Pancreatectomy and Pancreatic Surgery

Development and validation of a novel predictive model for postpancreatectomy hemorrhage using lasso-logistic regression: an international multicenter observational study of 9631 pancreatectomy patients

BACKGROUND

Hemorrhage following pancreatectomy represents a grave complication, exerting a significant impact on patient prognosis. The formulation of a precise predictive model for postpancreatectomy hemorrhage risk holds substantial importance in enhancing surgical safety and improving patient outcomes.

MATERIALS AND METHODS

This study utilized the patient cohort from the American College of Surgeons National Surgical Quality Improvement Program database, who underwent pancreatectomy between 2014 and 2017 ( n =5779), as the training set to establish the Lasso-logistic model. For external validation, a patient cohort ( n =3852) from the Chinese National Multicenter Database of Pancreatectomy Patients, who underwent the procedure between 2014 and 2020, was employed. A predictive nomogram for postpancreatectomy hemorrhage was developed, and polynomial equations were extracted. The performance of the predictive model was assessed through the receiver operating characteristic curve, calibration curve, and decision curve analysis.

RESULTS

In the training and validation cohorts, 9.0% (520/5779) and 8.5% (328/3852) of patients, respectively, experienced postpancreatectomy hemorrhage. Following selection via lasso and logistic regression, only nine predictive factors were identified as independent risk factors associated with postpancreatectomy hemorrhage. These included five preoperative indicators [BMI, American Society of Anesthesiologists (ASA) ≥3, preoperative obstructive jaundice, chemotherapy within 90 days before surgery, and radiotherapy within 90 days before surgery], two intraoperative indicators (total operation time, vascular resection), and two postoperative indicators (postoperative septic shock, pancreatic fistula). The new model demonstrated high predictive accuracy, with an area under the receiver operating characteristic curve of 0.87 in the external validation cohort. Its predictive performance significantly surpassed that of the previous five postpancreatectomy hemorrhage risk prediction models ( P <0.001, likelihood ratio test).

CONCLUSION

The Lasso-logistic predictive model we developed, constructed from nine rigorously selected variables, accurately predicts the risk of PPH. It has the potential to significantly enhance the safety of pancreatectomy surgeries and improve patient outcomes.

Endovascular Treatment of Hepatic Artery Pseudoaneurysm after Pancreaticoduodenectomy: A Literature Review

Pancreaticoduodenectomy (PD) is a complex surgical procedure performed in patients with periampullary tumors located within the pancreatic head, the papilla of Vater, the distal common bile duct, and the duodenum. In advanced tumors, the operative technique involves the need for dissection and divestment of the arteries located within the pancreaticoduodenal field, including the common hepatic artery (CHA) and the proper hepatic artery (PHA) and its branches. The second most important cause of post-PD visceral aneurysms is irritation of the peri-pancreatic arterial wall by pancreatic juice in a postoperative pancreatic fistula (POPF). Hepatic artery pseudoaneurysm (HAP) is a very dangerous condition because it is usually asymptomatic, but it is a rare and potentially lethal pathology because of the high risk of its rupture. Therefore, HAP requires treatment. Currently, selective celiac angiography is the gold-standard diagnostic and therapeutic management for postoperative bleeding and pseudoaneurysm in patients following PD. Open surgery and less invasive endovascular treatment are performed in patients with HAP. Endovascular treatment involves transarterial embolization (TAE) and stent graft implantation. The choice of treatment method depends on the general and local conditions, such as the patient's hemodynamic stability and arterial anatomy. In patients in whom preservation of the flow within the hepatic artery (to prevent hepatic ischemia complications such as liver infarction, abscess, or failure) is needed, stent graft implantation is the treatment of choice. This article focuses on a review of two common methods for endovascular HAP treatment. In addition, risk factors and diagnostic tools have been described.

Mahamana Technique of Pancreaticogastrostomy: A Safe and Reliable Technique for a Difficult Pancreatic Stump

Pancreatoduodenectomy is a complex surgical procedure involving three anastomoses. Anastomosis of the pancreatic stump with the gastrointestinal tract is associated with most complications described in the postoperative period. So, there have been multiple attempts to discover safe and sound steps for this particular anastomosis. Pancreaticogastrostomy involves anastomosis between the remaining pancreas and stomach. Since it was first performed, its surgical steps have been modified multiple times, but there is no gold standard method to perform it. In this paper, we describe the surgical steps of pancreaticogastrostomy in difficult pancreatic stumps in eight patients using two transpancreatic sutures, one purse string suture, and the incorporation of transpancreatic sutures in the third layer of the gastrojejunostomy anastomosis. Postoperative outcomes of this series have provided encouraging short-term results.

Impact of Cachexia on Chemotherapy Efficacy and Survival in Pancreatic Cancer: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Pancreatic cancer (PC) is a significant cause of cancer-related mortality, with limited curative options and high rates of cachexia, a debilitating syndrome associated with poor prognosis. While previous research has linked sarcopenia to poor outcomes in PC, the correlation between cachexia and treatment outcomes remains underexplored. This meta-analysis aims to investigate the association between cachexia and overall survival and time to treatment failure in advanced PC patients undergoing first-line chemotherapy.

METHOD

A systematic search of electronic databases was conducted following PRISMA guidelines. Eligible studies compared cachexic and non-cachexic PC patients, reporting outcomes of observed survival or time to treatment failure. Data extraction and analysis were performed using Comprehensive Meta-Analysis Version 3.3, employing random-effects models and sensitivity analyses to assess heterogeneity and bias.

RESULTS

Seven observational studies involving 2834 PC patients were included. The incidence of cachexia was 45% (95% CI: 0.27-0.65), with a higher prevalence in East Asian populations. Cachexic patients experienced significantly earlier treatment failure (SDM: -2.22, 95% CI: -2.6 to -1.7, P = 0.0001) and higher mortality risk (HR: 2.02, 95% CI: 1.17-3.48, P = 0.011) compared to non-cachexic patients. Overall survival was lower in cachexic patients (SDM: -2.34, 95% CI: -3.7 to -0.90, P = 0.001), with considerable heterogeneity across studies. Meta-regression analysis revealed significant differences between countries but insignificant correlations with age.

CONCLUSION

Cachexia is associated with reduced overall survival, early chemotherapy failure, and elevated mortality in advanced PC patients undergoing first-line chemotherapy. Recognition and management of cachexia are crucial for optimizing treatment outcomes and improving patient survival. Future research should focus on prospective studies to better understand the impact of cachexia on treatment response and develop tailored interventions to mitigate its adverse effects.