Prognostic significance of pancreatic fistula and postoperative complications after pancreaticoduodenectomy in patients with pancreatic ductal adenocarcinoma.

BACKGROUND: The influence of postoperative complications, specifically, pancreatic fistula (PF), on long-term oncologic outcome in patients with pancreatic ductal adenocarcinoma (PDAC) is unclear. METHODS: Prospectively collected data of patients who underwent pancreaticoduodenectomy (PD) for PDAC between 2008 and 2016 were retrospectively reviewed and analyzed. Deaths within 90 days were excluded. Median follow-up time was 22 months for the entire cohort (range 2-102 months). PF was graded as biochemical leak, grade B, or grade C according to the criteria of the International Study Group on Pancreatic Fistula. Postoperative complications were graded according to the Clavien-Dindo classification (CDC). Data on clinical and pathological characteristics as well as on recurrence and survival were collected. RESULTS: Twenty-nine of the 148 identified patients (19%) developed PF, of whom 17 (11.4%) had a PF grade B or C. 29 patients developed a postoperative complication CDC grade 3 or 4. The respective 3-year disease-free survival was 15.5% and 19.2% (P = 0.725), and the 5-year overall survival was 20% and 16% (P = 0.914) in patients with and without PF. On multivariate analysis, the use of adjuvant chemotherapy, lymph node involvement, surgical margin involvement, and tumor grade were associated with patient survival. PF and postoperative complications CDC grade 3 or 4 were not associated with decreased long-term survival, disease-free survival or local recurrence rate. CONCLUSIONS: While acknowledging the limited sample size, no association was seen between PF or postoperative complications and overall or disease-free survival in patients undergoing PD for PDAC.

R1 resection of colorectal liver metastasis - What is the cost of marginal resection?

BACKGROUND AND OBJECTIVES: The impact of resection margins on the outcome of patients with colorectal liver metastasis (CRLM) remains controversial. We evaluated the short and long-term results of R1 resection. METHODS: Between 2006 and 2016, 202 patients underwent liver resection for CRLM. R1 resection was defined as a distance of less than 1 mm between tumor cells and the transection plain. Patient and tumor characteristics, perioperative, and long-term outcomes were assessed. RESULTS: In 161 (79.7%) and 41 (20.3%) patients, an R0 and R1 resections were achieved, respectively. Patients that underwent an R1 resection had higher rates of disease progression while on chemotherapy (12.1% vs 5.5%, P = 0.001), need for second-line chemotherapy (17% vs 6.2%, P < 0.001), increased use of preoperative volume manipulation (14.6% vs 5.5%, P = 0.001), and inferior vena-cava involvement (21.9% vs 8.7%, P < 0.001). These patients had higher rates of major postoperative complications (19.5% vs 6.8%, P < 0.001) and reoperations (7.3% vs 2.4%, P < 0.001). Multivariate analysis demonstrated that R1 resections were not associated with decreased recurrence-free survival or overall survival. CONCLUSIONS: Although R1 resection is associated with worse disease behavior and postoperative complications, the long-term outcome of patients following an R1 resection is non-inferior to those who underwent an R0 resection.

Kidney transplantation in patients with inflammatory bowel diseases (IBD): analysis of transplantation outcome and IBD activity.

Inflammatory bowel diseases (IBD) is a systemic disorder with possible renal involvement, yet data regarding the outcome of kidney transplantation (KT) in those patients, and IBD course post KT, are scarce. In this retrospective analysis, we studied the outcome of 12 IBD kidney recipients (seven Crohn's disease, five ulcerative colitis; primary kidney disease was IgA nephropathy in five, polycystic disease in four), compared to two control groups: matched controls and a cohort of recipients with similar kidney disease. During a follow-up period of 60.1 (11.0-76.6) months (median, interquartile range), estimated 5-year survival was 80.8 vs. 96.8%, with and without IBD, respectively (P = 0.001). Risk of death with a functioning graft was higher with IBD (HR = 1.441, P = 0.048), and with increased age (HR = 1.109, P = 0.05). Late rehospitalization rate was higher in IBD [incidence rate ratio = 1.168, P = 0.030], as well as rate of hospitalization related to infection [1.42, P = 0.037]. All patients that were in remission before KT, remission was maintained. Patients that were transplanted with mild or moderate disease remained stable or improved with Infliximab or Adalimumab treatment. In conclusion, IBD is associated with an increased risk of mortality, hospitalization because of infection and late rehospitalization after KT. Clinical course of IBD is stable after KT.

