a non-infectious milky or creamy peritoneal fluid greater than 100 ml/day with a triglyceride concentration ≥110 mg/dl. The incidence and possible risk factors following pancreatic resection were evaluated. In this study, 1921 patients who underwent pancreatic resection were included. 49 patients developed CA. The overall incidence was 2.6 percent (49 out of 1921). The incidence following pancreaticoduodenectomy and distal pancreatectomy was much higher (35 out of 1241, 12 out of 332, respectively). A multivariable analysis demonstrated that manipulating para-aortic area and superior mesenteric artery root area; retroperitoneal invasion; focal chronic pancreatitis and early enteral feeding were the independent risk factors for CA after pancreatic surgery. In conclusion, CA is a rare complication after pancreatic resection. Some clinicopathological factors were associated with the development of CA following pancreatic resection.

Pancreatic surgery: evolution and current tailored approach

Surgical resection of pancreatic cancer offers the only chance for prolonged survival. Pancretic resections are technically challenging, and are accompanied by a substantial risk for postoperative complications, the most significant complication being a pancreatic fistula. Risk factors for development of pancreatic leakage are now well known, and several prophylactic pharmacological measures, as well as technical interventions have been suggested in prevention of pancreatic fistula. With better postoperative care and improved radiological interventions, most frequently complications can be managed conservatively. This review also attempts to address some of the controversies related to optimal management of the pancreatic remnant after pancreaticoduodenectomy.

Postoperative peripheral absolute blood lymphocyte-to-monocyte ratio predicts therapeutic outcome after pancreatic resection in patients with pancreatic adenocarcinoma

AIM

The aim of this study was to evaluate the significance of postoperative peripheral absolute blood lymphocyte-to-monocyte (ALC/AMC) ratio in pancreatic resections for pancreatic carcinoma.

PATIENTS AND METHODS

One hundred eleven patients who underwent pancreatic resection for pancreatic carcinoma were included in this study. We retrospectively examined perioperative findings as predictors of therapeutic outcome and the relation between postoperative ALC/AMC ratio and recurrence rate as well as overall survival of the patients with pancreatic carcinoma.

RESULTS

In univariate analysis, advanced tumor-node-metastasis (TNM) classification (p=0.0002), intraoperative flesh-frozen plasma (FFP) transfusion (p=0.0395), increased in preoperative serum carbohydrate antigen 19-9 (CA19-9) (p=0.0051) and lower postoperative ALC/AMC ratio (p=0.0007) were positively associated with poor disease-free survival. Advanced TNM classification (p=0.0008), intraoperative FFP transfusion (p=0.0343), elevated postoperative serum C-reactive protein (CRP) (p=0.0165) and lower postoperative ALC/AMC ratio (p=0.0029), as well as decreased preoperative lymphocyte counts (p=0.0248) were positively associated with poor overall survival. In multivariate analysis, advanced TNM classification (p=0.007), intraoperative FFP transfusion (p=0.0197), increase in preoperative serum CA19-9 (p=0.0075) and lower postoperative ALC/AMC ratio (p=0.0051) were independent factors for poor disease-free survival. Advanced TNM classification (p=0.0083), lower postoperative ALC/AMC ratio (p=0.0070) and elevated postoperative serum CRP (p=0.0094) were independent factors for poor overall survival.

CONCLUSION

Lower postoperative peripheral ALC/AMC ratio may have a negative impact on recurrence and overall survival after pancreatic resection for pancreatic carcinoma.

Pancreatico-jejunal anastomosis with invaginating jenunal "J"-loop. Preliminary report of a new technique

INTRODUCTION

The pancreatic anastomosis is the most demanding step after pancreaticoduodenectomy (PD) and the pancreatic fistula (PF) is the most dreaded complication. Many techniques have been investigated to assess the best way to deal with the pancreatic stump after PD and none of these has shown to be superior in terms of statistically significant reduction of PF rate. We report the preliminary experience of a new technique of pancreaticojejunostomy (PJ).

METHODS

Fifteen patients underwent PD for neoplasms with end-to-side PJ with dunking jejunal "J"-loop, between July 2011 and March 2014. The data about their post-operative outcomes were analyzed.

RESULTS

There were no intra-operative neither post-operative deaths. One patient had a grade A PF (6.7%). Total post-operative complications occurred in 6 patients (40%), major post-operative complications occurred in 3 patients (20%).

CONCLUSION

The new "sandwich" technique for dunking PJ after PD that we describe proved to be easy to perform and sure. It appears to be suitable for a dunking PJ when the diameter of the jejunum is too small than this of the pancreatic stump.

Impact of cardiac comorbidity on early outcomes after pancreatic resection

BACKGROUND

In patients undergoing pancreatic resection (PR), identification of subgroups at increased risk for postoperative complications can allow focused interventions that may improve outcomes.

STUDY DESIGN

Patients undergoing PR from 2005-2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database and categorized as having any history of cardiac disease (angina, congestive heart failure (CHF), myocardial infarction (MI), cardiac stent, or bypass) or as having acute cardiac disease (symptoms of CHF or angina within 30 days or MI within 6 months). These variables were utilized to examine the relationship between cardiac disease and outcomes after PR.

