Jejunal limb obstruction by a tumor thrombus from pancreatic metastasis of renal cell carcinoma: a case report

BACKGROUND

Renal cell carcinoma (RCC) is a primary tumor with the highest frequency of pancreatic metastasis. Although surgical resection can improve the prognosis of some patients with pancreatic metastasis of RCC (PM-RCC), the role of palliative surgery remains unclear. Herein, we described a case of jejunal limb occlusion caused by a tumor thrombus arising from a PM-RCC which was treated by surgical resection.

CASE PRESENTATION

A 75-year-old, male patient with metastatic RCC was admitted to our hospital with new-onset dysphagia and weight loss. Twenty years earlier he underwent a right nephrectomy with an adrenalectomy for the first surgical resection of RCC, and 12 years ago he underwent a left partial nephrectomy for metachronous primary RCC. Nine years later, multiple pancreatic metastases were detected. After discontinuing interferon therapy, he was followed up at his request without anticancer treatment. Multiple, pulmonary metastases developed 3 years ago, and resection of a brain metastasis was performed 6 months ago. He had also undergone a total gastrectomy with Roux-en Y reconstruction and splenectomy for gastric cancer 23 years ago. Computed tomography revealed a metastatic lesion in the pancreatic tail extending into the jejunal limb, which was obstructed by a tumor thrombus. Jejunal limb resection was performed concomitantly with a distal pancreatectomy as palliative surgery. The jejunal limb remnant was approximately 30 cm long and was re-anastomosed to the esophagus using a circular stapler. Blood perfusion at the anastomotic site was confirmed by indocyanine green fluorescence imaging. He was discharged on postoperative day 24 and was followed in the outpatient clinic. He achieved sufficient oral intake at 8 months postoperatively.

CONCLUSIONS

PM-RCC can invade the gastrointestinal tract and cause tumor thrombus formation resulting in bowel occlusion requiring surgical intervention.

Long-term survival after pancreatic metastasis resection from breast cancer: a systematic literature review

Background

Patients with advanced-stage breast cancer often demonstrate pancreatic metastases. However, pancreatic metastases resection from breast cancer has been rarely performed, with only 20 cases having been reported to date.

Case presentation

A 49-year-old woman presented to our hospital in September 2003 with complaints of uncontrollable oozing from her left breast tumor. Computed tomography revealed a left breast tumor approximately 9.3 cm in diameter as well as heterogeneously enhanced solid mass lesions with necrotic foci in the pancreatic tail and body, up to 6.2 cm, which were radiologically diagnosed as pancreatic metastases from breast cancer. An emergent left simple mastectomy was performed to control bleeding. After epirubicin and cyclophosphamide hydrate treatment failed to improve her condition, the pancreatic metastases responded to weekly paclitaxel treatment, but eventually regrew. The patient underwent distal pancreatectomy with splenectomy, left adrenalectomy, partial stomach resection, and paraaortic lymph nodes excision in December 2004 after no other metastasis was confirmed. Furthermore, she received radiation therapy for left parasternal lymph node metastasis 6 months later. The patient recovered well. Consequently, she has no evidence of disease > 15 years after pancreatectomy.

Conclusions

This is the first reported case of pancreatectomy for pancreatic metastases from breast cancer, which was simultaneously diagnosed. Patients with no metastasis other than resectable pancreatic metastases and breast cancer and who possess some sensitivity for chemotherapy may benefit from pancreatectomy.

Is primary total pancreatectomy in patients with high-risk pancreatic remnant justified and preferable to pancreaticoduodenectomy? -a matched-pairs analysis of 200 patients

BACKGROUND

Total pancreatectomy (TP) eliminates the risk of postoperative pancreatic fistula (POPF) and its associated secondary complications. Hence, it may theoretically offer advantages over pancreaticoduodenectomy (PD) regarding early postoperative outcome of patients with high-risk pancreatic remnant.

METHODS

Ninety-day mortality and morbidity of 100 TP vs. 100 PD for pancreatic head lesions were retrospectively compared. Groups were matched for pancreatic texture, pancreatic duct size, final histology, age, gender and surgeon. Only patients at high risk for POPF due to soft pancreatic texture and small pancreatic duct <3 mm were included.

RESULTS

Preoperatively, the TP-group was characterized by poorer general condition, more comorbidities and more pronounced obesity than the PD-group. Postoperatively, overall morbidity was lower after TP (63% vs. 88%, P<0.001) due to less mild complications. Postpancreatectomy hemorrhage rate was lower after TP than after PD (2% vs. 12%, P=0.014). Duration of surgery, hospital stay, major morbidity (30%) and mortality (7% vs. 5%) were the same. POPF was the most common complication after PD with 32%. Emergency completion pancreatectomy was necessary in 10% of PD with a significantly higher mortality compared to elective TP (50% vs. 7%, P=0.001).