Long term metabolic and renal outcomes of kidney donors compared to controls with excellent kidney function.

BACKGROUND: Only few studies of living kidney donors have included controls that were similarly healthy, including excellent kidney function. METHODS: In this study, we aimed to estimate long term metabolic and renal outcome in a cohort of 211 living donors compared to two control groups: paired-matched controls, and another control group of 2534 healthy individuals with excellent kidney function. RESULTS: Donors presented with higher estimated Glomerular Filtration Rate (eGFR): (97.6 ± 15.2 vs 96.1 ± 12.2 vs 94.5 ± 12.4 ml/min/1.73m2) and lower urine albumin to creatinine ratio (UACR) (4.3 ± 5.9 vs 5.9 ± 6.1 vs 6.1 ± 6.9 mg/g) for donors, matched controls and healthy controls, respectively (p <  0.001). In a mean follow up period of 5.5 for donors, donors presented with positive eGFR slopes during the first 3 years post donation, followed by negative slopes, compared to constantly negative slopes presented in the control group (p <  0.05). The variables related to the slope were being a donor, baseline eGFR, Body Mass Index (BMI) and age but not eGFR on the last day of follow-up or increased delta UACR. There was a significant increase in UACR in donors, as well as a higher rate of albuminuria, associated with a longer time since donation, higher pre-donation UACR and higher pre-donation BMI. Healthy controls had a lower BMI at baseline and gained less weight during the follow up period. Donors and controls had similar incidence of new onset diabetes mellitus and hypertension, as well as similar delta systolic and diastolic blood pressure. Donors were more likely to develop new onset metabolic syndrome, even after adjustment for age, gender and BMI. The higher incidence of metabolic syndrome resulted mainly from increased triglycerides and impaired fasting glucose criteria. However, prevalence of major cardiovascular events was not higher in this group. CONCLUSIONS: Donors are at increased risk to develop features of the metabolic syndrome in addition to the expected mild reduction of GFR and increased urine albumin excretion. Future studies are needed to explore whether addressing those issues will impact post donation morbidity and mortality.

Early reoperation following pancreaticoduodenectomy: impact on morbidity, mortality, and long-term survival.

BACKGROUND: Reoperation following PD is a surrogate marker for a complex post-operative course and may lead to devastating consequences. We evaluate the indications for early reoperation following PD and analyze its effect on short- and long-term outcome. METHODS: Four hundred and thirty-three patients that underwent PD between August 2006 and June 2016 were retrospectively analyzed. RESULTS: Forty-eight patients (11%; ROp group) underwent 60 reoperations within 60 days from PD. Forty-two patients underwent 1 reoperation, and 6 had up to 6 reoperations. The average time to first reoperation was 10.1 ± 13.4 days. The most common indications were anastomotic leaks (22 operations in 18 patients; 37.5% of ROp), followed by post-pancreatectomy hemorrhage (PPH) (14 reoperations in 12 patients; 25%), and wound complications in 10 (20.8%). Patients with cholangiocarcinoma had the highest reoperation rate (25%) followed by ductal adenocarcinoma (12.3%). Reoperation was associated with increased length of hospital stay and a high post-operative mortality of 18.7%, compared to 2.6% for the non-reoperated group. For those who survived the post-operative period, the overall and disease-free survival were not affected by reoperation. CONCLUSIONS: Early reoperations following PD carries a dramatically increased mortality rate, but has no impact on long-term survival.

Progression and new onset of nonalcoholic fatty liver disease in living kidney donors compared to healthy controls.

