Feasibility and Safety of Laparoscopic Radical Distal Pancreatosplenectomy with Adrenalectomy in Advanced Pancreatic Cancer.

INTRODUCTION: Pancreatic adenocarcinoma is a lethal condition with poor outcomes and an increasing incidence.1 However, recent meta-analysis reported improved survival and R0 resection rate following neoadjuvant chemotherapy with subsequent surgery in initially unresectable pancreatic cancer.2 In addition, as a result of technological advances during the past 2 decades, even in pancreatic cancers, minimally invasive surgery (MIS) approaches are being used more frequently and safely.3-5 This video shows the feasibility and safety of laparoscopic resection in advanced left-sided pancreatic cancer. METHOD: The patient was a 63-year-old male with hypertension and diabetes. Initial computed tomography (CT) scan showed a 31 mm-sized pancreatic tail cancer with celiac artery and left adrenal gland abutment. The patient underwent neoadjuvant chemotherapy due to the risk of retroperitoneal cancer infiltration. After four cycles of FOLFIRINOX chemotherapy, follow-up CT scan showed the tumor decreased to 2.6 cm and celiac artery abutment became less prominent. Based on the CT scan, laparoscopic radical distal pancreatosplenectomy with left adrenalectomy was planned. RESULTS: A five-port laparoscopic approach was performed, including three 12 mm trocars and an additional two 5 mm trocars. Initial intra-abdominal exploration showed no peritoneal seeding or micro liver metastasis. Gastric wedge resection was added due to cancer invasion for margin-negative resection. Operation time was 215 min and estimated blood loss was 200 cc without transfusion. The patient was discharged on postoperative day 6 without any complications, including postoperative pancreatic fistula. CONCLUSION: Laparoscopic distal pancreatosplenectomy can be technically feasible and safe to obtain negative resection margins in well-selected patients following neoadjuvant therapy in locally advanced pancreatic cancer.6.

Preoperative prognostic nutritional index as an independent prognostic factor for resected ampulla of Vater cancer.

INTRODUCTION: Prognostic nutritional index (PNI) reflects the nutritional and immunologic status of the patients. The clinical application of PNI is already well-known in various kinds of solid tumors. However, there is no study investigating the relationship between PNI and oncological outcome of the resected ampulla of Vater (AoV) cancer. MATERIALS AND METHODS: From January 2005 to December 2012, the medical records of patients who underwent pancreaticoduodenectomy for pathologically confirmed AoV cancer were retrospectively reviewed. Long-term oncological outcomes were compared according to the preoperative PNI value. RESULT: A total of 118 patients were enrolled in this study. The preoperative PNI was 46.13±6.63, while the mean disease-free survival was 43.88 months and the mean disease-specific survival was 55.3 months. In the multivariate Cox analysis, initial CA19-9 (p = 0.0399), lymphovascular invasion (p = 0.0031), AJCC 8th N-stage (p = 0.0018), and preoperative PNI (p = 0.0081) were identified as significant prognostic factors for resected AoV cancer. The disease-specific survival was better in the high preoperative PNI group (≤48.85: 40.77 months vs. >48.85: 68.05 months, p = 0.0015). A highly accurate nomogram was developed based on four clinical components to predict the 1, 3, and 5-year disease-specific survival probability (C-index 0.8169, 0.8426, and 0.8233, respectively). CONCLUSION: In resected AoV cancer, preoperative PNI can play a significant role as an independent prognostic factor for predicting disease-specific survival.

Prognostic potential of the preoperative plasma complement factor B in resected pancreatic cancer: A pilot study.

BACKGROUND: For patients with pancreatic cancer, a preoperative assessment of prognosis is crucial to predict cancer recurrence and to prepare a postoperative adjuvant strategy and appropriate patient-counsel. OBJECTIVE: We evaluated the prognostic predictive power of complement factor B (CFB) by comparing it to that of other known tumor markers in resected pancreatic cancer patients. METHODS: From 2012 to 2013 period, we retrospectively reviewed the plasma CFB levels of 35 pancreatic cancer patients. The patients were divided into two groups according to serologic CFB values. Disease-free survival (DFS) and overall survival (OS) rates were analyzed. RESULTS: Based on the cut-off values of plasma CFB, 15 patients were placed in the low CFB group and the other 20 patients were placed in the high CFB group. There was a significant difference in DFS between the two groups (Low CFB vs. High CFB: 36.9 months vs. 13.9 months, p: 0.007). In the OS analysis, there was also a significant difference in the survival rates of the two groups (Low CFB vs. High CFB: 49.7 months vs. 29.0 months, p: 0.048). CONCLUSION: Preoperative plasma CFB can be used to predict the prognosis of resectable pancreatic cancers; it outperforms both CA 19-9 and CEA.