CONCLUSIONS

TP may reduce severe POPF-associated complications and prevent mortality related to emergency completion pancreatectomy in some elderly, obese and polymorbid patients with high-risk pancreatic remnant. Careful individual selection by an experienced pancreatic surgeon is mandatory.

Surgical Treatment for Postprandial Hypoglycemia After Roux-en-Y Gastric Bypass: a Literature Review

Roux-en-Y gastric bypass (RYGB) is an effective treatment for severe obesity and obesity-related comorbidities. Postprandial hypoglycemia may occur as a long-term complication after RYGB. This study reviews the literature on surgical treatment for intractable post-RYGB hypoglycemia to provide updated information. A search was performed in Embase and PubMed, and 25 papers were identified. Thirteen papers on reversal were included. Resolution of postprandial hypoglycemic symptoms occurred in 42/48 (88%) patients after reversal. Twelve papers on pancreatectomy were included. Resolution occurred in 27/50 (54%) patients after pancreatectomy. The optimal surgical treatment for intractable post-RYGB hypoglycemia has not been defined, but reversal of RYGB seems to be more effective than other treatments. Further research on etiology and long-term evaluation of surgical outcomes may refine treatment options.

Pseudo-hyperglucagonemia was observed in pancreatectomized patients when measured by glucagon sandwich enzyme-linked immunosorbent assay

Glucagon is detected in plasma even after total pancreatectomy, and it is debated whether this glucagon is derived from the gastrointestinal tract. Here, we applied sandwich enzyme-linked immunosorbent assay (ELISA) and liquid chromatography-high-resolution mass spectrometry to measure plasma glucagon levels in one patient after partial pancreatectomy (one-seventh of the pancreas remaining) and three patients after total pancreatectomy. Sandwich ELISA detected higher glucagon levels in pancreatectomy patients than in healthy individuals. In contrast, liquid chromatography-high-resolution mass spectrometry showed that plasma glucagon levels in pancreatectomy patients were below the lower limit of quantification. Plasma glucagon measured by sandwich ELISA showed a striking correlation with plasma glicentin, suggesting cross-reaction with this gastrointestinal glucagon-related peptide. These results indicated that pancreatectomized patients falsely showed pseudo-hyperglucagonemia when measured by glucagon sandwich ELISA.

Role of Lymph Node Resection and Histopathological Evaluation in Accurate Staging of Nonfunctional Pancreatic Neuroendocrine Tumors: How Many Are Enough?

BACKGROUND

Nodal involvement has been identified as one of the strongest prognostic factors in patients with nonfunctional pancreatic neuroendocrine tumors (NF-PanNETs). Sufficient lymphadenectomy and evaluation is vital for accurate staging. The purpose of this study was to identify the optimal number of examined lymph nodes (ELN) required for accurate staging.

METHODS

The SEER database was used to identify patients with resected NF-PanNETs between 2004 and 2014. The distributions of positive lymph nodes (PLN) ratio and total lymph nodes were used to develop a mathematical model. The sensitivity of detecting nodal disease at each cutoff of ELN was estimated and used to identify the optimal cutoff for ELN.

RESULTS

A total of 1098 patients were included in the study of which 391 patients (35.6%) had nodal disease. The median ELN was 12 (interquartile range [IQR]: 7-19.5), and the median PLN was 2 (IQR: 1-4) for patients with nodal disease. With an increase in ELN, the sensitivity of detecting nodal disease increased from 12.0% (ELN: 1) to 92.2% (ELN: 20), plateauing at 20 ELN (< 1% increase in sensitivity with an additional ELN). This sensitivity increase pattern was similar in subgroup analyses with different T stages.

CONCLUSIONS

The sensitivity of detecting nodal disease in patients with NF-PanNETs increases with an increase in the number of ELN. Cutoffs for adequate nodal assessment were defined for all T stages. Utilization of these cutoffs in clinical settings will help with patient prognostication and management.

Sub-adventitial divestment technique for resecting artery-involved pancreatic cancer: a retrospective cohort study

PURPOSE

To introduce sub-adventitial divestment technique (SDT), a procedure to remove the tumor while preserving the artery during curative pancreatectomy. Peri-operative safety profile was also evaluated.

METHODS

In a single center consecutive series of pancreatectomy for pancreatic cancer, the outcome of patients who had pancreatectomy with SDT was compared to standard pancreatic surgery.

