Pancreaticoduodenectomy and Its Variants

Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon

Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.

The net parenchymal thickness predicts pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort study of objective data

BACKGROUND

The clinically relevant postoperative pancreatic fistula (CR-POPF) is still a challenging complication of pancreaticoduodenectomy (PD). This study aims to explore the predictors of CR-POPF after PD, including net parenchymal thickness (NPT) of pancreatic neck.

METHODS

The consecutive patients who underwent PD at a tertiary hospital were retrospectively reviewed. Univariate and multivariate analyses were conducted on the perioperative data, which was mainly extracted from the objective data, containing the results from the laboratory tests and the imaging examination. NPT refers to the total thickness of pancreatic gland excluding main pancreatic duct (MPD) at the CT film.

RESULTS

Univariate analyses showed that total serum bilirubin (TBiL) and albumin (ALB) levels, MPD size and NPT were significantly different between the patients with and without CR-POPF. The white blood cell count, the rate of intra-abdominal infection (IAI) and the postoperative length of hospital stay (LOS) were associated with the incidence of CR-POPF. The proportion of patients with pancreatic adenocarcinoma or chronic pancreatitis was significantly lower in the CR-POPF group than in the non-CR-POPF group. Multivariate analyses manifested that ALB ≤35 g/L and NPT >10 mm were two of the independent risk factors for CR-POPF.

CONCLUSION

Preoperative ALB ≤35 g/L and NPT > 10 mm were both the independent predictors of CR-POPF. CR-POPF was associated with the higher IAI rate and the extended LOS.

Ratio of CA19-9 Level to Total Tumor Volume as a Prognostic Predictor of Pancreatic Carcinoma After Curative Resection

Background: Pancreatic ductal adenocarcinoma (PDAC) is known to have a poor prognosis, early local invasion, and distant metastasis. Surgical resection is the most effective treatment, and tumor recurrence can be the key factor affecting the surgical outcome. Serum carbohydrate antigen 19-9 (CA19-9) is a tumor marker with high sensitivity to pancreatic cancer; elevated CA19-9 levels often indicate poor biological behavior. Tumor size is also a crucial factor that affects the prognosis. Therefore, we developed a program to evaluate the effect of the ratio of CA19-9 to total tumor volume (CA19-9/TTV) as a prognostic marker on tumor recurrence and long-term survival in patients with PDAC following pancreaticoduodenectomy (PD). Methods: Data from 200 patients who underwent PD for PDAC were retrospectively analyzed. CA19-9/TTV was calculated according to preoperative CA19-9 and TTV, and patients were divided into two groups according to the optimal cut-off value. Univariate and multivariate analyses were performed on the clinicopathological data to screen the risk factors affecting postoperative recurrence and long-term prognosis of patients with PDAC undergoing PD. Results: The receiver operating characteristic curve showed that the best cut-off value was 5.62 (area under curve [AUC], 0.633; 95% CI: 0.548-0.718). Multivariate analysis showed that tumor differentiation and CA19-9/TTV were independent risk factors for the long-term prognosis of PDAC (P = 0.004, P = 0.007), as well as for tumor recurrence (P = 0.008, P = 0.008). Conclusion: CA19-9/TTV is an independent risk factor for the prognosis of PDAC and may be a new marker for lower survival benefits.

Variation and Acquisition of Complex Techniques

Background. Complex procedures often have numerous acceptable approaches; it is unclear how surgical fellows choose between techniques. We used pancreaticoduodenectomy as a model to catalogue variability between surgeons and investigate factors that affect fellows’ acquisition of techniques. Materials and methods. Semistructured interviews and operative note analysis were conducted to determine techniques of 5 attending surgeons, and these data were mapped to identify variations. Identical interviews and questioning were completed with 4 fellowship graduates whose practice includes pancreaticoduodenectomy. Results. All surgeons performed a different operation, both in order and techniques employed. Based on minor variations, there were 21 surgical step data points that differed. Of 5 surgeons, 4 were unable to identify colleagues’ techniques. Fellows reported adopting techniques from mentors who had regimented techniques, teaching styles they related to, and with whom they frequently operated. Residency training did not strongly influence their choice of technique; however, senior partners after fellowship did influence technique. Conclusions. The number of variants of pancreaticoduodenectomy based on granular, step-by-step differences is larger than previously described. Results hint that variation may be furthered by the fact that surgeons are not aware of the techniques used by colleagues. Fellows choose techniques based on factors not directly related to their own outcomes but rather mentor factors. Whether fellows adopt techniques that will be optimal given their abilities is worthy of further investigation, as are changes in technique over time. Better codification of variation is needed to facilitate these investigations as well as matching of technical variations to patient outcomes.