BACKGROUND: There is growing evidence linking nonalcoholic fatty liver disease (NAFLD) with reduced glomerular filtration rate (GFR). Living kidney donors do not have underlying kidney disease, but have reduced GFR as a result of nephrectomy. Whether kidney donation is associated with a higher risk for development or progression of NAFLD is currently unknown. METHODS: Retrospective evaluation of metabolic parameters and sonographic evidence of NAFLD were performed in 232 living kidney donors and 162 healthy controls. RESULTS: A total of 25 donors and 44 controls had NAFLD at baseline. During a mean follow-up of 6.8 years, 6 donors (24%) and 17 controls (38.6%) (P = .29) had a remission of NAFLD, related with decreased body mass index (BMI). The progression of NAFLD fibrosis score was similar in both groups. New onset of NAFLD was observed in 14 (6.8%) donors and 13 (11.01%) controls (P = .211), and was related to increased BMI and a higher baseline Fatty Liver Index score. Neither eGFR nor urine albumin excretion in the donors were related to new onset or progression of NAFLD. CONCLUSIONS: Reduced kidney function secondary to kidney donation is not associated with increased incidence or progression of NAFLD.

Suffer from Dialysis as a Predictor of Mental Health Among Kidney Transplant Recipients: a Preliminary Longitudinal Study.

Kidney transplant (KT) recipients are exposed to extreme physiological and psychological stressors, which make posttraumatic stress disorder (PTSD) symptoms a reasonable concern for this population. In this preliminary longitudinal study, we aimed to explore whether dialysis's duration and level of suffering from dialysis contribute to the explained variance of post-transplant PTSD symptomatology among KT recipients. One hundred and four consecutive KT recipients (wave 1) were surveyed and approached again (wave 2, N = 61) with the same measurement tools. The results revealed that the main predictor of mental health incidents in wave 1 and wave 2 was suffering from dialysis.

Resection of colorectal liver metastases in the elderly-Is it justified?

BACKGROUND AND OBJECTIVES: Liver resection of colorectal liver metastasis (CRLM) may necessitate large metabolic and physiologic reserve. As the population ages, resection of CRLM is increasingly required in the elderly. We assessed the safety and efficacy of these operations. METHODS: Between February 2010 and 2015, 174 patients underwent liver resection of CRLM. Fifty-four and 120 patients were over and under the age of 70 at the time of surgery, respectively (mean ages: 76 ± 4 and 56.5 ± 9 years). Patient and tumor characteristics, perioperative, and long-term outcomes were compared. RESULTS: Elderly patients had increased rates of IHD (18.5% versus 6.6%, P = 0.0002), COPD (9.2% versus 4.1%, P = 0.01), and DM (30% versus 14%, P = 0.02). Operative time was shorter in elderly patients (222 ± 109 versus 261 ± 110 min; P = 0.04). Intraoperative blood loss was comparable. The rate of minor postoperative complications was similar between groups, but elderly patients had higher rate of major complications (11.1% versus 2.5%, P < 0.0001). One elderly patient died following surgery (1.8%). Length of hospital stay was similar between groups. No difference in 3-year survival was demonstrated. CONCLUSIONS: Although associated with a small increase in postoperative morbidity and mortality, liver resection may be performed safely and effectively in carefully selected elderly patients. J. Surg. Oncol. 2016;113:485-488. © 2016 Wiley Periodicals, Inc.

The implications of body-image dissatisfaction among kidney-transplant recipients.

The role that body image plays in the psychological adjustment of kidney-transplant recipients is an understudied issue. In the current study, the association between three variables - (a) body-image dissatisfaction, (b) quality of life (QOL), and (c) psychological distress - was investigated. The research participants were 45 kidney-transplant recipients who were under follow-up care at the Transplant Unit of the Tel-Aviv Medical Center (Israel). Body image, psychological distress, and QOL were measured using self-report questionnaires [Body-Image Ideals Questionnaire (BIIQ), Brief Symptoms Inventory (BSI), and SF-12]. Medical and background data were collected from medical and administrative records. The findings indicated an association between higher level of body-image dissatisfaction and a decrease in several quality-of-life dimensions (role emotional, physical pain, general health, and social functioning), and with an increase in psychological distress. These findings highlight the importance of body-image dissatisfaction as a factor that is associated with QOL and psychological distress among kidney-transplant recipients. Body image warrants further attention and should be screened and treated among those who demonstrate high levels of dissatisfaction.

Early and late presentations of graft arterial pseudoaneurysm following pancreatic transplantation.