RESULTS

From June 2014 to June 2016, 72 patients had pancreatectomy with SDT and 235 had standard surgery. Tumor stage was T4 in all 72 (100%) tumors removed using SDT compared to four (2%) with standard pancreatectomy (p < 0.001). All 72 (100%) tumors in the SDT group were stage III compared to 24 (10%) in the standard surgery group (p < 0.001). Both groups had a high proportion of poorly differentiated tumors (52 (72%) and 163 (69%) respectively) and perineural tumor invasion (62 (86%) and 186 (79%) respectively). R1 (< 1 mm) was found in 24 (86%) of 28 tumors in the SDT group, and in 72 (60%) out of 120 standard pancreatectomy tumors (p = 0.01). Complications occurred in 29 (40%) of the SDT group and in 88 (37%) of the standard group. The in-hospital mortality was four (6%) in the SDT group and one (0.4%) in the standard group (p = 0.01), with a 90-day mortality of 5 (8%)/60 and 6 (3%)/209 (p = 0.07) respectively.

CONCLUSIONS

The sub-adventitial divestment technique appeared to be an effective surgical technique to remove the tumor while preserving the artery. This approach warrants further validation in prospective studies.

Clinical impact of preoperative tumour contact with superior mesenteric-portal vein in patients with resectable pancreatic head cancer

INTRODUCTION

The NCCN classification of resectability in pancreatic head cancer does not consider preoperative radiological tumour ≤ 180° contact with portal vein/superior mesenteric vein (PV/SMV) as a negative prognostic feature. The aim of this study is to evaluate whether this factor is associated with higher rate of incomplete resection and poorer survival.

METHODS

All patients considered for pancreatic resection between 2012 and 2017 at two Spanish referral centres were included. Patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC) according to NCCN classification were excluded. Preoperative CT scans were reviewed by dedicated radiologists to identify radiologic tumour contact with PV/SMV.

RESULTS

Out of 302, 71 patients were finally included in this study. Twenty-two (31%) patients showed tumour-PV/SMV contact (group 1) and 49 (69%) did not show any contact (group 2). Patients in group 1 showed a statistically significantly higher rate of R1 and R1-direct margins compared with group 2 (95 vs 28% and 77 vs 10%) and lower median survival (24 vs 41 months, p = 0.02). Preoperative contact with PV/SMV, lymph node metastases, R1-direct margin and NO adjuvant chemotherapy were significantly associated with disease-specific survival at multivariate analysis.

CONCLUSION

Preoperative radiological tumour contact with PV/SMV in patients with NCCN resectable PDAC is associated with high rate of pathologic positive margins following surgery and poorer survival.

A drainage strategy for postoperative pancreatic fistula after left-sided pancreatectomy based on the wall status of collected fluid

PURPOSE

Postoperative pancreatic fistula (POPF) after pancreatectomy is one of the severe postoperative adverse events. We aimed to clarify the outcomes of a strategy for POPF after left-sided pancreatectomy with one-step endoscopic ultrasonography-guided drainage (EUSD) and percutaneous drainage (PCD) based on the wall status of collected fluid.

METHODS

From January 2012 to September 2017, 90 of 336 patients developed grade B/C POPF and were retrospectively analyzed. Primary outcome measures were the technical and clinical success and resolution rates. Secondary outcome measures were time from surgery to intervention, and time from intervention to discharge/resolution or stent/tube removal and adverse events.

RESULTS

Seventeen patients underwent EUSD and 73 patients underwent PCD for POPF. The technical success rates were 100% in both the EUSD and PCD groups. The clinical success and resolution rates in the EUSD group were 100%, while those in the PCD group were 98.6%. The time from surgery to intervention was significantly longer in the EUSD group than in the PCD group (20 vs. 11 days, p < 0.001). The time from intervention to discharge/resolution was significantly shorter in the EUSD group than in the PCD group (11 vs. 22 days, p < 0.001/10 vs. 20 days, p < 0.001). The time from intervention to stent/tube removal was significantly shorter in the PCD group than in the EUSD group (20.5 vs. 873 days, p < 0.001). Adverse event rates were similar in the two groups (11.8% vs. 5.5%).

CONCLUSION

A drainage strategy for POPF based on the wall status of collected fluid is appropriate.

Worldwide diffusion of robotic approach in general surgery

The robotic system has overcome some laparoscopic shortcomings, such as stereoscopic 3D-magnified vision, a stable camera and flexible and tremor filtering manipulation. Therefore, robotic surgery has made many steps forward gaining more diffusion in the field of general surgery and this trend was associated with a decrease in laparoscopic surgery. Although the safety and effectiveness of robotic surgical systems in most procedures has been confirmed, some difficult procedures have not been widely performed but rather limited to a few highly specialized centers. This study describes the worldwide diffusion of robotic surgery in their respective fields in terms of hepatectomy, gastrectomy, esophagectomy, colectomy and pancreatectomy, respectively. The worldwide diffusion of robotic surgery is uneven, which may be related to the local economic strength, government health care policies, and surgeons' preference for minimally invasive surgery of various countries and regions. In the future, with the gradual decrease of cost of robotic surgical systems, and the standardization of surgical procedures, as well as the coverage of medical insurance, we believe that robotic surgery will become the gold standard procedure in general surgery.

