Study of Risk Factors for Readmission After Pancreatectomy for Cancer: Analysis of Nationwide Cohort.

OBJECTIVE: To identify the factors associated with readmission after pancreatectomy for cancer and to assess their impact on the 1-year mortality in a French multicentric population. BACKGROUND: Pancreatectomy is a complex procedure with high morbidity that increases the length of hospital stay and jeopardizes survival. Hospital readmissions lead to increased health system costs, making this a topic of great interest. METHODS: Data collected from patients who underwent pancreatectomy for cancer between 2011 and 2019 were extracted from a French national medico-administrative database. A descriptive analysis was conducted to evaluate the association of baseline variables, including age, sex, liver-related comorbidities, Charlson Comorbidity Index, tumor localization, and use of neoadjuvant therapy, along with hospital type and volume, with readmission status. Centers were divided into low and high volumes according to the cutoff of 26 cases/year. Logistic regression models were developed to determine whether the identified bivariate associations persisted after adjusting for the patient characteristics. The mortality rates during readmission and at 1 year postoperatively were also determined. RESULTS: Of 22,935 patients who underwent pancreatectomy, 9129 (39.3%) were readmitted within 6 months. Readmission rates by year did not vary over the study period, and mean readmissions occurred within 20 days after discharge. Multivariate analysis showed that male sex [odds ratio (OR) = 1.12], age >70 years (OR = 1.16), comorbidities (OR = 1.21), distal pancreatectomy (OR = 1.11), and major postoperative complications (OR = 1.37) were predictors of readmission. Interestingly, readmission and surgery in low-volume centers increased the risk of death at 1 year by a factor of 2.15 [(2.01-2.31), P < 0.001] and 1.31 [(1.17-1.47), P < 0.001], respectively. CONCLUSIONS: Readmission after pancreatectomy for cancer is high with an increased rate of 1-year mortality.

Evolution of minimally invasive liver surgery in France over the last decade.

BACKGROUND: Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS). METHODS: We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice. RESULTS: MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from - 1.8% (- 3.9; - 0.3) per year in 2013-2018 to - 5.9% (- 7.9; - 3.9) per year in 2018-2022 (p = 0.013). CONCLUSIONS: This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.

Comparison Between Radial and Femoral Artery Access for Transarterial Chemoembolisation in Patients With Hepatocellular Carcinoma.

PURPOSE: The purpose of this study was to compare the technical success rate, the selectivity of transarterial chemoembolisation (TACE), the complication rate, the radiation dose given to the patients and the hospitalization stay between TACE performed using femoral artery approach (FAA) and TACE performed using radial artery approach (RAA) in patients with hepatocellular carcinoma (HCC). METHODS: Between June 2020 and April 2022, 49 patients with HCC who underwent 116 TACEs (75 using FAA and 41 using RAA) were included. Differences in technical success rate, selectivity of micro-catheterization, radiation dose given to the patients, fluoroscopy time, hospitalization stay duration, and complication rate were compared between FAA and RAA using Fisher exact or Student t tests. RESULTS: No differences in technical success rates were found between RAA (93%; 39/41 TACEs) and FAA (100%; 75/75 TACEs) (P = .12). There were no differences between the two groups in terms of selectivity of catheterization, radiation dose, fluoroscopy time and hospitalization stay duration. Five patients had Grade 2 complications (hematoma) after FAA vs. one patient with one Grade 1 complication (radial artery occlusion) after RAA (5/75 [7%] vs. 1/41 [2%], respectively; P = .42). No major arterial access site complications occurred with FAA or RAA. CONCLUSIONS: This study confirms that RAA is a safe approach that does not compromise the technical efficacy and the selectivity of TACE compared to FAA in patients with HCC.

Management and outcomes of hemorrhage after distal pancreatectomy: a multicenter study at high volume centers.

