Thrombosis and anticoagulation after portal vein reconstruction during pancreatic surgery - A systematic review.

OBJECTIVE: To comprehensively assess thrombotic events and their clinical impact in patients receiving pancreatic surgery with venous resection and reconstruction. BACKGROUND: Portal vein (PV, including the portal vein and superior mesenteric vein) resection and reconstruction enables surgical removal of borderline-resectable and locally advanced pancreatic cancer. Thrombosis of the reconstructed PV represents a major source of early postoperative and long-term morbidity and mortality. No universally accepted standard for anticoagulation exists. Here, we aimed to assess early and late thrombosis rates after PV reconstruction with special regard to type of PV reconstruction as well as anticoagulation regimen. METHODS: PRISMA guidelines were followed. Studies reporting on PV resection and reconstruction providing data on thrombosis rates were included. The following parameters were assessed: Study type, year of publication, number of patients, type/number of PV reconstruction, follow-up period, postoperative mortality, rate of thrombosis of reconstructed PV axis, intraoperative blood loss, and anticoagulation. RESULTS: 23 studies with 2751 patients were included in the final analysis. 670 patients received tangential resection of the PV with venorrhaphy or patch repair, 1505 patients had segmental resection with end-to-end reconstruction, and 576 patients received reconstruction with an interposition graft/conduit. The pooled overall thrombosis rate was 15%. Reconstruction of tangential defects with either venorrhaphy or patch repair as well as end-to-end repair of segmental defects resulted in a thrombosis rate of 12%. Subgroup analysis according to the type of graft reconstruction revealed the highest occlusion rates of 55% in patients with allogeneic grafts, followed by up to 27% in patients with synthetic PV conduits. Autologous conduits had a thrombosis rate of 10%. Early thrombotic events were detected in 5% of patients after venorrhaphy/patch reconstruction and end-to-end reconstruction. Early events were most common in the allogeneic graft subgroup (22%), followed by synthetic conduits (15%). There were fewer early events in the autologous graft group (7%). Early PV thrombosis was associated with relevant mortality of up to 26%. Anticoagulation regimens varied between studies. CONCLUSION: The overall rate of thrombosis after portal vein resection is low. However, among different reconstruction techniques, allogeneic interposition grafts/conduits had the highest thrombosis rates among the different types of reconstruction after PV resection. No specific anticoagulation strategy can be considered beneficial on the basis of the existing literature. MINI-ABSTRACT: Thrombosis of the reconstructed portal vein (PV) after PV resection in pancreatic surgery represents a relevant source of major morbidity and mortality. In this systematic review, while we observed an overall low thrombosis rate following PV resection, reconstruction with allogeneic grafts harbors the highest risk of postoperative thrombosis. Early thrombosis was most common after reconstruction with allogeneic grafts and associated with postoperative mortality. Anticoagulation strategies vary greatly among different studies.

Prevalence of metabolic dysfunction-associated fatty liver disease after pancreatic surgery in a historical Belgian cohort and review of the literature.

Background and objectives: Metabolic dysfunction-associated fatty liver disease (MAFLD) has been reported as a complication after pancreatic surgery. The aim of this study is to assess this phenomenon in a Belgian population, specifically in a period in time when less perioperative chemotherapy was given. Methods: We performed a retrospective monocentric cohort study with 124 selected patients who underwent pancreatic surgery - pancreaticoduodenectomy (PD), distal pancreatectomy (DP) or total pancreatectomy - between 2005 and 2014. Steatosis was assessed radiologically, using Hounsfield units on liver and spleen. Data on imaging, liver function, weight and other relevant parameters were gathered preoperatively as well as 2 and 6 months, 1 and 2 years after surgery. Results: Thirty-eight (31%) out of 124 patients developed liver steatosis at least at one point in time in the two years following surgery, with a prevalence of 21.0% at 2 months, 28.6% at 6 months, 16.4% at 1 year and 20.8 % at 2 years. A statistically significant association with preoperative AST and ALT values, administration of pancreatic enzyme supplementation as a surrogate for pancreatic exocrine insufficiency (PEI) and weight loss at 2 years was detected. Conclusion: MAFLD is seen in 31% of patients with PD or DP pancreatic resection in this retrospective analysis of a monocentric Belgian cohort. Both early and late onset of MAFLD was observed, implying that long-term follow-up is necessary. Clinical impact as well as a direct correlation with patients' weight and oral enzyme supplements needs to be further investigated.