Imaging prediction of islet yield and post-operative insulin requirement in children undergoing total pancreatectomy with islet autotransplantation

BACKGROUND

Predicting post-operative glycemic control in children undergoing total pancreatectomy with islet autotransplantation (TPIAT) remains difficult. The purpose of our study was to explore preoperative imaging as a marker for islet yield and insulin need in pediatric patients undergoing TPIAT.

METHODS

This was a retrospective study of children (≤18 years) who had undergone TPIAT between April 2015 and December 2018 and had 6 or more months of post-TPIAT follow-up. Patient specific factors (height, weight, body mass index [BMI], body surface area [BSA]) and pancreas volume segmented from the most recent pre-operative cross-sectional imaging were explored as predictors of islet yield (total islet counts [TIC], total islet equivalents [TIE], islet equivalents per kilogram body weight [IEQ/kg]) and glycemic control (total daily dose of insulin per kilogram body weight [TDD/kg], insulin independence) using Pearson correlation and univariate and multiple regression.

RESULTS

Thirty-three patients, median age 13 years (IQR: 10-15 years), 64% female (21/33) met inclusion criteria. Nine patients (27%) achieved insulin independence at six months. Median TIE isolated was 310,000 (IQR: 200,000-460,000). Segmented pancreas volume was moderately associated with TIE (coefficient estimate = 0.34, p = 0.034). On multiple regression analysis, there was no significant predictor of insulin independence but number of attacks of pancreatitis (estimate = 0.024; p = 0.018) and segmented pancreas volume by body weight (estimate = -0.71; p < 0.001) were significant predictors of insulin TDD/kg.

CONCLUSION

Pancreas volume segmented from pre-TPIAT imaging has predictive performance for post-TPIAT insulin need in children.

Quality of Care Among Medicare Patients Undergoing Pancreatic Surgery: Safety Grade, Magnet Recognition, and Leapfrog Minimum Volume Standards-Which Quality Benchmark Matters?

BACKGROUND

The association of national quality benchmarking metrics with postoperative outcomes following complex surgery remains unknown. We assessed the relationship between the "quality trifactor" of Leapfrog minimum volume standards, Hospital Safety Grade A, and Magnet Recognition with outcomes of Medicare patients undergoing pancreatectomy.

METHODS

The Standard Analytic Files (SAF) merged with Leapfrog Hospital Survey and Leapfrog Safety Scores Denominator Files were reviewed to identify Medicare patients who underwent pancreatic procedures between 2013 and 2015. Primary outcomes were overall and serious complications, as well as 30- and 90-day mortality. Multivariable logistic regression analyses were conducted to evaluate possible associations among hospitals meeting the quality trifactor and short-term outcomes.

RESULTS

Among 4853 Medicare patients, 909 (18.7%) underwent pancreatectomy at hospitals meeting the quality trifactor. Among 260 hospitals, 7.3% (n = 19) met the quality trifactor. Safety Grade A (48.8%, n = 127) was the most commonly met criterion followed by Magnet Recognition (36.2%, n = 94); the Leapfrog minimum volume standards were achieved by 25% (n = 65) of hospitals. Patients undergoing surgery at hospitals that were only Safety Grade A and Magnet designated, but did not meet Leapfrog criteria, had higher odds of serious complications (OR 1.59, 95% CI 1.00-2.51). In contrast, patients undergoing treatment at hospitals having all three designations (i.e., the quality trifactor) had 40% and 39% lower odds of both serious complications (OR 0.60, 95% CI 0.37-0.97) and 90-day mortality (OR 0.61, 95% CI 0.42-0.89), respectively. In turn, patients undergoing pancreatectomy at quality trifactor hospitals had higher odds of experiencing the composite quality measure textbook outcome (OR 1.28, 95% CI 1.03-1.59) versus patients undergoing pancreatectomy at non-trifactor hospitals.

CONCLUSION

While Safety Grade A and Magnet designation alone were not associated with higher odds of an optimal composite outcome following pancreatectomy, compliance with Leapfrog criteria to achieve the "quality trifactor" metric was associated with lower odds of serious complications and mortality.