BACKGROUND: Data on clinically relevant post-pancreatectomy hemorrhage (CR-PPH) are derived from series mostly focused on pancreatoduodenectomy, and data after distal pancreatectomy (DP) are scarce. METHODS: All non-extended DP performed from 2014 to 2018 were included. CR-PPH encompassed grade B and C PPH. Risk factors, management, and outcomes of CR-PPH were evaluated. RESULTS: Overall, 1188 patients were included, of which 561 (47.2 %) were operated on minimally invasively. Spleen-preserving DP was performed in 574 patients (48.4 %). Ninety-day mortality, severe morbidity and CR-POPF rates were 1.1 % (n = 13), 17.4 % (n = 196) and 15.5 % (n = 115), respectively. After a median interval of 8 days (range, 0-37), 65 patients (5.5 %) developed CR-PPH, including 28 grade B and 37 grade C. Reintervention was required in 57 patients (87.7 %). CR-PPH was associated with a significant increase of 90-day mortality, morbidity and hospital stay (p < 0.001). Upon multivariable analysis, prolonged operative time and co-existing POPF were independently associated with CR-PPH (p < 0.005) while a chronic use of antithrombotic agent trended towards an increase of CR-PPH (p = 0.081). As compared to CR-POPF, the failure-to-rescue rate in patients who developed CR-PPH was significantly higher (13.8 % vs. 1.3 %, p < 0.001). CONCLUSION: CR-PPH after DP remains rare but significantly associated with an increased risk of 90-day mortality and failure-to-rescue.

Defining Benchmark Outcomes for Distal Pancreatectomy: Results of a French Multicentric Study.

OBJECTIVE: Defining robust and standardized outcome references for distal pancreatectomy (DP) by using Benchmark analysis. BACKGROUND: Outcomes after DP are recorded in medium or small-sized studies without standardized analysis. Therefore, the best results remain uncertain. METHODS: This multicenter study included all patients undergoing DP for resectable benign or malignant tumors in 21 French expert centers in pancreas surgery from 2014 to 2018. A low-risk cohort defined by no significant comorbidities was analyzed to establish 18 outcome benchmarks for DP. These values were tested in high risk, minimally invasive and benign tumor cohorts. RESULTS: A total of 1188 patients were identified and 749 low-risk patients were screened to establish Benchmark cut-offs. Therefore, Benchmark rate for mini-invasive approach was ≥36.8%. Benchmark cut-offs for postoperative mortality, major morbidity grade ≥3a and clinically significant pancreatic fistula rates were 0%, ≤27%, and ≤28%, respectively. The benchmark rate for readmission was ≤16%. For patients with pancreatic adenocarcinoma, cut-offs were ≥75%, ≥69.5%, and ≥66% for free resection margins (R0), 1-year disease-free survival and 3-year overall survival, respectively. The rate of mini-invasive approach in high-risk cohort was lower than the Benchmark cut-off (34.1% vs ≥36.8%). All Benchmark cut-offs were respected for benign tumor group. The proportion of benchmark cases was correlated to outcomes of DP. Centers with a majority of low-risk patients had worse results than those operating complex cases. CONCLUSION: This large-scale study is the first benchmark analysis of DP outcomes and provides robust and standardized data. This may allow for comparisons between surgeons, centers, studies, and surgical techniques.

Imaging of Pancreatic Ductal Adenocarcinoma: An Update on Recent Advances.

Pancreatic ductal carcinoma (PDAC) is one of the leading causes of cancer-related death worldwide. Computed tomography (CT) remains the primary imaging modality for diagnosis of PDAC. However, CT has limitations for early pancreatic tumor detection and tumor characterization so that it is currently challenged by magnetic resonance imaging. More recently, a particular attention has been given to radiomics for the characterization of pancreatic lesions using extraction and analysis of quantitative imaging features. In addition, radiomics has currently many applications that are developed in conjunction with artificial intelligence (AI) with the aim of better characterizing pancreatic lesions and providing a more precise assessment of tumor burden. This review article sums up recent advances in imaging of PDAC in the field of image/data acquisition, tumor detection, tumor characterization, treatment response evaluation, and preoperative planning. In addition, current applications of radiomics and AI in the field of PDAC are discussed.

Interobserver Variability and Accuracy of Preoperative CT and MRI in Pancreatic Ductal Adenocarcinoma Size Estimation: A Retrospective Cohort Study.