Transduodenal resection of a large papillary tumor by means of intraoperative cholangioscopy.

INTRODUCTION: Papillary adenomas are very rare benign tumors of the gastrointestinal tract. If manageable, purely endoscopic resection is favored. As an alternative, surgical resection via ampullectomy or pancreaticoduodenectomy can be performed. Often, the depth of infiltration cannot be assessed with sufficient precision, leading to pancreaticoduodenectomy for safety reasons. CASE PRESENTATION: We present the case of a 77-year-old patient in whom a transduodenal papillary resection of a large papillary adenoma was performed, after two unsuccessful endoscopic attempts. Intraoperatively, a 3 cm large papillary adenoma was identified in the duodenum. The infiltration depth into the Vater's papilla was evaluated through intraoperative cholangioscopy. Due to the shallow depth of invasion, we strived for a papillary resection under endoscopic guidance, allowing complete tumor removal. The postoperative course was uneventful, and the patient was discharged on postoperative day 14. CLINICAL DISCUSSION: The decision between ampullectomy and pancreaticoduodenectomy is an intraoperative challenge. Intraoperative cholangioscopy demonstrated its potential to aid this decision-making process in this case. Larger-scale studies are needed to establish its clinical value. CONCLUSION: Intraoperative cholangiography can help surgeons assess the depth of infiltration of large papillary adenomas, leading to more precise surgical decisions about the necessary extent of resection.

Surgical treatment of chronic pancreatitis with an inflammatory pancreatic head mass: a retrospective study.

BACKGROUND: Conservative treatment of chronic pancreatitis has only a limited effect in most patients. Surgery offers very good long-term results, even in the early stages of the disease. Unfortunately, only a minority of patients undergo surgical treatment. The aim of this work was to summarise the current treatment options for patients with an inflammatory mass of the pancreatic head. Data from patients in our study demonstrates that the surgery is a safe method, and here we compare the perioperative and early postoperative outcomes of patients who underwent a pancreatoduodenectomy and duodenum-preserving pancreatic head resection for chronic pancreatitis. METHODS: All patients who underwent a pancreaticoduodenectomy or a duodenum-preserving pancreatic head resection in our department between 2014 and 2022 were included in this study. Perioperative and early postoperative results were statistically analysed and compared. RESULTS: Thirty-eight pancreaticoduodenectomies and 23 duodenum-preserving pancreatic head resections were performed. The overall mortality was 3%, whereas the in-hospital mortality after pancreaticoduodenectomy was 5%. The mortality after duodenum-preserving pancreatic head resection was 0%. No statistically significant differences in the hospital stay, blood loss, and serious morbidity were found in either surgery. Operative time was significantly shorter in the duodenum-preserving pancreatic head resection group. CONCLUSIONS: Both pancreatoduodenectomy and duodenum-preserving pancreatic head resection are safe treatment options. Duodenum-preserving pancreatic head resection showed a statistically significant superiority in the operative time compared to pancreaticoduodenectomy. Although other monitored parameters did not show a statistically significant difference, the high risk of complications after pancreaticoduodenectomy with a mortality of 5%; maintenance of the duodenum and upper loop of jejunum, and lower risk of metabolic dysfunctions after duodenum-preserving pancreatic head resection may favour duodenum-preserving pancreatic head resection in recommended diagnoses. Attending physicians should be more encouraged to use a multidisciplinary approach to assess the suitability of surgical treatment in patients with chronic pancreatitis.

DRG payment for major pancreatic surgery: analysis of resource consumption and suggestions from a tertiary hospital in China.