Promoting Pro-Endocrine Differentiation and Graft Maturation Following Surgical Resection of the Mouse Pancreas

Type 1 diabetes (T1D) is an autoimmune disease, where insulin-producing β-cells in the pancreas are inappropriately recognized and destroyed by immune cells. Islet transplantation is the most successful cell-based therapy for T1D individuals who experience frequent and severe life-threatening hypoglycemia. However, this therapy is extremely restricted owing to the limited availability of donor pancreas. In recent years, significant progress has been made in generating β-cells from stem/progenitor cells using different approaches of in vitro differentiation. The insulin production from such in vitro generated β-cells is still far less than that observed in islet β-cells. We employed a novel strategy to improve the efficiency of progenitor cell differentiation by performing partial mouse pancreas resection after transplanting in vitro generated insulin-producing cells under the kidney capsule of these mice. Pancreas resection (pancreatectomy) has been shown to induce regenerative pathways, leading to regeneration of almost the entire resected pancreas over 3-5 weeks in mice. We found that in our method, regenerating mouse pancreas promotes better graft differentiation/maturation and insulin production from transplanted cells. In this chapter, we detail the protocols used for transplantation of in vitro differentiated cells in immunocompromised mice, partial pancreatectomy in host (NOD scid) mice, and assessment of graft function. We believe that our protocols provide a solid platform for further studies aimed at understanding growth/differentiation molecules secreted from regenerating pancreas that promote graft maturation.

A Network Meta-analysis of Surgery for Chronic Pancreatitis: Impact on Pain and Quality of Life

BACKGROUND

The surgical operation associated with improved pain and quality of life (QoL) in patients with chronic pancreatitis (CP) is unknown.

METHOD

The Scopus, EMBASE, Medline and Cochrane databases were systematically searched until May 2019, and all randomised trials (RCTs) comparing surgical operations for CP pain were included in a network meta-analysis (NMA).

RESULTS

Four surgical operations for treating CP were directly compared in eight RCTs including 597 patients. Patients were mainly male (79%, 474/597) with alcoholic CP (85%, 382/452). Surgical operations included were pancreatoduodenectomy (224, 38%), Berne procedure (168, 28%), Beger procedure (133, 22%) and Frey procedure (72, 12%). The NMA revealed that the Beger procedure ranked best for pain relief, whilst the Frey procedure ranked best for postoperative QoL, postoperative pancreatic fistula rate and postoperative exocrine insufficiency rate during a median follow-up of 26 months (reported range 6-58 months). Overall the Frey procedure ranked best for the combination of primary outcome measures based on surface under cumulative ranking curve scores.

CONCLUSIONS

Overall the Frey procedure may perform the best for both pain relief and postoperative QoL in patients with CP. Further trials are warranted in defining the role of surgery in relation to endotherapy.

Laparoscopic repeated pancreatectomy for isolated local recurrence in remnant pancreas following laparoscopic radical pancreatectomy for pancreatic ductal adenocarcinoma: Two cases report

Typical treatment for recurrent pancreatic cancer is potent chemotherapy or chemoradiotherapy. However, recent clinical investigations suggest a potential therapeutic role of local resection in recurrent pancreatic cancer. Based on accumulating surgical experience of minimally invasive pancreatectomy, we report cases of two patients who underwent successful laparoscopic re-resection of isolated local recurrence following laparoscopic radical pancreatectomy for pancreatic cancer.

Recent advances in radical resection combined with arterial resection in pancreatic cancer

Pancreatic cancer (PC) is a highly malignant tumor of the digestive tract, with a very poor prognosis and a 5-year survival rate of less than 8%. Most patients with PC have lost the chance of surgery at diagnosis because of the early invasion of important peripheral blood vessels, although R0 resection is the most important standard of radical surgery for PC. In recent years, the clinical application of pancreatectomy combined with portal vein/superior mesenteric vein resection has significantly improved the survival of patients with locally advanced PC. Therefore, many scholars are investigating whether pancreatectomy combined with arterial resection can benefit patients with locally advanced PC. Here, we review the recent progress regarding the treatment of PC using pancreatectomy combined with artery resection. Artery resection is not an absolute taboo for radical surgery in PC, and in selected patients with locally advanced PC, radical R0 resection and joint artery resection could achieve a relatively good clinical effect.

Short internal pancreatic stent reduces pancreatic fistula in pancreatoduodenectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a major complication of pancreatoduodenectomy (PD). A pancreatic stent is usually used for drainage of the pancreatic duct, but the best type of the stent remains unclear. The aim of this study was to investigate perioperative factors and their influence on the risk of CR-POPF following PD.

METHODS

From 2006 to 2019, the records of 246 patients who underwent PD were retrospectively reviewed, and the relationship between perioperative factors including type of pancreatic stent and CR-POPF was investigated. External or internal pancreatic stents were used for drainage of the pancreatic duct, and the internal stent was inserted 1 cm into the jejunum to decrease stent obstruction.