Purpose: To assess interobserver variability and accuracy of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) in pancreatic ductal adenocarcinoma (PDAC) size estimation using surgical specimens as standard of reference. Methods: Patients with PDAC who underwent preoperative CT and MRI examinations before surgery were included. PDAC largest axial dimension was measured by 2 readers on 8 MRI sequence and 2 CT imaging phases (pancreatic parenchymal and portal venous). Measurements were compared to actual tumour size at pathologic examination. Interobserver variability was assessed using intraclass correlation coefficients (ICC) and Bland-Altman plots. Differences in tumour size (Δdiameter) between imaging and actual tumour size were searched using Wilcoxon rank sum test. Results: Twenty-nine patients (16 men; median age, 70 years) with surgically resected PDAC were included. Interobserver reproducibility was good to excellent for all MRI sequences and the 2 CT imaging phases with ICCs between .862 (95%CI: .692-.942) for fat-saturated in-phase T1-weighted sequence and .955 (95%CI: .898-.980) for portal venous phase CT images. Best accuracy in PDAC size measurement was obtained with pancreatic parenchymal phase CT images with median Δdiameters of -2 mm for both readers, mean relative differences of -9% and -6% and no significant differences with dimensions at histopathological analysis (P = .051). All MRI sequences led to significant underestimation of PDAC size (median Δdiameters, -6 to -1 mm; mean relative differences, -21% to -11%). Conclusions: Most accurate measurement of PDAC size is obtained with CT images obtained during the pancreatic parenchymal phase. MRI results in significant underestimation of PDAC size.

Assessing textbook outcome after single large hepatocellular carcinoma resection.

BACKGROUND: This study aimed to investigate the impact and predictors of an ideal surgical care following SLHCC resection. METHODS: SLHCC patients who underwent LR in two tertiary hepatobiliary centers between 2000 and 2021 were retrieved from prospectively maintained databases. The quality of surgical care was measured by the textbook outcome (TO). Tumor burden was defined by the tumor burden score (TBS). Factors associated with TO were determined on multivariate analysis. The impact of TO on oncological outcomes was assessed using Cox regressions. RESULTS: Overall, 103 SLHCC patients were included. Laparoscopic approach was considered in 65 (63.1%) patients and 79 (76.7%) patients presented with moderate TBS. TO was achieved in 54 (52.4%) patients. Laparoscopic approach was independently associated with TO (OR 2.57; 95% CI 1.03-6.64; p = 0.045). Within 19 (6-38) months of median follow up, patients who achieved TO had better OS compared to non-TO patients (1-year OS: 91.7% vs. 66.9%; 5-year OS: 83.4% vs. 37.0%, p < 0.0001). On multivariate analysis, TO was independently associated with improved OS, especially in non-cirrhotic patients (HR 0.11; 95% CI 0.02-0.52, p = 0.005). CONCLUSIONS: TO achievement could be a relevant surrogate marker of improved oncological care following SLHCC resection in non-cirrhotic patients.

Results from the european survey on preoperative management and optimization protocols for PeriHilar cholangiocarcinoma.

BACKGROUND: Major surgery, along with preoperative cholestasis-related complications, are responsible for the increased risk of morbidity and mortality in perihilar cholangiocarcinoma (pCCA). The aim of the present survey is to provide a snapshot of current preoperative management and optimization strategies in Europe. METHODS: 61 European centers, experienced in hepato-biliary surgery completed a 59-questions survey regarding pCCA preoperative management. Centers were stratified according to surgical caseload (<5 and ≥ 5 cases/year) and preoperative management protocols' application. RESULTS: The overall case volume consisted of 6333 patients. Multidisciplinary discussion was routinely performed in 91.8% of centers. Most respondents (96.7%) recognized the importance of a well-structured preoperative protocol. The preferred method for biliary drainage was percutaneous transhepatic biliary drainage (60.7%) while portal vein embolization was the preferred technique for liver hypertrophy (90.2%). Differences in preoperative pathologic confirmation of malignancy (35.8% vs 28.7%; p < 0.001), number of mismanaged referred patients (88.2% vs 50.8%; p < 0.001), biliary drainage (65.1% vs 55.6%; p = 0.015) and liver function evaluation (37.2% vs 5.6%; p = 0.001) were found between centers according to groups' stratification. CONCLUSION: The importance of a correct preoperative management is recognized. Nevertheless, the current lack of guidelines leads to wide heterogeneity of behaviors among centers. This survey can provide recommendations to improve pCCA perioperative outcomes.

Feasibility and outcomes of multiple simultaneous laparoscopic liver resections.