Aim: To investigate the cost homogeneity within the Diagnosis-Related Group (DRG) "major operation of pancreas and liver, with general complications or comorbidities" (HB13), its cost-influencing factors, and to propose suggestions for better grouping efficacy. Methods: Medical and insurance settlement data of inpatients covered by the DRG payment system at the author's institution were collected from March 15, 2022 to December 31, 2023. The cost homogeneity of group HB13 was assessed using the coefficient of variation (CV). Clinical factors that may have an impact on hospitalization cost for patients undergoing pancreatic surgery were identified through a semi-structured interview administered to the pancreatic surgeons in author's department, their significance was analyzed using multiple linear regression, along with their impact on the cost of different service categories. A proposal to subdivide HB13 was made and evaluated by CV and t-test. Results: The CV of the HB13 group was 0.4. Robotic-assisted surgery and pancreaticoduodenectomy were two independent factors that significantly affected the total cost. Patients undergoing robotic-assisted surgery have an average increase of 41,873 CNY in total cost, primarily derived from operation fee. Patients undergoing pancreaticoduodenectomy have an average increase of 37,487 CNY in total cost, with significant increases across all service categories. HB13 was subdivided based on whether pancreaticoduodenectomy was performed. The newly formed groups exhibited lower CVs than the original HB13. Conclusion: The cost homogeneity of HB13 was lower than that of other DRG groups in author's department. It is recommended to introduce a supplementary payment for patients requiring robotic-assisted surgery, to guarantee their access to this advanced technology. It is recommended to establish a new group with higher payment standard for patients undergoing pancreaticoduodenectomy. A tiered CV criterion for the evaluation of grouping efficacy is recommended to increase intra-group homogeneity, facilitating a better allocation of health insurance funds, and the prevention of unintended negative outcomes such as service cuts and cherry-picking.

Comprehensive Geriatric Assessment, Treatment Decisions, and Outcomes in Older Patients Eligible for Pancreatic Surgery.

INTRODUCTION: Periampullary cancer has a poor prognosis. Surgical resection is a potentially curative but high-risk treatment. Comprehensive geriatric assessment (CGA) can inform treatment decisions, but has not yet been evaluated in older patients eligible for pancreatic surgery. METHODS: This prospective observational study included patients ≥ 70 years of age eligible for pancreatic surgery. Frailty was defined as impairment in at least two of five domains: somatic, psychological, functional, nutritional, and social. Outcomes included postoperative complications, functional decline, and mortality. RESULTS: Of the 88 patients included, 87 had a complete CGA. Sixty-five patients (75%) were frail and 22 (25%) were non-frail. Frail patients were more likely to receive nonsurgical treatment (43.1% vs. 9.1% p = 0.004). Fifty-seven patients underwent surgery, of which 52 (59%) underwent pancreaticoduodenectomy. The incidence of postoperative delirium was three times higher in frail patients (29.7% vs. 0%, p = 0.005). The risk of mortality was three times higher in frail patients (HR: 3.36, 95% CI: 1.43-7.89, p = 0.006). CONCLUSION: Frailty is common in older patients eligible for pancreatic surgery and is associated with treatment decision, a higher incidence of delirium and a three times higher risk of all-cause mortality. CGA can contribute to shared decision-making and optimize perioperative care in older patients.

How to Reduce Delayed Gastric Emptying After Pancreatoduodenectomy: A Systematic Literature Review and Meta-Analysis.