RESULTS

External and internal pancreatic stents were used in 137 and 109 patients, respectively. Multivariate analysis revealed that the diameter of the main pancreatic duct (odds ratio = 0.292, 95% confidence interval = 0.140-0.605, P = 0.001), diagnosis (odds ratio = 3.359, 95% confidence interval = 1.498-7.693, P = 0.003), and type of pancreatic stent (odds ratio = 0.435, 95% confidence interval = 0.203-0.934, P = 0.033) were independent factors related to CR-POPF after PD. Internal stent was associated with a low rate of CR-POPF (P < 0.001) and short postoperative hospital stay (P < 0.001) compared to external stent.

CONCLUSION

A short pancreatic internal stent could decrease the incidence of CR-POPF.

Time interval-based indication for liver resection of metastasis from pancreatic cancer

Background

Surgical indications for liver metastases from pancreatic ductal adenocarcinoma (PDAC) are lacking because outcomes are usually poor. However, liver resection and the recent progress in perioperative chemotherapy have been observed to improve survival.

Methods

We performed liver resection for liver metastases from PDAC only under the following criteria: (1) liver-only metastasis, (2) up to three tumors, and (3) no increase in the number of metastases during the 3-month observation period. No limitations were placed on the location or size of liver metastasis. In this study, we aimed to validate our surgical criteria and analyze factors affecting survival in patients with PDAC.

Results

Seventy-nine patients underwent curative resection for PDAC between 2005 and 2015. Seventy-one patients experienced recurrence, with liver-only recurrence in 17 patients. Among these, nine patients underwent liver resection and eight did not. The median survival time was significantly better for patients who underwent liver resection (55 months) than for those with other recurrences (17.5 months, p = 0.016). The median survival after liver recurrence was significantly better in the liver resection group (31 months) than in the non-liver resection group (7 months, p = 0.0008). The median disease-free interval (DFI) after pancreatectomy was significantly longer in the liver resection group (21 months; range, 3–44 months) than in the non-liver resection group (3 months; range, 2–7 months; p = 0.02).

Conclusion

Good indications for liver metastases from PDAC include solitary metachronous tumors and longer DFIs.

Sterility Cultures Following Pancreatectomy with Islet Autotransplantation in the Pediatric Population: Do They Matter?

BACKGROUND

Pancreatectomy with islet autotransplantation (IAT) is a treatment option for children with debilitating chronic pancreatitis. Sterility cultures from preservation solutions are often positive, yet their impact has not been well studied in children.

METHODS

A retrospective review of all patients who underwent IAT from 2015 to 2018 at a single institution was performed. Sterility culture data were obtained from both the pancreas transport and islet transplant media. All patients received prophylactic perioperative meropenem and vancomycin for 72 h per our protocol. If cultures resulted positive, antibiotics were extended for a total of 7 days. Primary outcomes were postoperative fever and 30-day infectious complications.

RESULTS

Forty-one patients underwent IAT during the study period. Seventeen (41.5 %) patients had negative cultures of both the transport and transplant media, while 24 (58.5 %) patients had a positive culture from either sample. Of these patients, 13 (31.7 %) were positive in both, 10 (24.4 %) were positive in only the transport media, and 1 (2.4 %) was positive in only the transplant media. Patients with positive transplant media were similar with regard to age, gender, etiology, and disease duration compared to those with negative transplant media (all p > 0.05), but the positive group was more likely to have a pancreatic stent in place at the time of surgery (38.5 % vs. 4.2 %, p = 0.01). The overall postoperative infectious complication rate was 31.2 % (n = 13). No difference was detected between the transplant positive and negative culture groups in postoperative fever or 30-day infectious complications (p > 0.05 for each).

CONCLUSION

An existing pancreatic stent at the time of pancreatectomy with IAT is a risk factor for positive sterility cultures. However, positive islet transplant media culture was not associated with increased risk of post-IAT infection or morbidity in the setting of an empiric antibiotic protocol. Future work is necessary to study the optimal perioperative antibiotic regimen in pediatric IAT.

CT in the prediction of margin-negative resection in pancreatic cancer following neoadjuvant treatment: a systematic review and meta-analysis

OBJECTIVES

We aimed to systematically evaluate the diagnostic accuracy of CT-determined resectability following neoadjuvant treatment for predicting margin-negative resection (R0 resection) in patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

Original studies with sufficient details to obtain the sensitivity and specificity of CT-determined resectability following neoadjuvant treatment, with a reference on the pathological margin status, were identified in PubMed, EMBASE, and Cochrane databases until February 24, 2020. The identified studies were divided into two groups based on the criteria of R0 resectable tumor (ordinary criterion: resectable PDAC alone; extended criterion: resectable and borderline resectable PDAC). The meta-analytic summary of the sensitivity and specificity for each criterion was estimated separately using a bivariate random-effect model. Summary results of the two criteria were compared using a joint-model bivariate meta-regression.

