Patients' treatment preferences for potentially resectable tumors of the head of the pancreas.

BACKGROUND: The primary aim of this study was to assess if patients with potentially resectable ductal adenocarcinoma (PDAC) of the head of the pancreas would choose a Whipple procedure versus palliative chemotherapy. METHODS: A cohort of adults with radiological resectable PDAC was enrolled at a tertiary Canadian teaching hospital. Participants were informed about treatment options, expected outcomes, and adverse events using data from the most recent scientific literature. Probability trade-off (PTO) was used to elicit treatment preferences. RESULTS: Surgery was preferred by all participants except one (96.7% vs. 3.3%; P = 0.0001). For 90% of participants preferring surgery, the main reason was the hope of being cured (P = 0.001). If the risk of perioperative mortality was higher than 57%, the risk of perioperative morbidity higher than 85% and the survival benefit was less than 4 months, half of the participants preferred palliative chemotherapy. The likelihood of needing blood transfusions, the length of hospital stay, and long-term consequences such as diabetes or pancreatic exocrine insufficiency were negligible concerns to participants. CONCLUSIONS: Informed patients with early-stage PDAC prefer resection over palliative chemotherapy. The dominating factor influencing their decision is the hope of a cure that overshadow the risks of complications, mortality and recurrent disease.

Totally laparoscopic versus laparoscopic-assisted left colectomy for cancer: a retrospective review.

BACKGROUND: Laparoscopic left colectomy (LLC) became the standard of care for treating distal transverse and descending colon cancer in many centers. Most centers use laparoscopic-assisted colectomy with extracorporeal anastomosis (LAC/EA). A totally laparoscopic colectomy with intracorporeal anastomosis (TLC/IA) has been proposed. The purpose of our study is to compare these two techniques. METHODS: A series of 52 patients undergoing LLC for left-sided colon cancer was retrospectively evaluated. Thirty-three patients underwent TLC/IA, and 19 underwent LAC/EA. The following data were collected: gender, age, body mass index, American Society of Anesthesiologists risk class, operation duration, conversion to laparotomy, intraoperative complications, postoperative complications, postoperative course (duration of stay, time to first flatus), number of excised lymph nodes, readmission, and reoperation rates. Data were prospectively recorded in a colorectal cancer database and retrospectively analyzed. RESULTS: The only demographic parameter that differed significantly between the groups was age (64.2 ± 12.4 years for the TLC/IA group, vs. 72.7 ± 2.1 years for LAC/EA, p = 0.0116). The mini-laparotomy incision was significantly shorter in the TLC/IA than in the LAC/EA group (5.8 ± 0.9 vs. 8.2 ± 0.9 cm, respectively, p < 0.00001). Hospital stay duration was shorter in the TLC/IA group (4.2 ± 1.2 vs. 6.3 ± 1.9, p = 0.0001). The average number of harvested lymph nodes did not differ significantly between the groups (12.9 ± 5.7 in TLC/IA vs. 11.2 ± 4.2 in LAC/EA, p = 0.2546). No significant differences between the groups were observed in any other perioperative or surgical outcome parameters. CONCLUSIONS: TLC/IA in LLC for the treatment of left colon cancer is technically feasible and can be performed with a low complication rate, favorable cosmetics, and possibly shorter hospital stay, without significantly lengthening operative duration or compromising oncologic radicality principles. Although further prospective randomized studies are needed to determine its role and limitations, we encourage using it as an alternative to LAC/EA in LLC.

A randomized prospective controlled trial comparing the laryngeal tube suction disposable and the supreme laryngeal mask airway: the influence of head and neck position on oropharyngeal seal pressure.

BACKGROUND: The Laryngeal Tube Suction Disposable (LTS-D) and the Supreme Laryngeal Mask Airway (SLMA) are second generation supraglottic airway devices (SADs) with an added channel to allow gastric drainage. We studied the efficacy of these devices when using pressure controlled mechanical ventilation during general anesthesia for short and medium duration surgical procedures and compared the oropharyngeal seal pressure in different head and-neck positions. METHODS: Eighty patients in each group had either LTS-D or SLMA for airway management. The patients were recruited in two different institutions. Primary outcome variables were the oropharyngeal seal pressures in neutral, flexion, extension, right and left head-neck position. Secondary outcome variables were time to achieve an effective airway, ease of insertion, number of attempts, maneuvers necessary during insertion, ventilatory parameters, success of gastric tube insertion and incidence of complications. RESULTS: The oropharyngeal seal pressure achieved with the LTS-D was higher than the SLMA in, (extension (p=0.0150) and right position (p=0.0268 at 60 cm H2O intracuff pressures and nearly significant in neutral position (p = 0.0571). The oropharyngeal seal pressure was significantly higher with the LTS-D during neck extension as compared to SLMA (p= 0.015). Similar oropharyngeal seal pressures were detected in all other positions with each device. The secondary outcomes were comparable between both groups. Patients ventilated with LTS-D had higher incidence of sore throat (p = 0.527). No major complications occurred. CONCLUSIONS: Better oropharyngeal seal pressure was achieved with the LTS-D in head-neck right and extension positions , although it did not appear to have significance in alteration of management using pressure control mechanical ventilation in neutral position. The fiberoptic view was better with the SLMA. The post-operative sore throat incidence was higher in the LTS-D. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02856672 , Unique Protocol ID:BnaiZionMC-16-LG-001, Registered: August 2016.

The severity of liver injury following blunt trauma does not correlate with the number of fractured ribs: an analysis of a national trauma registry database.