BACKGROUND: Graft pseudoaneurysm (PSA) following pancreatic transplantation (PT) is a rarely reported complication that has significant morbidity and mortality. Few case reports and small series of this complication exist. METHODS: Retrospective review of files of 106 patients who underwent PT at the Tel-Aviv Sourasky Medical center between 1995 and 2010. Accessible asymptomatic patients (n = 35) were referred for graft PSA screening using ultrasound-Doppler. RESULTS: Eight patients developed graft PSA (8 %). All had early posttransplant sepsis. PSA incidence among patients who had perioperative sepsis is 13 %. Three patients developed early postoperative PSA, presenting as massive abdominal bleeding requiring urgent laparotomy and graft resection. Five patients were diagnosed with late-onset graft PSA between 3 months and 11 years posttransplant: clinical presentations were massive gastrointestinal bleeding (n = 2), acute renal failure (n = 1), and asymptomatic finding on screening ultrasound-Doppler (n = 2, 6 % of screened patients). CONCLUSIONS: PSA following PT occurs in 8 % of patients. Perioperative infection is a risk factor. Early PSAs present as massive intra-abdominal bleeding. PSA may develop years posttransplant, may be asymptomatic, but late rupture is possible and presents as gastrointestinal bleeding. We recommend screening of patients at risk with ultrasound Doppler for early detection and treatment of asymptomatic PSAs.

Intrasplenic preconditioning: a model for the study of xenostimuli accommodation.

BACKGROUND: Discordant xenotransplantation, the grafting of organs from one phylogenic species to another, results in hyper-acute rejection (HAR). HAR is associated with the deposition of recipient preformed xenoreactive natural antibodies and complement on the endothelium of the donor organ, leading to activation and apoptosis of the endothelium, an event associated with xenograft rejection. Endothelial resistance to HAR, termed "accommodation," an active protection of graft endothelium, may be achieved by previous stimulation of endothelial cells by discordant xenoantibodies. MATERIALS AND METHODS: Forty-eight male Wistar rats were used to evaluate HAR induction in an isolated, dually perfused in-situ rat liver transfused with human blood. This ex-vivo model served to mimic rat-to-human liver xenotransplantation. Preconditioning of the liver endothelium was induced by rat intrasplenic injection of human blood (n=8) or effluent of previously xenotransfused rat liver (n=8), i.e., high versus low xenoantibody solution, each undertaken 1d before liver xenotransfusion. Two other groups were not preconditioned. Preconditioned and non-preconditioned rats were perfused directly with human blood, and eight rats were used as controls (non-preconditioned Krebs-perfused). Eight rats were perfused directly with human blood, and eight rats were used as controls. The effluent that exited these first-line livers was used to perfuse the second-line livers. RESULTS: Portal and hepatic artery perfusion pressures, resistances, rates of oxygen extraction, lactic acid and pH, and wet-to-dry weight ratio values were significantly increased in livers xenotransfused with blood indicating HAR, compared with unchanged values in livers perfused with Krebs solution. Portal pressure and resistance were best protected from HAR by the blood preconditioning in the blood perfused group, while the hepatic artery perfusion system was better protected by the perfusate precondition-blood perfused group. The physiologic effects of HAR were attenuated in most second-line livers. CONCLUSIONS: Attenuation of HAR in rats' livers is achieved by preconditioning with xenoantibodies and/or by "filtering out" xenoantibodies present in the circulation, and is suggestive of accommodation. This novel method may be useful in future studies aimed at refining methods for accommodating xenotransplantation.

Pancreatic cancer: surgery is a feasible therapeutic option for elderly patients.