Introduction: The occurrence of delayed gastric emptying (DGE) following pancreatoduodenectomy is of high clinical relevance. Despite the pivotal nature of this topic, the existing evidence is limited and often conflicting. This meta-analysis aims to assess the impact of various interventions, such as the type of surgical reconstruction (specifically pylorus resection or preservation), enhanced recovery after surgery (ERAS), epidural anesthesia (EA), as well as strategies involving nasogastric decompression on DGE. Methods: Following the PRISMA guidelines, a systematic search was conducted. Studies that compared patients undergoing pancreatoduodenectomy regarding one of the following interventions were included: pylorus-preserving pancreaticoduodenectomy (ppPD) versus pylorus-resecting pancreaticoduodenectomy (prPD), ERAS versus no ERAS, epidural anesthesia EA versus no EA, nasogastric decompression versus no nasogastric decompression and jejunostomy/nasojejunal feeding tube placement (J/NJF) versus no J/NJF. Results: The analysis included 5930 patients from 29 studies. Patients undergoing ppPD exhibited a higher incidence of DGE compared with those undergoing prPD (logOR, -0.95; 95% CI = -1.57 to -0.34; P = 0.002). Additionally, patients in the ERAS group showed reduced rates of DGE (logOR, -0.712; 95% CI = -1.242 to -0.183; P = 0.008). Lower rates of DGE were observed in patients without a J/NJF (logOR, -0.618; 95% CI, 0.39-0.84; P < 0.001). Conclusion: In summary, our meta-analysis reveals that pylorus resection, adherence to ERAS protocols, and the absence of a J/NJF are associated with lower rates of DGE after pancreatoduodenectomy. Although these results are partially based on observational studies, they contribute valuable insights to the current understanding of interventions impacting DGE in these complex procedures.

Bacterial shift and resistance pattern in pancreatic head resections after selective decontamination of the digestive tract - a propensity score-matched analysis.

BACKGROUND: Pancreatic head resection is associated with postoperative morbidity, primarily because of infectious complications. The microbiota in these infections is crucial, and selective decontamination of the digestive tract (SDD) aims to mitigate this risk by targeting pathogenic organisms while preserving beneficial flora. This study aimed to determine the effect of SDD on bacterial shifts and resistance patterns in pancreatic head resection. METHODS: All patients who underwent pancreatic head resection either between January 2012 and August 2018 (non-SDD group) or between January 2019 and December 2021 (SDD group) were included. Propensity score-matched analysis was performed to compare the bacterial presence and resistance patterns in bile duct smear tests and postoperative complications. RESULTS: Positive bile duct smear tests were observed more often in the non-SDD group (63.5%) than in the SDD group (51.0%). Moreover, the SDD group exhibited a significant reduction in the median number of bacterial species in the bile ducts compared with the non-SDD group (P = .04). However, a notable increase in gram-negative species was observed in the SDD group. The SDD group experienced higher rates of postoperative complications, including relevant pancreatic fistulas (24.8% in the SDD group vs 11.6% in the non-SDD group; P < .01) and delayed gastric emptying (33.8% in the SDD group vs 21.9% in the non-SDD group; P < .01). No significant difference in antibiotic resistance patterns was observed. CONCLUSION: SDD in pancreatic head resection reduces bacterial load in the biliary tract, but it is associated with a shift toward more gram-negative species and higher rates of severe postoperative complications. Our findings suggest that SDD may negatively affect postoperative outcomes and should be carefully considered in clinical practice.

Replacing middle colic artery arising from the splenic artery-an arterial variety in a patient undergoing total pancreatoduodenectomy.

Knowledge of variations in arterial vascular supply is crucial in HPB and general surgery. Although the arterial configuration of the coeliac trunk and the superior mesenteric artery had been investigated, there are still arterial branching patterns to be described. We herein present the case of an 84-year-old male patient who underwent total pancreatectomy due to a not specified pancreas head tumor with a replacing right hepatic artery according to Michel's classification III and a replacing middle colic artery arising from the splenic artery and running on the ventral side of the pancreas. To the best of our knowledge, this arterial branching pattern has never been described so far. In this case, two arterial variations had been presented with a type III arterial supply according to Michel's classification, and a replacing middle colic artery arising from the SA.

Laparoscopic Central Pancreatectomy with Modified Blumgart Pancreatojejunostomy for Pancreatic Neuroendocrine Tumor.

