Histometric analysis of the distal pancreas in pancreatic head cancer

Central pancreatectomy of the remnant pancreas without reconstruction after pancreatoduodenectomy

BACKGROUND

There are several reports on the safety and feasibility of pancreatoduodenectomy (PD) without reconstruction of the small remnant pancreas. However, a few studies have explored central pancreatectomy (CP) for non-reconstructed small remnant pancreases after PD. This study presents a case of CP without pancreatic reconstruction after PD.

CASE PRESENTATION

A 58-year-old man with cerebral palsy underwent PD for distal cholangiocarcinoma. Three years postoperatively, a 12-mm tumor was detected in the remnant pancreatic body and diagnosed as a pancreatic neuroendocrine neoplasm. Surgical resection was performed, because the tumor was enlarged and chemotherapy resistant. The afferent loop with pancreatojejunostomy anastomosis was dissected, and CP, including pancreatojejunostomy anastomosis, was performed. Given the remnant pancreas was hard and atrophic, the pancreatic tail was transected using a stapler without reconstructing the small remnant pancreas. The patient experienced no postoperative complications including postoperative pancreatic fistula, and the endocrine function of the pancreas was preserved.

CONCLUSIONS

We present a case of remnant pancreatic CP that did not require reconstruction after PD. Preservation of the small remnant pancreas without reconstruction during CP may be feasible to maintain endocrine function in select patients after PD.

Machine learning to predict completion of treatment for pancreatic cancer

BACKGROUND

Chemotherapy enhances survival rates for pancreatic cancer (PC) patients postsurgery, yet less than 60% complete adjuvant therapy, with a smaller fraction undergoing neoadjuvant treatment. Our study aimed to predict which patients would complete pre- or postoperative chemotherapy through machine learning (ML).

METHODS

Patients with resectable PC identified in our institutional pancreas database were grouped into two categories: those who completed all intended treatments (i.e., surgery plus either neoadjuvant or adjuvant chemotherapy), and those who did not. We applied logistic regression with lasso penalization and an extreme gradient boosting model for prediction, and further examined it through bootstrapping for sensitivity.

RESULTS

Among 208 patients, the median age was 69, with 49.5% female and 62% white participants. Most had an Eastern Cooperative Oncology Group (ECOG) performance status of ≤2. The PC predominantly affected the pancreatic head. Neoadjuvant and adjuvant chemotherapies were received by 26% and 47.1%, respectively, but only 49% completed all treatments. Incomplete therapy was correlated with older age and lower ECOG status. Negative prognostic factors included worsening diabetes, age, congestive heart failure, high body mass index, family history of PC, initial bilirubin levels, and tumor location in the pancreatic head. The models also flagged other factors, such as jaundice and specific cancer markers, impacting treatment completion. The predictive accuracy (area under the receiver operating characteristic curve) was 0.67 for both models, with performance expected to improve with larger datasets.

CONCLUSIONS

Our findings underscore the potential of ML to forecast PC treatment completion, highlighting the importance of specific preoperative factors. Increasing data volumes may enhance predictive accuracy, offering valuable insights for personalized patient strategies.

Increased plasma levels of IL-6 and IL-8 are associated with surgical site infection after pancreaticoduodenectomy

OBJECTIVES

Cytokines and chemokines potentially modulate postoperative immune response. Association of circulating cytokines and chemokines with postoperative infectious complications after pancreaticoduodenectomy was evaluated.

METHODS

Plasma concentrations of interleukin (IL) 6, IL-10, IL-8, macrophage chemoattractant protein 1, heat shock protein 70, and amylase, as well as amylase levels in peritoneal exudative fluid, were measured perioperatively in 60 consecutive patients who underwent pancreaticoduodenectomy.

RESULTS

Of the 60 patients, 27 patients had surgical site infection (SSI), including peritoneal infection in all, intra-abdominal abscess in 14, and radiologically visualized pancreatic leakage in 6. Postoperative plasma levels of IL-6, IL-8, and macrophage chemoattractant protein 1, as well as peritoneal amylase levels, were significantly higher in patients with SSI than in those without SSI (P < 0.05). Nonpancreatic cancer as a histopathologic diagnosis, high pancreatic juice flow, and increased levels of IL-6 and IL-8 were independently associated with SSI (P < 0.05) in multiple logistic regression analysis. Plasma levels of IL-6 and IL-10 among patients with SSI were significantly higher in those with pancreatic leakage than in those without leakage.

CONCLUSIONS

These results suggest that, in addition to pancreatic exocrine function, IL-6 and IL-8 are associated with postoperative SSI, including pancreatic leakage after pancreaticoduodenectomy.

Use of the time-signal intensity curve from dynamic magnetic resonance imaging to evaluate remnant pancreatic fibrosis after pancreaticojejunostomy in patients undergoing pancreaticoduodenectomy

BACKGROUND

This study assessed the value of the time-signal intensity curve (TIC) obtained from dynamic magnetic resonance imaging (MRI) in the evaluation of remnant pancreatic fibrosis after pancreaticojejunostomy in patients undergoing pancreaticoduodenectomy.

METHODS

Two modes of pancreaticojejunostomy-duct-to-mucosa anastomosis (DMA; 24 patients) and pancreatojejunoserosal anastomosis (PJSA; 22 patients)-were used in 46 consecutive patients undergoing pancreaticoduodenectomy. All patients underwent dynamic contrast-enhanced MRI of the pancreas before pancreaticoduodenectomy. Retrospective review of the pancreatic magnetic resonance images and histological examination of the pancreas were performed, and the patterns of TICs from dynamic MRI were compared with the degree of pancreatic fibrosis. Dynamic MRI of the residual pancreas was carried out for 1-3 years after pancreaticoduodenectomy in 26 patients (14 DMA, 12 PJSA) who had a histologically verified normal pancreas with no fibrosis at the time of pancreaticoduodenectomy.

RESULTS

Evaluation of preoperative dynamic magnetic resonance images showed that a pancreatic TIC with a rapid rise to a peak followed by a rapid decline (type I) was characteristic of a normal pancreas without fibrosis. Pancreatic TICs with a slow rise to a peak followed by a slow decline or a plateau (types II and III) indicated a fibrotic pancreas. Postoperative pancreatic MRI demonstrated that six of 12 patients with a PJSA had a type II TIC, whereas 12 of 14 patients with a DMA had a type I curve (P = 0.046).

CONCLUSION

The TIC obtained from dynamic MRI is a reliable indicator of fibrosis in the remnant pancreas after pancreaticoduodenectomy. Use of a DMA was associated with a lower risk of pancreatic fibrosis 1-3 years after surgery than a PJSA.