BACKGROUND: Compromised physiological reserve, comorbidities, and the natural history of pancreatic cancer may deny pancreatic resection from elderly patients. We evaluated outcomes of elderly patients amenable to pancreatic surgery. METHODS: The medical records of all patients who underwent pancreatic resection at our institution (1995-2007) were retrospectively reviewed. Patient, tumor, and outcomes characteristics in elderly patients aged ≥ 70 years were compared to a younger cohort (<70 y). RESULTS: Of 460 patients who had surgery for pancreatic neoplasm, 166 (36%) aged ≥ 70 y. Compared to patients < 70 y (n = 294), elderly patients had more associated comorbidities; 72% vs. 43% (p = 0.01) and a higher rate of malignant pathologies; 73% vs. 59% (p = 0.002). Operative time and blood products consumption were comparable; however, elderly patients had more post-operative complications (41% vs. 29%; p = 0.01), longer hospital stay (26.2 vs. 19.7 days; p < 0.0001), and a higher incidence of peri-operative mortality (5.4% vs. 1.4%; p = 0.01). Multivariable analysis identified age ≥ 70 y as an independent predictor of shorter disease-specific survival (DSS) among patients who had surgery for pancreatic adenocarcinoma (n = 224). Median DSS for patients aged ≥ 70 y vs. < 70 y were 15 months (SE: 1.6) vs. 20 months (SE: 3.4), respectively (p = 0.05). One, two, and 5-Y DSS rates for the cohort of elderly patients were 58%, 36% and 23%, respectively. CONCLUSIONS: Properly selected elderly patients can undergo pancreatic resection with acceptable post-operative morbidity and mortality rates. Long term survival is achievable even in the presence of adenocarcinoma and therefore surgery should be seriously considered in these patients.

Contemporary surgical approach to hilar cholangiocarcinoma.

BACKGROUND: The diagnostic and therapeutic approach to hilar cholangiocarcinoma and thus the prognosis have changed significantly over the last two decades. Nonetheless, hilar cholangiocarcinoma presents a complex surgical challenge. OBJECTIVES: To assess the outcome of the radical approach for the management of types III and IV hilar cholangiocarcinoma. METHODS: We conducted a retrospective single-center study. Preoperative diagnosis was based on ultrasound, computed tomography and selective percutaneous cholangiography without tissue diagnosis. Surgery was radical and included en-bloc liver, extrahepatic biliary tree and hilar lymph nodes resection, followed by biliary reconstruction with hepaticojejunostomy. RESULTS: Fifteen patients (mean age 49 years, range 24-72) were managed accordingly. Anatomic classification of the biliary involvement was Bismuth-Corlette type IIIA (n=4), type IIIB (n=3) and type IV (n=8). The surgical procedures performed included four right hepatic lobectomies, five left hepatic lobectomies and six trisegmentectomies (all extended to the caudate lobe). Complete negative resection margins (RO) were accomplished in 12 cases (80%). Regional lymph node metastases were detected in five cases. There were two perioperative mortalities. Long-term follow-up (mean 30 months, range 6-72) revealed local recurrences in two cases, distant metastases in three, and both local and distant in two cases. Eleven patients are alive and 6 are without evidence of disease. The overall 2- and 5-year survival is 78% and 38% respectively. CONCLUSIONS: In selected patients the aggressive surgical approach to hilar cholangiocarcinoma is justified and can result in long-term survival.

Cystic tumors of the pancreas: high malignant potential.

BACKGROUND: Cystic tumors of the pancreas are rare, accounting for 10% of pancreatic cysts and 1% of all pancreatic tumors; surgery is dictated by their malignant potential. OBJECTIVES: To evaluate the malignancy rate of pancreatic cystic tumors and patient outcome, and to determine predictors for malignant potential. METHODS: We retrospectively reviewed the medical records of patients who underwent pancreatic resection for cystic tumors between January 1996 and December 2007. RESULTS: The charts showed that 116 patients were operated on for a pancreatic cystic tumor; most were women (63%). The chief complaint was abdominal pain (57%). Incidental detection occurred in 27%. Preoperative workup included ultrasound, tomography, endoscopic ultrasound and fine-needle aspiration biopsy. Indications for surgery were mucinous tumor, symptomatic or enlarging cyst under surveillance, high carcinoembryonic antigen levels within the cyst, and typical manifestations of intraductal papillary mucinous tumor (IPMT). All tumors but one were resectable. Whipple operation was performed in 40%, distal pancreatectomy in 55% and total pancreatectomy in 5%. Mucinous tumors were found in 40%, of which 37T were cystadenocarcinoma and/or borderline tumor. IPMT was found in 39%; 38% of them with cancer. Other pathologies included symptomatic serous cystadenomas, neuroendocrine cystic tumors and pseudopapillary tumors. The perioperative mortality rate was 2.6%. Five-year survival rates for patients with benign vs. invasive/borderline mucinous neoplasms was 90% vs. 59%, and for non-invasive vs. invasive IPMT 89% vs. 45% respectively. CONCLUSIONS: Cystic tumors of the pancreas should be carefully evaluated. Surgery should be considered when a mucinous component is suspected due to the high rate of malignancy. Complete resection carries a high cure rate even in the presence of cancer.