INTRODUCTION: This report with a video describes a laparoscopic central pancreatectomy with modified Blumgart pancreatojejunostomy for pancreatic neuroendocrine tumor. PATIENTS AND METHODS: A 71-year-old woman presented with a single 17 mm lesion in the pancreatic neck, responsible for dilatation of the main pancreatic duct. Cancer staging showed no additional location. Somatostatin receptor imaging was positive. After a multidisciplinary discussion in the French national reference network for the management of neuroendocrine tumor (RENATEN) surgery with central pancreatectomy was decided. RESULTS: The operation time was 320 min and the estimated blood loss was less than 100 ml. Final pathology confirmed a pancreatic NET of 13 mm staged as T1 N0 M0 R0 G1 with a Ki-67 of 2%. After lymph node dissection, five nodes were analyzed and were found to be noninvaded. The postoperative course was uneventful. CONCLUSIONS: Laparoscopic central pancreatectomy is an excellent alternative for sparing pancreatic parenchyma.

A single-center prospective analysis of the impact of glucose metabolism on pancreatic fistula onset after pancreaticoduodenectomy for periampullary tumors.

BACKGROUND: Glucose impairment notably affects the postoperative course of gastrointestinal surgeries. However, evidence on its impact on clinically relevant pancreatic fistulas(CR-POPFs) after pancreaticoduodenectomy(PD) is lacking. This study evaluates if and how preoperative glucose metabolism affects the development of CR-POPF after PD. METHODS: One hundred and ten consecutive PDs were included. Patients underwent preoperative metabolic profiling using the Oral Glucose Tolerance Test(OGTT) and the hyperinsulinemic euglycemic clamp procedure. Accordingly, patients were categorized as normal glucose tolerant (NGT), impaired glucose tolerant (IGT), diabetic (DM), and longstanding-DM. Receiver operating characteristics(ROC) analyses were performed to determine the values of metabolic features in prediction of CR-POPF. RESULTS: The CR-POPF rate was 36.3 â€‹%(40 patients). NGT patients had a higher CR-POPF rate (51.7 â€‹%) compared to IGT(45.2 â€‹%), DM (15.8 â€‹%), and longstanding-DM (25.8 â€‹%) (p â€‹= â€‹0.03). CR-POPF patients had lower median fasting glucose levels (p â€‹= â€‹0.01) and higher c-peptide values at all OGTT time points (p â€‹< â€‹0.05). Fasting glucose and c-peptide levels had high diagnostic accuracy for CR-POPF (AUC>0.8) and were independent risk factors for CR-POPF (OR: 24.7[95%CI: 3.7-165.3] for fasting glucose; OR: 19.9[95%CI: 3.2-125.3] for c-peptide). CONCLUSION: Normoglycemia and normal beta cell function may be risk factors for CR-POPF after PD. Fasting glucose and c-peptide levels effectively predicted CR-POPF development following PD. CLINICALTRIALS GOV IDENTIFIER: NCT02175459.

Indocyanine green fluorescence in the evaluation of post-resection pancreatic remnant perfusion after a pancreaticoduodenectomy: a clinical study protocol.

BACKGROUND: Pancreaticoduodenectomy is associated with an incidence of postoperative complications of approximately 41%. One of the most severe complications is a postoperative pancreatic fistula. The exact cause of postoperative fistula development is still unknown, but it appears to be multifactorial. Proper perfusion of pancreatic remnant is essential for the healing of pancreaticojejunostomy. To date, there is no method to reliably evaluate the vascular supply of the remnant. One of the methods for the assessment of organ perfusion is the indocyanine green fluorescence. This study aims to determine if indocyanine green fluorescence is a reliable method to measure the perfusion of the post-resection pancreatic remnant. The secondary outcome is to determine if intraoperative evaluation of the vascular supply of the post-resection remnant may predict the increased risk of postoperative pancreatic fistula development. METHODS: This study is designed as a prospective, observational study. All consecutive patients undergoing open or robotic pancreaticoduodenectomies at our department during the 1st May 2024-31st December 2026 period will be enrolled. The exclusion criteria are an allergy to indocyanine green and refusal by the patient. The adequacy of the vascular supply of the post-resection pancreatic remnant will be intraoperatively evaluated using a fluorescence detector. Patients will be divided into two groups: Those with high risk of pancreatic fistula development and those with low risk. The incidence of pancreatic fistulas in both groups is to be compared. Postoperative data including morbidity, mortality, hospital stay, intensive care unit stay and postoperative fistula development will be collected. DISCUSSION: If an intraoperative assessment of the perfusion of post-resection pancreatic remnant using indocyanine green is proven to be a suitable method to estimate the increased risk of the pancreatic fistula, the list of the existing known risk factors could be expanded. In the most high-risk patients the modification of the surgical procedure could be considered. TRIAL REGISTRATION: Number: NCT06198400 ClinicalTrials.Gov. Date 08.01.2024.