RESULTS

Of 739 studies initially searched, 6 studies (6 with ordinary criterion and 5 with extended criterion) were included for analysis. The meta-analytic summary of sensitivity and specificity was 45% (95% confidence interval [CI], 19-73%; I² = 88.3%) and 85% (95% CI, 65-94%; I² = 60.5%) for the ordinary criterion, and 81% (95% CI, 71-87%; I² = 0.0%) and 42% (95% CI, 28-57%; I² = 6.2%) for the extended criterion, respectively. The diagnostic accuracy significantly differed between the two criteria (p = 0.02).

CONCLUSIONS

For determining resectability on CT, the ordinary criterion might be highly specific but insensitive for predicting R0 resection, whereas the extended criterion increased sensitivity but would decrease specificity. Further investigations using quantitative parameters may improve the identification of R0 resection.

KEY POINTS

• CT-determined resectability of PDAC after neoadjuvant treatment using the ordinary criterion shows low sensitivity and high specificity in predicting R0 resection. • With the extended criterion, CT-determined resectability shows higher sensitivity but lower specificity than with the ordinary criterion. • CT-determined resectability with both criteria achieved suboptimal diagnostic performances, suggesting that care should be taken while selecting surgical candidates and when determining the surgical extent after neoadjuvant treatment in patients with PDAC.

Distal pancreatectomy with celiac axis resection (DP-CAR): Optimal perioperative outcome in a patient with locally advanced pancreas adenocarcinoma

•

DP-CAR: A rare, technically demanding operation with significant morbidity & mortality.

•

DP-CAR may provide curative (R0) resection of an otherwise unresectable cancer.

•

Our patient had optimal perioperative outcome and excellent histology result.

•

To the best of our knowledge this is the first DP-CAR case in Greece.

Introduction

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is an operation technically demanding, uncommonly performed, even in high-volume pancreatic centers, which may offer a curative resection in patients with locally advanced cancer of the body of the pancreas, otherwise considered unresectable.

Presentation of case

We present, in clinical and technical detail, a patient with DP-CAR with a very good intraoperative and postoperative course, no complications, short hospital stay, and histology consistent with a curative resection.

Discussion

Because of the scarcity of DP-CAR, even high-volume individual centers have been able to gather relatively limited experience, and only in a time frame of more than a decade each.

Conclusion

DP-CAR can be curative for a minority of patients with pancreatic adenocarcinoma and is performed only in centers with a long, dedicated interest in advanced pancreatic surgery with a well-known track record in resection of borderline and locally advanced pancreatic cancer involving major peripancreatic veins.

Epidural Versus Transabdominal Wall Catheters: A Comparative Study of Outcomes After Pancreatic Resection

BACKGROUND

This study compared epidural analgesia with local anesthetic administration via transabdominal wall catheters (TAWC), to determine the effect on perioperative outcomes in pancreatic surgery.

MATERIALS AND METHODS

A retrospective review of patients undergoing open pancreatic surgery at Auckland City Hospital from 2015 to 2018 was undertaken. Data collected included patient demographics, type of perioperative analgesia, intravenous fluid and vasopressor use, length of high dependency unit stay, postoperative complications, and length of hospital stay.

RESULTS

Seventy-two patients underwent pancreatic surgery, of which 47 had epidural analgesia and 25 TAWC. The median age was 64 y (range 29-85). Failure of analgesia method occurred in 45% of epidural patients and 28% of TAWC patients (P = 0.209). There was no significant difference in volume of intravenous fluid given or need for vasopressors in the first 3 postoperative days, length of high dependency unit stay (median 1 d, P = 0.2836), rates of postoperative pancreatic fistula (32% versus 40%, P = 0.6046), postoperative complications (38% versus 20%, P = 0.183), or mortality (0.04% versus 0.04%, P = 1.0).

CONCLUSIONS

Epidural analgesia and TAWC may have comparable perioperative outcomes in patients undergoing pancreatic surgery. Further randomized studies with a larger cohort of patients are warranted to identify the best postoperative analgesic method in patients undergoing pancreatic resection.