[Treatment of colorectal liver metastases: surgical resection vs. local ablative therapy].

INTRODUCTION: Surgical resection of colorectal liver metastases (CRLM) is the most common indication for hepatic resection at the present time and is considered to be the standard of care. However, advancement in imaging and local ablative therapy (LAT) techniques creates an apparently attractive alternative. The utilization of LAT is increasing for the treatment of CRLM in a non-controlled fashion. METHODS: A systematic and critical review of the Literature was undertaken according to the hierarchy of evidence based medicine (EBM). An analysis was conducted of the potential causes of the premature adoption of LAT as the first line treatment of CRLM. RESULTS: There is no level 1a meta-analysis available. A single Level 1b (randomized control study) is poorly presented; 2b cohort studies with some degree of risk adjustment, present a significant superiority to resection over LAT both in local control and in Long term resuLts. A single level 3a review points out a comparable local control following LAT for lesions smaller than 3 cm, but inferior long-term results, which may be biased by patient selection. Level 3b and 4 series point to different and contradicting results, prohibiting any conclusions. CONCLUSIONS: Based on the current knowLedge, LAT cannot replace surgical resection as the treatment of choice for CRLM. The increasing application of LAT in this setting is based on Level 5 evidence and is therefore inappropriate.

Clinical presentation can predict disease course in patients with intraductal papillary mucinous neoplasm of the pancreas.

BACKGROUND: Preoperative diagnosis of malignancy within intraductal papillary mucinous neoplasm of the pancreas (IPMN) solely by clinical or radiological findings is not always possible. We sought a correlation between preoperative clinico-radiological findings and outcome. METHODS: A prospective database of pancreatic resections for IPMN (2002-2008) and a retrospective pathological revision of all pancreatic cancer specimens (1995-2001) were analyzed. The patients were grouped into asymptomatic with preoperative diagnosis of IPMN (group 1), symptomatic with a preoperative diagnosis of IPMN (group 2), and those with a preoperative diagnosis of pancreatic cancer whose specimen revealed a background of IPMN (group 3). The groups were compared for demographics, clinical presentation, pathological findings, and outcome. RESULTS: Of the 62 patients with IPMN, 19 were in group 1, 23 in group 2, and 20 in group 3. Their median age (range) was 65.6 (46-80), 67 (50-84), and 73.4 (57-86) years, respectively. The clinical presentation for groups 2 and 3 included abdominal pain (56% vs. 32 %), weight loss (8% vs. 52%), obstructive jaundice (4% vs. 57%), pancreatitis (22% and 5%), and new onset of diabetes (14% and 44%). Invasive cancer was found in one patient in group 1 (5.2%), two patients in group 2 (8.7%), and all patients in group 3. IPMN was present in 23 of 217 (10.6%) of all resected pancreatic cancer specimens. Five year survival for patients with invasive disease was 47% and 92% for patients with noninvasive disease (mean follow-up 37.6 months). CONCLUSIONS: Benign IPMN can usually be differentiated from adenocarcinoma preoperatively. The clinical presentation is highly indicative of disease course.

Transjugular intrahepatic portosystemic shunt: current indications, patient selection and results.

BACKGROUND: Inserting a transjugular intrahepatic portosystemic shunt by means of interventional radiology has become the procedure of choice for decompression of portal hypertension. The indications and criteria for patient selection have been expanded and refined accordingly. OBJECTIVES: To review our experience with TIPS and analyze the results with emphasis on patient selection and indication (conventional vs. atypical). METHODS: In this retrospective analysis in a single center all cases were managed by a multidisciplinary team (comprising liver surgery and transplantation, hepatology, imaging, interventional radiology and intensive care). RESULTS: Between August 2003 and December 2009, 34 patients (mean age 51, range 27-76 years) were treated with TIPS. The cause of portal hypertension was cirrhosis (23 cases), hypercoagulability complicated by Budd-Chiari syndrome (n=6), and acute portal vein thrombosis (n=5). Clinical indications for TIPS included treatment or secondary prevention of variceal bleeding (10 cases), refractory ascites (n=18), mesenteric ischemia due to acute portal vein thrombosis (n=5), and acute liver failure (n=1). TIPS was urgent in 18 cases (53%) and elective in 16. Three deaths occurred following urgent TIPS. The overall related complication rate was 32%: trasient encephalopathy (6 cases), ischemic hepatitis (n=2), acute renal failure (n=2) and bleeding (n=1). Long-term results of TIPS were defined as good in 25 cases (73%), fair in 4 (12%) and failure in 5 (15%). In three of five patients with mesenteric ischemia following acute portal vein thrombosis, surgery was obviated. Revision of TIPS due to stenosis or thrombosis was needed in 7 cases (20%). CONCLUSIONS: TIPS is safe and effective. While its benefit for patients with portal hypertension is clear, the role of TIPS in treatment of portal-mesenteric venous thrombosis needs further evaluation. Patient selection, establishing the indication and performing TIPS should be done by a multidisciplinary dedicated team.