Surgery for Borderline Resectable Pancreatic Ductal Adenocarcinoma: Preoperative Planning, Technical Considerations, and Building a Program.

Pancreaticoduodenectomy, first described in 1935, has subsequently been refined over decades into the operation performed today for tumors of the pancreatic head and periampullary region. For years following Whipple's first publication, tumors found to be inseparable from the surrounding vasculature were considered locoregionally advanced and unresectable. Fortner began performing regional pancreatectomy with routine enbloc resection of the portal vein/superior mesenteric vein in an attempt to address high local recurrence rates and high rates of aborted operations due to vascular involvement.

Feasibility, safety and preliminary efficacy of preoperative stereotactic radiotherapy on the future pancreatic neck transection margin to reduce the risk of pancreatic fistula after high-risk pancreatoduodenectomy (FIBROPANC): protocol for a multicentre, single-arm trial.

INTRODUCTION: Postoperative pancreatic fistula (POPF) occurs in 25% of patients undergoing a high-risk pancreatoduodenectomy (PD) and is a driving cause of major morbidity, mortality, prolonged hospital stay and increased costs after PD. There is a need for perioperative methods to decrease these risks. In recent studies, preoperative chemoradiotherapy in patients with pancreatic ductal adenocarcinoma (PDAC) reduced the rate of POPF seemingly due to radiation-induced pancreatic fibrosis. However, patients with a high risk of POPF mostly have a non-pancreatic periampullary tumour and do not receive radiotherapy. Prospective studies using radiotherapy specifically to reduce the risk of POPF have not been performed. We aim to assess the safety, feasibility and preliminary efficacy of preoperative stereotactic radiotherapy on the future pancreatic neck transection margin to reduce the rate of POPF. METHODS AND ANALYSIS: In this multicentre, single-arm, phase II trial, we aim to assess the feasibility and safety of a single fraction of preoperative stereotactic radiotherapy (12 Gy) to a 4 cm area around the future pancreatic neck transection margin in patients at high risk of developing POPF after PD aimed to reduce the risk of grade B/C POPF. Adult patients scheduled for PD for malignant and premalignant periampullary tumours, excluding PDAC, with a pancreatic duct diameter ≤3 mm will be included in centres participating in the Dutch Pancreatic Cancer Group. The primary outcome is the safety and feasibility of single-dose preoperative stereotactic radiotherapy before PD. The most relevant secondary outcomes are grade B/C POPF and the difference in the extent of fibrosis between the radiated and non-radiated (uncinate margin) pancreas. Evaluation of endpoints will be performed after inclusion of 33 eligible patients. ETHICS AND DISSEMINATION: Ethical approval was obtained by the Amsterdam UMC's accredited Medical Research Ethics Committee (METC). All included patients are required to have provided written informed consent. The results of this trial will be used to determine the need for a randomised controlled phase III trial and submitted to a high-impact peer-reviewed medical journal regardless of the study outcome. TRIAL REGISTRATION NUMBER: NL72913 (Central Committee on Research involving Human Subjects Registry) and NCT05641233 (ClinicalTrials).