INTRODUCTION: Surgeons often remain reluctant to consider laparoscopic approach in multiple liver tumors. This study assessed feasibility and short-term results of patients who had more than 3 simultaneous laparoscopic liver resections (LLR). METHODS: All consecutive patients who underwent LLR for primary or secondary malignancies between 2009 and 2019 were analyzed. After exclusion of major LLR, patients were divided into three groups: less than three (Group A), between three and five (Group B), and more than five resections (Group C) in the same procedure. Intraoperative details, postoperative outcomes, and textbook outcome (TO) were compared in the 3 groups. RESULTS: During study period, 463 patients underwent minor LLR. Among them, 412 (88.9%) had less than 3 resections, 38 (8.2%) between 3 and 5 resections, and 13 (2.8%) more than 5 resections. Despite a difficulty score according to IMM classification comparable in the 3 groups (with high difficulty grade 3 procedures of 16.5% vs. 15.7% vs. 23.1% in Group A, B, and C, respectively, p = 0.124), mean operative time was significantly longer in Group C (p = 0.039). Blood loss amount (p = 0.396) and conversion rate (p = 0.888) were similar in the 3 groups. Rate of R1 margins was not significantly different between groups (p = 0.078). Achievement of TO was not different between groups (p = 0.741). In multivariate analysis, non-achievement of TO was associated with difficulty according to IMM classification (OR = 2.29 (1.33-3.98)). CONCLUSION: Since intra- and post-operative outcomes and quality of resection are comparable, multiple liver resections should not preclude the laparoscopic approach.

Factors of Early Recurrence After Resection for Intrahepatic Cholangiocarcinoma.

BACKGROUND: Two-thirds of patients undergoing liver resection for intrahepatic cholangiocarcinoma experience recurrence after surgery. Our aim was to identify factors associated with early recurrence after resection for intrahepatic cholangiocarcinoma. METHODS: Patients with intrahepatic cholangiocarcinoma undergoing curative intent resection (complete resection and lymphadenectomy) were included in two centers between 2005 and 2021 and were divided into three groups: early recurrence (< 12 months after resection), delayed recurrence (> 12 months), and no recurrence. Patients experiencing early (< 90 days) postoperative mortality were excluded. RESULTS: Among 120 included patients, 44 (36.7%) experienced early recurrence, 24 (20.0%) experienced delayed recurrence, and 52 (43.3%) did not experience recurrence after a median follow-up of 59 months (IQR: 26-113). The median recurrence-free survival was 16 months (95% CI: 9.6-22.4). Median overall survival was 55 months (95% CI: 45.7-64.3), while it was 25 months for patients with early recurrence (p < 0.001). Patients with early recurrence had significantly larger tumors (59.1% of tumors > 70 mm in early vs. 58.3% in delayed vs. 26.9% in no recurrence group, p = 0.002), multiple lesions (65.9% vs. 29.2% vs. 11.5%, p < 0.001), and positive lymph nodes (N +) (38.6% vs. 37.5% vs. 11.5%, p = 0.005). In multivariable analysis, presence of multiple lesions (OR: 9.324; 95% CI: 3.051-28.489; p < 0.001) and positive lymph nodes (OR: 3.307. 95% CI: 1.001-11.011. p = 0.05) were associated with early recurrence. CONCLUSION: Early recurrence after curative resection of intrahepatic cholangiocarcinoma is frequent and is associated with the presence of multiple lesions and positive lymph nodes, raising the question of surgery's futility in this context.

Double purse-string telescoped pancreaticogastrostomy is not superior in preventing pancreatic fistula development in high-risk anastomosis: a 6-year single-center case-control study.

PURPOSE: The double purse-string telescoped pancreaticogastrostomy (PG) technique has been suggested as an alternative approach to reduce the risk of postoperative pancreatic fistula (POPF). Its efficacity in high-risk situations has not yet been explored. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients with high-risk anastomosis undergoing PG and those undergoing pancreaticojejunostomy (PJ). METHODS: From 2013 to 2019, 198 consecutive patients with high-risk anastomosis, an updated alternative fistula risk score > 20%, and who underwent pancreatoduodenectomy with the PJ (165) or PG (33) technique were included. Optimal mitigation strategy (external stenting/octreotide omission) was applied for all patients. The primary endpoint was the incidence of CR-POPF. RESULTS: The mean ua-FRS was 33%. CR-POPF (grade B/C) was found in 42 patients (21%) and postoperative hemorrhage in 30 (15%); the mortality rate was 4%. CR-POPF rates were comparable between the PJ (19%) and PG (33%) groups (P = 0.062). The PG group had a higher rate of POPF grade C (24% vs. 10%; P = 0.036), longer operative time (P = 0.019), and a higher transfusion rate (P < 0.001), even after a matching process on ua-FRS. In the multivariate analysis, the type of anastomosis (P = 0.88), body mass index (P = 0.47), or main pancreatic duct diameter (P = 0.7) did not influence CR-POPF occurrence. CONCLUSIONS: For patients with high-risk anastomosis, the double purse-string telescoped PG technique was not superior to the PJ technique for preventing CR-POPF.