Aggressiveness of solid pseudopapillary neoplasm of the pancreas: A literature review and meta-analysis.

BACKGROUND: Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare tumors considered to be benign although 10% to 15% of SPNs have been reported to be aggressive. Due to its rarity, there have only been a few cases reported regarding the clinical course of patients with aggressive SPNs. The goal of this study is to describe the clinical course of patients diagnosed with aggressive SPNs. METHODS: A PubMed search was done looking for articles describing the clinical course of patients diagnosed with SPN that locally invaded, recurred, or metastasized. Institutional experience was also added to the pooled data. Patient information was extracted from the articles. Survival and recurrence curves were plotted and factors associated with survival and recurrences were analyzed. RESULTS: A total of 59 patients were identified to have aggressive SPN. Seven patients were males and 52 were females and the mean age was 37.44 ±â€Š2.21 years. Systemic metastasis constituted 81.4% while recurrence and deep tissue invasion were found in 11.9% and 6.8% of the patients, respectively. Disease-free survival was 45 ±â€Š6.28 months and disease-specific survival was 152.67 ±â€Š12.8 months. In survival analysis, age, gender, tumor size, tumor location, combined resection, type of recurrence, and stage IV on diagnosis were not significant factors in predicting survival. However, an unresectable tumor (hazards ratio [HR] = 4.871, 95% confidence interval [CI] 1.480-16.03, P = .009), and metastasis within 36 months (HR = 6.399, 95% CI: 1.390-29.452, P = .017) were identified as independent variables in predicting survival. CONCLUSION: SPNs of the pancreas carry a favorable course. Despite having aggressive properties, patients can still survive for more than 10 years as long as the tumor can be resected completely.

Oncologic outcomes after radical surgery for periampullary cancer in octogenarians.

BACKGROUNDS/AIMS: Interest in treatments for elderly patients has increased with life expectancy, and various studies have reported on the safety and feasibility of radical surgery in elderly patients with cancer. Here, we investigated oncologic outcomes of periampullary cancer in octogenarians. METHODS: We retrospectively reviewed medical records of 68 patients over 80 years of age who were diagnosed with periampullary cancer and were eligible for surgery; we analyzed overall survival (OS) and immediate postoperative complications and mortality. RESULTS: There were no significant differences in mean age, disease type, oncologic features, comorbidities, or nutritional status between the patients who had surgery and those who did not. Five patients (20.0%) had major postoperative complications, but there was no immediate postoperative mortality. Patients who had surgery (n=25) had better OS (29.3 months; 95% confidence interval [CI]: 5.6-53.0) than did those who did not (n=43, OS: 7.6 months; 95% CI: 3.2-12.0 months; p<0.001). Similarly, patients with distal common bile duct cancer who underwent surgery had better OS than those who did not (surgery group: n=13, OS: 29.3 months, 95% CI: 8.9-49.7; non-surgery group: n=15, OS: 5.7 months, 95% CI: 4.2-7.2 months; p=0.002). CONCLUSIONS: Radical surgery for octogenarian patients with periampullary cancer is safe, feasible, and expected to result in better survival outcomes, especially for patients with common bile duct cancer.

Predictors for Amputation in Patients with Diabetic Foot Wound.

PURPOSE: Diabetic foot wound (DFW) is known as a major contributor of nontraumatic lower extremity amputation. We aimed to evaluate overall amputation rates and risk factors for amputation in patients with DFW. MATERIALS AND METHODS: From January 2014 to December 2017, 141 patients with DFW were enrolled. We determined rates and risk factors of major amputation in DFW and in DFW with peripheral arterial occlusive disease (PAOD). In addition, we investigated rates and predictors for amputation in diabetic foot ulcer (DFU). RESULTS: The overall rate of major amputation was 26.2% in patients with DFW. Among 141 DFWs, 76 patients (53.9%) had PAOD and 29 patients (38.2%) of 76 DFWs with PAOD underwent major amputation. Wound state according to Wagner classification, congestive heart failure, leukocytosis, dementia, and PAOD were the significant risk factors for major amputation. In DFW with PAOD, Wagner classification grades and leukocytosis were the predictors for major amputation. In addition, amputation was performed for 28 patients (38.4%) while major amputation was performed for 5 patients (6.8%) of 73 DFUs. Only the presence of osteomyelitis (OM) showed significant difference for amputation in DFU. CONCLUSION: This study represented that approximately a quarter of DFWs underwent major amputation. Moreover, over half of DFW patients had PAOD and about 38.2% of them underwent major amputation. Wound state and PAOD was major predictors for major amputation in DFW. Systemic factors, such as CHF, leukocytosis, and dementia were identified as risk factors for major amputation. In terms of DFU, 38.4% underwent amputation and the presence of OM was a determinant for amputation.