Preserving a Rare Type of Variant Right Hepatic Artery Combines Surgical Radicality and Intact Liver Perfusion during Pancreatectomy

An anomalous anatomy of the celiac trunk, and particularly of the right hepatic artery, may have a significant impact on major hepatobiliary and pancreatic surgery. According to some authors, every third patient has an aberrant right hepatic artery. We present a very rare case of replaced right hepatic artery (RRHA) arising from the gastroduodenal artery associated with an accessory left hepatic artery originating from the left gastric artery in a 54-year-old woman with a pancreatic head carcinoma. The patient underwent total pancreatectomy on account of a soft lipomatous pancreas with heterogeneous changes of the pancreatic body and tail. We preserved the RRHA and achieved R0 resection margins. Preoperative evaluation of CT angiograms, an awareness of any anomalous arterial anatomy of the upper abdomen, and a meticulous surgical technique are the key to performing oncologically radical surgery without threatening the arterial liver supply.

Does Preoperative MELD Score Predict Adverse Outcomes Following Pancreatic Resection: an ACS NSQIP Analysis

BACKGROUND

Higher MELD scores correlate with adverse operative outcomes regardless of the presence of liver disease, but their impact on pancreatectomy outcomes remains undefined. We aimed to compare 30-day adverse postoperative outcomes of patients undergoing elective pancreatectomy stratified by MELD score.

METHODS

Elective pancreatoduodenectomies (PDs) and distal pancreatectomies (DPs) were identified from the 2014-2016 ACS NSQIP Procedure Targeted Pancreatectomy Participant Use Data Files. Outcomes examined included mortality, cardiopulmonary complications, prolonged postoperative length-of-stay, discharge not-to-home, transfusion, POPF, CR-POPF, any complication, and serious complication. Outcomes were compared between MELD score strata (< 11 vs. ≥ 11) as established by the United Network for Organ Sharing (UNOS). Multivariable logistic regression models were constructed to examine the risk-adjusted impact of MELD score on outcomes.

RESULTS

A total of 7580 PDs and 3295 DPs had evaluable MELD scores. Of these, 1701 PDs and 223 DPs had a MELD score ≥ 11. PDs with MELD ≥ 11 exhibited higher risk for mortality (OR = 2.07, p < 0.001), discharge not-to-home (OR = 1.26, p = 0.005), and transfusion (OR = 1.7, p < 0.001). DP patients with MELD ≥ 11 demonstrated prolonged LOS (OR = 1.75, p < 0.001), discharge not-to-home (OR = 1.83, p = 0.01), and transfusion (OR = 2.78, p < 0.001). In PD, MELD ≥ 11 was independently predictive of 30-day mortality (OR = 1.69, p = 0.007) and transfusion (OR = 1.55, p < 0.001). In DP, MELD ≥ 11 was independently predictive of prolonged LOS (OR = 1.42, p = 0.026) and transfusion (OR = 2.3, p < 0.001).

CONCLUSION

A MELD score ≥ 11 is associated with a near twofold increase in the odds of mortality following pancreatoduodenectomy. The MELD score is an objective assessment that aids in risk-stratifying patients undergoing pancreatectomy.

Preoperative Chemotherapy for Pancreatic Cancer Improves Survival and R0 Rate Even in Early Stage I

BACKGROUND

While preoperative chemotherapy for patients with stage II-III pancreatic adenocarcinoma (PDAC) is frequently practiced, its impact on very early PDAC (stage I) remains unclear today.

MATERIAL AND METHODS

Patients undergoing pancreatectomy for PDAC between 2010 and 2016 were identified in the National Cancer Database. Early-stage patients (IA-IB) with complete oncologic and clinical information and more than 30-day survival were included. The effect of preoperative chemotherapy on margin status was assessed with binary logistic regression. Following correction for confounders, the effect of therapy sequencing was assessed via comparison of preoperative, postoperative, perioperative (pre- and post-operative) chemotherapy, and surgery only using Cox regression.

RESULTS

Of 4785 patients, 688 (14.4%) were stage IA, and 4197 (87.7%) IB. The rate of preoperative chemotherapy was only 8.8%. Rate of margin positivity was lower for preoperative chemotherapy (12.3% vs 19.7%). After correcting for confounders, the risk of a positive margin was lower in preoperative chemotherapy (odd ratio [OR] 0.703, p = 0.042). Cox regression showed a significant overall survival advantage for preoperative (hazard ratio [HR] 0.784, p = 0.002), postoperative (HR 0.618, p < 0.001), and perioperative (HR 0.601, p < 0.001) chemotherapy compared with surgery alone. There was no significant difference in survival between chemotherapy groups but a trend towards optimal survival for preoperative chemotherapy.

CONCLUSION

Despite preoperative chemotherapy vs surgery alone resulting in improved R0 rates and overall survival even in stage I PDAC, it is rarely practiced. The results presented here suggest that preoperative chemotherapy should be strongly considered in all patients with resectable PDAC, including very early PDAC.