Intraoperative frozen section analysis of para-aortic lymph nodes after neoadjuvant FOLFIRINOX: will it soon become useless?

PURPOSE: Positive para-aortic lymph nodes (PALN) (station 16) are commonly detected in the final pathologic examination (ranging from 15 to 26%) among patients who undergo upfront pancreatoduodenectomy for resectable pancreatic ductal adenocarcinoma. However, after neoadjuvant treatment (NAT) the role of positive PALN as a watershed for surgical resection remains unclear. We aimed to determine the incidence of intraoperative detection of PALN after NAT with FOLFIRINOX for pancreatic head adenocarcinoma and its impact on survival, as our policy was to not resect the tumor in such situations. METHODS: From January 2014 to December 2020, 136 patients with non-metastatic cancer who received neoadjuvant FOLFIRINOX and underwent explorative laparotomy were included. RESULTS: Intraoperative positive PALN were observed in 7 patients (5%). Patients had resectable (n = 5) or locally advanced (n = 2) disease at the time of surgery, but none of them underwent surgical resection. Positive PALN were significantly associated with a lower median number of FOLFIRINOX cycles (4 vs. 6, P = 0.05). There was no significant difference in overall survival between patients with positive loco-regional lymph nodes after resection and patients with non-resection owing to positive PALN (22 versus 16 months, P = 0.16), Overall survival with positive PALN, carcinomatosis, and liver metastasis was 16, 14, and 10 months, respectively (P > 0.05). CONCLUSIONS: Our results suggest that NAT may lower PALN involvement. We have modified our policy, positive PALN after NAT are no longer a contraindication to resection, rather a holistic picture of the disease guides management.

Venous Reconstruction During Pancreatectomy Using Polytetrafluoroethylene Grafts: A Single-Center Experience with Standardized Perioperative Management.

BACKGROUND: Although primary end-to-end anastomosis is preferred for portal vein-superior mesenteric vein (PV-SMV) reconstruction, interposition graft use may be required in some situations. We investigated the efficacy of polytetrafluoroethylene (PTFE) grafts when used during pancreatectomy in this context. METHODS: From 2014 to 2019, 19 patients who underwent pancreatectomy requiring PV-SMV reconstruction using ringed PTFE grafts were entered prospectively into a clinical database (NCT02871336, CNIL No. Sy50955016U). Unfractionated heparin was used during the first 24 h postoperatively. The administration of low-molecular-weight heparin was initiated twice a day (two injections of 1 mg/kg enoxaparin) on postoperative day 2 and was continued until the first clinical follow-up. Patency was assessed by CT scan before home discharge. Patients were switched to antiplatelet therapy (75 mg of aspirin-based drug Kardegic®) without a deadline. RESULTS: Pancreatoduodenectomy was the most commonly performed procedure (15 patients, 79%), and pancreatic duct adenocarcinoma was the predominant etiology (17 patients, 89%). The median PTFE graft diameter and length were 10 mm and 8 cm, respectively. The median clamping time was 25 min. The overall severe morbidity and 90-day mortality values were 21% and 10%, respectively. None of the patients experienced anticoagulation-related morbidity or PTFE graft-related infection. The 6-month PTFE graft patency rate was 68%. Patients who underwent distal pancreatectomy showed a higher late thrombosis rate than those who underwent a pancreaticoduodenectomy (50% vs. 8%, p = 0.049). The median long-term PTFE graft patency duration was 37 months. CONCLUSIONS: PTFE reconstruction can be safely performed with simple perioperative management in cases requiring interposition graft use.

Pancreatectomy with Vascular Resection After Neoadjuvant FOLFIRINOX: Who Survives More Than a Year After Surgery?