Effects of intraoperative different fluid therapy protocols on postoperative renal functions.

PURPOSE: Planning intraoperative fluid therapy in patients undergoing major abdominal surgery is important. It was aimed to define the difference between fluid therapy protocols for renal function, bleeding and postoperative service follow-ups. MATERIALS AND METHODS: This is an observational case-controlled prospective study. Sixty patients aged 18-65 years who had undergone pancreatic surgery between December 2023- February 2023 were included in the study. Liberal (Group 1; n = 30) and targeted fluid therapies (Group 2; n = 30) were administered to the patients. Liberal fluid therapy was planned with 8-10 ml/kg/h crystalloid infusion. The targeted fluid therapy (TFT) group (Group 2; n = 30) began with a 2 ml/kg/h crystalloid infusion at the baseline. Additional fluid boluses were given in 250 ml of colloid infused over 10 min if PVI was > 13% for at least five minutes. The patients were staged using the KDIGO (Kidney Disease: Improving Global Outcomes) criteria. The amount of bleeding during surgery was recorded for both groups. RESULTS: No significant difference was observed in postoperative renal function. A significant difference was observed in the amount of intraoperative bleeding. The amount of bleeding was greater in patients managed with liberal fluid therapy. No significant difference was observed between the groups in the oral intake (hour), drain withdrawal (hour) mobilization (hour) and discharge (day) times and there isn't any statistically significant differance between groups in cost effectivity (p>0.05). CONCLUSION: Kidney function was preserved during individualized targeted fluid therapy using non-invasive haemodynamic monitoring parameters.

Benchmarking in pancreatic surgery: a systematic review of metric development and validation.

Benchmarking in healthcare, particularly in the context of complex surgical procedures like pancreatic surgery, plays a pivotal role in comparing and evaluating the quality of care provided to patients. There is a growing body of evidence validating existent metrics and introducing new ones in the pursuit of safety and excellence in pancreatic surgery. A systematic review adhering to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted on metric development and validation across multiple databases, including PUBMED Medline, Scopus, and Web of Science, until February 2024. The extracted data were categorized into three domains according to the Donabedian model: structure, process, and outcomes. Thirty-four studies were deemed eligible for inclusion in this review. Among these articles, 20 contributed to metric development, while 14 studies validated them. A total of 234 metrics were identified across the 34 studies, of which 185 were included in the analysis. Thirty-three of these metrics were relative to structure, 79 to processes, and 73 to outcomes. The distribution of metric domains across the included studies revealed that structure, process, and outcome domains were reported in 12, 26, and 26 studies, respectively. In conclusion, this systematic review underscores the heterogeneity in metric development methodologies and the varying degrees of consensus among different quality indicators, despite the growing interest in benchmarking in pancreatic surgery. This review aims to inform future research efforts and contribute to the ongoing pursuit of excellence in pancreatic surgical care.

Enucleation for Sporadic Nonfunctioning Pancreatic Neuroendocrine Tumors Larger than 2 Centimeters Is Associated with Equivalent Morbidity and Survival Compared to Smaller Tumors: A Multi-Institutional Study.