RESULTS

The rate of serious complications and perioperative mortality in patients with any history of cardiac disease vs. those without was 34 vs. 24 % (p < 0.001) and 4.5 vs. 2.0 % (p < 0.001), respectively, and in patients with acute cardiac disease compared to patients without was 37 vs. 25 % (p < 0.001) and 8.6 vs. 2.2 % (p < 0.001), respectively. In multivariate analysis, the two cardiac disease variables remained associated with mortality.

CONCLUSIONS

In patients undergoing PR, cardiac disease is a significant risk factor for adverse outcomes. These observations are critical for meaningful informed consent in patients considering pancreatectomy.

A novel postoperative inflammatory score predicts postoperative pancreatic fistula after pancreatic resection

AIM

The aim of this study was to characterize a high-risk group of patients for pancreatic fistula (PF) after pancreatic resection using postoperative clinical variables of patients.

PATIENTS AND METHODS

The retrospective study included 297 patients who underwent pancreatic resection between January 2001 and December 2011. We examined the relationship between perioperative findings and the incidence of postoperative PF (POPF) among patients who underwent pancreatic resection between 2001 and 2009 (early period). Next, patients were stratified into three groups using serum albumin and CRP on postoperative day 1 (score 0: albumin ≥2.7 g/dl and CRP ≤10 mg/dl; score 1: albumin <2.7 g/dl or CRP >10 mg/dl; score 2: albumin <2.7 g/dl and CRP >10 mg/dl) as postoperative inflammatory score (PIS). We examined perioperative findings including PIS and POPF among patients who underwent pancreatic resection between 2010 and 2011 (late period).

RESULTS

In univariate and multivariate analyses, male gender (p=0.032), serum albumin on postoperative day 1 (p=0.024) and serum CRP on postoperative day 1 were identified as independent risk factors for POPF in early-period patients. In univariate and multivariate analyses, postoperative hospital stay (p=0.009) and PIS (score 1: p=0.005, score 2: p=0.017) were identifical as independent risk factors for POPF in late-period patients.

CONCLUSION

We found a novel PIS to indicate risk for PF after elective pancreatic resection.

Negative impact of fresh-frozen plasma transfusion on prognosis of pancreatic ductal adenocarcinoma after pancreatic resection

BACKGROUND

Excessive blood loss and blood transfusion may influence postoperative complications and prognosis of patients after pancreatic resection. We evaluated the influence of blood products use on postoperative recurrence and outcome of patients with pancreatic ductal adenocarcinoma.

PATIENTS AND METHODS

The study included 82 patients who underwent elective pancreatic resections for pancreatic ductal adenocarcinoma without distant metastasis or other malignancies between January 2001 and December 2010. We retrospectively investigated the influence of the use of perioperative blood products including red cell concentrate, fresh-frozen plasma (FFP), and albumin preparation, and clinical variables regarding disease-free and overall survival.

RESULTS

In disease-free survival, serum carcinoembryonic antigen more than 10 ng/ml (p=0.015), serum carbohydrate antigen 19-9 (CA19-9) more than 200 U/ml (p=0.0032), R1 resection (p=0.005), and FFP transfusion were independent risk factors for cancer recurrence in the Cox proportional regression model, pancreaticoduodenectomy (p=0.057) and advanced tumor stage (p=0.083) tended to associate with poor disease-free survival, but were not statistically significant. In overall survival, male gender (p=0.012), advanced tumor stage (p=0.005), serum CA19-9 more than 200 U/ml (p<0.001), and FFP transfusion (p=0.003) were positively associated with poor overall survival in the Cox proportional regression model.

CONCLUSION

FFP transfusion is associated with poor therapeutic outcome after elective pancreatic resection for pancreatic ductal adenocarcinoma.

False-negative rate of endoscopic ultrasound-guided fine-needle aspiration for pancreatic solid and cystic lesions with matched surgical resections as the gold standard: one institution's experience

BACKGROUND

The diagnosis of pancreatic tumors is often complicated because of sampling and interpretive challenges. The current study was performed to determine the rates, types, and causes of diagnostic discrepancies.

METHODS

The authors retrospectively reviewed cytology cases from 2004 to 2010 using matched surgical resection cases as the gold standard.

RESULTS

A total of 733 cases were divided into 3 categories: 1) positive or suspicious (290 cases); 2) negative or atypical (403 cases); and 3) unsatisfactory (40 cases). Of these cases, 101 fine-needle aspiration (FNA) cases had matched surgical resections including 58 positive diagnoses, 39 negative diagnoses, and 4 unsatisfactory diagnoses. All 19 discrepant cases represented false-negative diagnoses without any false-positive cases noted, which included 2 cases with interpretive errors (10%) and 17 cases with sampling errors (90%). All matched cytology cases were divided into 5 subgroups based on the type of lesion or type of error and were analyzed for sensitivity and specificity. The sampling error rate in cystic lesions (8 of 24; 33%) was significantly higher than that in solid lesions (9 of 73; 12%). The false-negative rate in the interpretive error group (3%) was significantly lower than that in the sampling error group (23%).

CONCLUSIONS

The results of the current study confirm that pancreatic endoscopic ultrasound-guided FNA diagnosis has a very low false-positive rate but a relatively high false-negative rate using matched surgical resections as the gold standard. The major cause of a false-negative cytology diagnosis is sampling error and the rate of sampling error in cystic lesions is significantly higher than that in solid lesions.