BACKGROUND: Experienced pancreatic surgeons, for whom complexity is not an issue, must decide at the end of neoadjuvant therapy whether to continue or discontinue surgery, when pancreatectomy with vascular resection is planned in patients with pancreatic ductal adenocarcinoma (PDAC). OBJECTIVE: Our study aimed to determine preoperative factors that can predict short postoperative survival in such situations. METHODS: Overall, 105 patients with borderline or locally advanced PDAC received neoadjuvant FOLFIRINOX (followed by chemoradiation in 22% of patients) and underwent pancreatectomy with segmental venous and/or arterial resection at two high-volume centers. The primary endpoint was overall survival (OS) of < 1 year after surgery for patients who did not die from the surgery. RESULTS: Tumors were classified as borderline in 78% of cases and locally advanced in 22% of cases. Mean CA19-9 at diagnosis was 934 U/mL, which significantly decreased to 213 U/mL (p < 0.01) after a median of six cycles of FOLFIRINOX. Pancreaticoduodenectomy was performed most often (76%). The vast majority of patients underwent venous resection (92%), and a simultaneous arterial resection was performed in 16 patients (15%). The severe morbidity rate and 30- and 90-day mortality rates were 21%, 8.5%, and 10.4%, respectively. The median OS after surgery was 23 months. In the multivariate analysis, preoperative CA19-9 ≥ 450 U/mL was the only preoperative factor independently associated with OS of < 1 year (p = 0.044). CONCLUSION: The preoperative CA19-9 value should be considered in the clinical decision-making process when complex vascular resection is required.

Laser Treatment of Pancreatic Cancer with Immunostimulating Interstitial Laser Thermotherapy Protocol: Safety and Feasibility Results From Two Phase 2a Studies.

PURPOSE: Ablative techniques have emerged as new potential therapeutic options for patients with locally advanced pancreatic cancer (LAPC). We explored the safety and feasibility of using TRANBERG|Thermal Therapy System (Clinical Laserthermia Systems AB, Lund, Sweden) in feedback mode for immunostimulating Interstitial Laser Thermotherapy (imILT) protocol, the newest ablative technique introduced for the treatment of LAPC. METHODS: The safety and feasibility results after the use of imILT protocol treatment in 15 patients of a prospective series of postsystemic therapy LAPC in two high-volume European institutions, the General and Pancreatic Unit of the Pancreas Institute, of the University of Verona, Italy, and the Department of Surgical Oncology of the Institut Paoli-Calmettes of Marseille, France, were assessed. RESULTS: The mean age was 66 ± 5 years, with a mean tumor size of 34.6 (±8) mm. The median number of cycles of pre-imILT chemotherapy was 6 (6-12). The procedure was performed in 13 of 15 (86.6%) cases; indeed, in two cases, the procedure was not performed; in one, the procedure was considered technically demanding; in the other, liver metastases were found intraoperatively. In all treated cases, the procedure was completed. Three late pancreatic fistulas developed over four overall adverse events (26.6%) and were attributed to imILT. Mortality was nil. A learning curve is necessary to interpret and manage the laser parameters. CONCLUSIONS: Safety, feasibility, and device handling outcomes of using TRANBERG|Thermal Therapy System with temperature probes in feedback mode and imILT protocol on LAPC were not satisfactory. The metastatic setting may be appropriate to evaluate the hypothetic abscopal effect.#NCT02702986 and #NCT02973217.

Middle and left hepatic vein trunk control during laparoscopic liver resection (with video).

BACKGROUND: While inflow control can be easily applied by Pringle maneuver, outflow control of the left liver has not been formally described. We report here a safe and reproductible technique of middle and left hepatic veinous trunk control (MLHVC) before parenchymal transection during laparoscopic left hepatectomy. METHODS: A retrospective review of laparoscopic liver resection was conducted from January 2013 to March 2018 from our prospective database. All cases of laparoscopic left hepatectomy (LLH) were included, and intra- and postoperative outcomes data collected. We collected cases where the middle and left hepatic vein trunk control has been attempted and clamping used, and we analyzed outcomes associated with this maneuver. RESULTS: MLHVC was attempted in 28 cases (77.8) of the 36 LLH identify in a monocentric study. It was technically not feasible only in 3 cases (8.3%) and clamping applied in 15 cases (41.7%). No significant intraoperative unexpected event occurred. CONCLUSION: We present here a technique for left liver outflow control that can be safely added to the armamentarium of laparoscopic liver surgery.

Standardized salvage completion pancreatectomy for grade C postoperative pancreatic fistula after pancreatoduodenectomy (with video).