INTRODUCTION: Nonfunctioning pancreatic neuroendocrine tumor (NF-PanNET) ≤2 cm can be observed or resected. Surgery remains recommended for NF-PanNET >2 cm but its extent, enucleation (EN) versus formal resection, remains controversial. METHODS: Multicentric retrospective cohort of sporadic NF-PanNET patients treated with EN. Short- and long-term outcomes were compared according to tumor size on imaging ≤2 cm versus >2 cm. RESULTS: 131 patients underwent EN for NF-PanNET, including 103 (79.0%) ≤2 cm and 28 (21.0%) >2 cm (extremes, 4-55 mm). Patients' characteristics were comparable, and tumor characteristics only differed in their diameter. Clavien III-IV complications were similar (18.4% vs. 17.9%, p = 1.00) with one death in NF-PanNET ≤2 cm. Grade B/C pancreatic fistula were comparable (16.5% vs. 10.7%, p = 0.850). In NF-PanNET >2 cm there were more pT2/3 stage tumors (85.7% vs. 21.4%, p < 0.001), similar rates of grade G2/3 tumors (25% vs. 16.5%, p = 0.408) with a median Ki67 of 2 (interquartile range: 1-3), and of lymphovascular and perineural invasions. Lymph node picking was done in 46 (35.1%) patients, with a higher median number of harvested lymph nodes in NF-PanNET >2 cm (4 vs. 3, p = 0.01). All were pN0. R0 resection rate (78.6% vs. 82.5%, respectively; p = 0.670) was equivalent. Five-year overall (100% vs. 99%, p = 0.602) and 10-year disease-free (96% vs. 92%, respectively; p = 0.532) survivals were comparable. CONCLUSIONS: EN for selected NF-PanNET >2 cm carries equivalent morbidity, overall and disease-free survivals compared to those observed with NF-PanNET ≤2 cm.

Robotic surgery reduces the consumption of medical consumables: cost analysis of robotic pancreatic surgery from a tertiary hospital in China.

Robotic surgery has been increasingly adopted in various surgical fields, but the cost-effectiveness of this technology remains controversial due to its high cost and limited improvements in clinical outcomes. This study aims to explore the health economic implications of robotic pancreatic surgery, to investigate its impact on hospitalization costs and consumption of various medical resources. Data of patients who underwent pancreatic surgery at our institution were collected and divided into robotic and traditional groups. Statistical analyses of hospitalization costs, length of stay, costs across different service categories, and subgroup cost analyses based on age, BMI class, and procedure received were performed using t tests and linear regression. Although the total hospitalization cost for the robotic group was significantly higher than that for the traditional group, there was a notable reduction in the cost of medical consumables. The reduction was more prominent among elderly patients, obese patients, and those undergoing pancreaticoduodenectomy, which could be attributed to the technological advantages of the robotic surgery platform that largely facilitate blood control, tissue protection, and suturing. The study concluded that despite higher overall costs, robotic pancreatic surgery offers significant savings in medical consumables, particularly benefiting certain patient subgroups. The findings provide valuable insights into the economic viability of robotic surgery, supporting its adoption from a health economics perspective.

[Sex differences in pancreatic cancer]. / Geschlechtsunterschiede beim Pankreaskarzinom.

This review article discusses the currently available evidence on the importance of biological and social sex in pancreatic cancer in the context of the operative, perioperative and multimodal treatment. In pancreatic cancer there are gender differences with respect to the incidence, treatment response and prognosis. Sex significantly influences both innate and adaptive immune responses, thereby affecting treatment response and survival rates. Women are less likely to receive systemic treatment and tend to wait longer for surgery but have better perioperative outcomes after pancreatic resection. Overall, female pancreatic cancer patients seem to have longer survival under treatment; however, they report a subjectively lower quality of life and higher disease burden.

[Pancreatic cystic neoplasms]. / Zystische Pankreastumoren.

Pancreatic cystic lesions represent a challenging heterogeneous entity with a potential risk of malignant transformation. The diagnostics include in particular medical history taking with collection of relevant clinical information and high-resolution imaging, preferably using magnetic resonance imaging (MRI) with MR cholangiopancreatography (MRCP) and/or endoscopic ultrasonography. A differentiation between different cystic entities and identification of risk factors are crucial for making appropriate treatment decisions. Only a small proportion of pancreatic cystic neoplasms require surgery. Pancreatic cystic lesions with a relevant risk of malignancy, such as main duct intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), solid pseudopapillary neoplasms (SPN) and general cystic pancreatic lesions with risk factors regardless of the entity, should be resected, whereas an individualized approach is required for branch duct IPMN and serous cystic neoplasms (SCN) and dysontogenetic cysts require no treatment. Parenchyma-sparing and minimally invasive resection techniques should be preferred whenever possible for resecting pancreatic cystic tumors. Approximately 10% of patients develop recurrences over time.