REDISCOVER International Guidelines on the Perioperative Care of Surgical Patients With Borderline-resectable and Locally Advanced Pancreatic Cancer.

OBJECTIVE: The REDISCOVER consensus conference aimed at developing and validating guidelines on the perioperative care of patients with borderline-resectable (BR-) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC). BACKGROUND: Coupled with improvements in chemotherapy and radiation, the contemporary approach to pancreatic surgery supports the resection of BR-PDAC and, to a lesser extent, LA-PDAC. Guidelines outlining the selection and perioperative care for these patients are lacking. METHODS: The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used to develop the REDISCOVER guidelines and create recommendations. The Delphi approach was used to reach a consensus (agreement ≥80%) among experts. Recommendations were approved after a debate and vote among international experts in pancreatic surgery and pancreatic cancer management. A Validation Committee used the AGREE II-GRS tool to assess the methodological quality of the guidelines. Moreover, an independent multidisciplinary advisory group revised the statements to ensure adherence to nonsurgical guidelines. RESULTS: Overall, 34 recommendations were created targeting centralization, training, staging, patient selection for surgery, possibility of surgery in uncommon scenarios, timing of surgery, avoidance of vascular reconstruction, details of vascular resection/reconstruction, arterial divestment, frozen section histology of perivascular tissue, extent of lymphadenectomy, anticoagulation prophylaxis, and role of minimally invasive surgery. The level of evidence was however low for 29 of 34 clinical questions. Participants agreed that the most conducive means to promptly advance our understanding in this field is to establish an international registry addressing this patient population ( https://rediscover.unipi.it/ ). CONCLUSIONS: The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with BR-PDAC and LA-PDAC, and serve as the basis of a new international registry for this patient population.

Pancreas sparing duodenectomy and aortic reconstruction with custom-made bovine pericardial tubular graft for primary aorto duodenal fistula. Case report.

Primary aorto-duodenal fistula (PADF) is a rare life-threatening condition consisting in a direct communication between the abdominal aorta and the gastrointestinal tract without any previous vascular intervention. PADF results most commonly from an abdominal aortic aneurism (AAA) or aortic bacterial/mycotic infection, with the fistula forming between the native aorta and the third or fourth portion of the duodenum. Symptoms are nonspecific and the diagnosis is often delayed after AAA rupture with high rate of morbidity and mortality. We present a case of 69-year-old-male with a history of untreated abdominal aortic aneurysm who came to the attention of the emergency department for Abdominal aortic aneurysm rupture (RAAA). The patient was successfully treated with staged therapy: endovascular aneurysm repair (EVAR) to control hemorrhage rapidly, followed by pancreas sparing duodenectomy and aortic reconstruction with xenopericardial tube grafts. KEY WORDS: Biological graft, Bovine pericardial tubular graft, Primary aorto-duodenal fistula, Pancreas sparing duodenectomy.