Resection Versus Observation of Small Asymptomatic Nonfunctioning Pancreatic Neuroendocrine Tumors.

BACKGROUND: Management of asymptomatic, nonfunctioning small pancreatic neuroendocrine tumors (PNETs) is controversial because of their overall good prognosis, and the morbidity and mortality associated with pancreatic surgery. Our aim was to compare the outcomes of resection with expectant management of patients with small asymptomatic PNETs. METHODS: Retrospective review of patients with nonfunctioning asymptomatic PNETs < 2 cm that underwent resection or expectant management at the Tel-Aviv Medical Center between 2001 and 2018. RESULTS: Forty-four patients with small asymptomatic, biopsy-proven low-grade PNETs with a KI67 proliferative index < 3% were observed for a mean of 52.48 months. Gallium67DOTATOC-PET scan was completed in 32 patients and demonstrated uptake in the pancreatic tumor in 25 (78%). No patient developed systemic metastases. Two patients underwent resection due to tumor growth, and true tumor enlargement was evidenced in final pathology in one of them. Fifty-five patients underwent immediate resection. Significant complications (Clavien-Dindo grade ≥ 3) developed in 10 patients (18%), mostly due to pancreatic leak, and led to one mortality (1.8%). Pathological evaluation revealed lymphovascular invasion in 1 patient, lymph node metastases in none, and a Ki67 index ≥ 3% in 5. No case of tumor recurrence was diagnosed after mean follow-up of 52.8 months. CONCLUSIONS: No patients with asymptomatic low-grade small PNETs treated by expectant management were diagnosed with regional or systemic metastases after a 52.8-month follow-up. Local tumor progression rate was 2.1%. Surgery has excellent long-term outcomes, but it harbors significant morbidity and mortality. Observation can be considered for selected patients with asymptomatic, small, low grade PNETs.

Response to chemotherapy predicts survival following resection of hepatic colo-rectal metastases in patients treated with neoadjuvant therapy.

BACKGROUND: Prognosis of patients following resection of CRC metastases to the liver has traditionally been predicted by clinical risk factors. In the era of neoadjuvant chemotherapy, determination of new prognostic indicators of outcome are necessary. METHODS: This retrospective study includes patients with CRC liver metastases, who received oxaliplatin or irinotecan based neoadjuvant chemotherapy and underwent R0 resection. Patients were followed by CT and PET-CT, before, during and after chemotherapy and surgery. The predictive value of the Memorial Sloan-Kettering Cancer Center Clinical Score (MSKCC-CS) and degree of response to chemotherapy (measured by CT and PET-CT), were analyzed by univariate and multivariate COX regression. RESULTS: Included are 54 patients. Overall 1-, 2-, 3-year survival rates 88%, 70%, and 39%. Response to chemotherapy on CT was a significant predictor of survival on univariate (P = 0.03) and multivariate analysis (P = 0.03), whereas MSKCC-CS and response to chemotherapy on PET-CT were not. Multivariate analysis demonstrated response to chemotherapy as a predictor of time to recurrence on CT (P = 0.02) and PET-CT (P = 0.03), while the MSKCC-CS (P = 0.64) was not. CONCLUSIONS: In this cohort of patients treated by neoadjuvant chemotherapy, the outcome was not predicted by the traditional clinical scoring system, but rather by response to chemotherapy as evaluated by CT and PET-CT.