BACKGROUND: Emergency completion pancreatectomy (CP) after pancreatoduodenectomy (PD) is a technically demanding procedure. We report our experiences with a four-step standardized technique used at our center since 2012. METHODS: In the first step, the gastrojejunostomy is divided with a stapler to quickly access the pancreatic anastomosis and permit adequate exposure, especially in cases of active bleeding. Second, the bowel loops connected to the pancreatic anastomosis is divided in cases of pancreaticojejunostomy. Third, the pancreatectomy is completed with or without the splenic vessels and spleen conservation according to the local conditions. Finally, the fourth step reconstructs in a Roux-en-Y fashion and ensures drainage. RESULTS: From January 2012 to December 2019, 450 patients underwent PD at our center. Reintervention for grade C postoperative pancreatic fistula was decided for 30 patients, and CP was performed in 21 patients. The mean intraoperative blood loss and operative duration were relatively low (600 ml and 240 min, respectively). During the perioperative period, three patients died from multiple organ failure, and two patients died intraoperatively from a cataclysmic hemorrhage originating from the superior mesenteric artery. DISCUSSION: Our standardized procedure appears to be relatively safe, reproducible, and could be particularly useful for young surgeons.

Does pre-operative embolization of a replaced right hepatic artery before pancreaticoduodenectomy for pancreatic adenocarcinoma affect postoperative morbidity and R0 resection? A bi-centric French cohort study.

BACKGROUND: Sacrificing a replaced right hepatic artery (rRHA) from the superior mesenteric artery is occasionally necessary to obtain an R0 resection after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). Preoperative embolization (PEA) of the rRHA has been proposed to avoid the onset of postoperative biliary and ischemic liver complications. METHODS: Eighteen patients with cephalic PA with an rRHA underwent PEA of the rRHA from 2013 to 2019. The monitoring after embolization and PD was systematic and included a clinical-biological evaluation and a computed tomography scan. This study aimed to determine the feasibility of PEA of the rRHA, postoperative morbidity at 90 days, and quality of oncologic resection after PD. RESULTS: Feasibility of PEA was 100% without complications. A PD was performed in 16/18 patients. Mortality was 2/16 with one death after septic shock with hepatic ischemia without an arterial obstruction. Overall morbidity was 44% including one hepatic abscess after hepatic ischemia (6%). Two resections were R1 (<1 mm) in contact with the origin of the rRHA (2/4 R1). CONCLUSION: PEA of the rRHA before PD was safe and reproducible. PEA of the rRHA followed by en bloc PD resection seems to limit the risk of bilio-hepatic ischemia and could facilitate oncologic resection.

Outcomes of patients with initially locally advanced pancreatic adenocarcinoma who did not benefit from resection: a prospective cohort study.

BACKGROUND: The current study aimed to evaluate the outcomes of patients with unresectable non-metastatic locally advanced pancreatic adenocarcinoma (LAPA) who did not benefit from resection considering the treatment strategy in the clinical settings. METHODS: Between 2010 and 2017, a total of 234 patients underwent induction chemotherapy for LAPA that could not be treated with surgery. After oncologic restaging, continuous chemotherapy or chemoradiation (CRT) was decided for patients without metastatic disease. The Kaplan-Meier method was used to determine overall survival (OS), and the Wilcoxon test to compare survival curves. Multivariate analysis was performed using the stepwise logistic regression method. RESULTS: FOLFIRINOX was the most common induction regimen (168 patients, 72%), with a median of 6 chemotherapy cycles and resulted in higher OS, compared to gemcitabine (19 vs. 16 months, hazard ratio (HR) = 1.2, 95% confidence interval: 0.86-1.6, P = .03). However, no difference was observed after adjusting for age (≤75 years) and performance status score (0-1). At restaging, 187 patients (80%) had non-metastatic disease: CRT was administered to 126 patients (67%) while chemotherapy was continued in 61 (33%). Patients who received CRT had characteristics comparable to those who continued with chemotherapy, with similar OS. They also had longer progression-free survival (median 13.3 vs. 9.6 months, HR = 1.38, 95% confidence interval: 1-1.9, P < .01) and limited short-term treatment-related toxicity. CONCLUSIONS: The median survival of patients who could not undergo surgery was 19 months. Hence, CRT should not be eliminated as a treatment option and may be useful as a part of optimised sequential chemotherapy for both local and metastatic disease.