PURPOSE: Rib fractures are a marker of severe injury, predicting a higher incidence of associated injuries. The purpose of this study was to assess whether an increasing number of rib fractures predicts the severity of liver injury in blunt trauma patients. METHODS: We performed a retrospective cohort study involving blunt trauma patients with concomitant liver injuries and rib fractures who were registered in a national trauma registry. RESULTS: Of 57,130 patients with blunt torso injuries, 14,651 patients sustained rib fractures, and 2,899 patients suffered liver injuries. Concomitant liver injury occurred in 1,087 of the patients with rib fractures (7.4%), while 1,812 patients sustained liver injury without rib fractures (4.3%). The presence of six or more rib fractures predicted a higher incidence of liver injury. Among the patients with liver injury, those with concomitant rib fractures had a higher Injury Severity Score (ISS), but similar mortality rates. Among the patients with concomitant rib fractures and liver injury, there was no relationship between the number of fractured ribs and the severity of the liver injury. CONCLUSIONS: Although the presence of rib fractures was associated with an increased probability of liver injury in patients with blunt torso trauma, there is no relationship between the number of fractured ribs and the severity of liver injury.

Multi-Center Real-World Outcomes of Nivolumab Plus Ipilimumab and Chemotherapy in Patients with Metastatic Non-Small-Cell Lung Cancer.

Immune checkpoint inhibitors have become the standard of care in the treatment of metastatic non-small-cell lung cancer (NSCLC). The combination of nivolumab plus ipilimumab and chemotherapy has been shown to improve outcomes in terms of overall survival (OS) and progression-free survival (PFS). The aim of this study was to evaluate the outcomes of metastatic NSCLC treated in routine practice on the treatment regimen of the CheckMate 9LA protocol. Medical records of 58 patients treated at Soroka and Bnai Zion Medical Centers between May 2020 and February 2022 were analyzed. All patients were treated with a regimen of platinum-based chemotherapy combined with immunotherapy of nivolumab every three weeks and ipilimumab every 6 weeks. The patients received 2-3 cycles of chemotherapy according to the physician's choice: platinum-based cisplatin or carboplatin with either pemetrexed or paclitaxel. The median PFS was 10.2 months, longer than that of the 9LA trial (6.7 months). Adenocarcinoma patients exhibited a higher median OS of 13.7 (range 5-33) months than squamous cell carcinoma (SCC) patients at 12.3 (5-20) months and PFS of 10.3 (4-33) months, while squamous cell carcinoma patients had a PFS of 9.2 (4-18) months. Patients whose programmed death ligand-1 (PD-L1) tumor expression level was ≥1% showed a higher median OS than those with PD-L1 expression of less than 1%. Treatment-related adverse events (TRAEs) were reported in 93.1% of patients, mostly grade 1 in severity. The first-line treatment of metastatic NSCLC patients in combination with nivolumab plus ipilimumab and chemotherapy can be given safely in routine clinical practice, with results comparable to those achieved in clinical trials of the regimen.

Factors Predicting Type I Gastric Neuroendocrine Neoplasia Recurrence: A Single-Center Study.

Type I gastric neuroendocrine neoplasms (gNENs) are associated with atrophic gastritis and have a high recurrence rate, which means frequent endoscopies are required. The objective of this study was to identify factors predicting the local recurrence of type I gNENs. The clinical course and the pathological and biochemical data of patients with type I gNENs treated at Bnai Zion Medical Center between 2006 and 2022 were analyzed retrospectively. Twenty-seven type I gNENs were evaluated. The follow-up period was 41 months (range: 11-288 months). Recurrence of the tumor occurred in 13/27 (48%) patients after 35 months (median (M), interquartile range (IQR): 21-67.5). Serum gastrin levels were significantly higher in patients with recurrent disease versus patients with non-recurrent disease (788 vs. 394 ng/L; p = 0.047), while the Ki-67 index was significantly lower in patients with recurrent disease versus patients with non-recurrent disease (1% vs. 3.5%; p = 0.035). Tumor size, mitotic count, and serum chromogranin A levels did not correlate with recurrence. The present study emphasizes the role of gastrin in the pathogenesis of gNEN recurrence and highlights the debate regarding the ability of the Ki-67 index to predict the clinical course of this disease.

Response Rate of the Third and Fourth Doses of the BNT162b2 Vaccine Administered to Cancer Patients Undergoing Active Anti-Neoplastic Treatments.

The BNT162b2 vaccine is globally used for preventing morbidity and mortality related to COVID-19. Cancer patients have had priority for receiving the vaccine due to their diminished immunity. This study reports the response rate of administering the third and fourth vaccine doses to cancer patients receiving active anti-neoplastic treatment. A total of 142 patients received two doses of the mRNA-based BNT162b2 COVID-19 vaccine, while 76 and 25 patients received three and four doses, respectively. The efficacy of the humoral response following two vaccine doses was diminished in cancer patients, especially in the group of patients receiving chemotherapy. In a multivariate analysis, patients who received three and four BNT162b2 vaccine doses were more likely to have antibody titers in the upper tertile compared to patients who received two doses of the vaccine (odds ratio (OR) 7.62 (95% CI 1.38-42.12), p = 0.02 and 17.15 (95% CI 5.01-58.7), p < 0.01, respectively). Unlike the response after two doses, the third and fourth BNT162b2 vaccine booster doses had an increased efficacy of 95-100% in cancer patients while undergoing active treatment. This result could be explained by different mechanisms including the development of memory B cells.

Minimally Invasive Primary Liver Cancer Surgery.

Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) has been rapidly expanding. With increasing experience, the safety and feasibility of LLR for HCC have been demonstrated. LLR of HCC is becoming the standard of care for minor liver resections, and even major LLR are being performed safely in experienced centers. In most reports, patients undergoing LLR had less blood loss, fewer transfusions, less postoperative morbidity, and shorter length of stay compared with open liver resections (OLR). The 5-year overall and disease-free survival rates for patients undergoing LLR for HCC are comparable to OLR.

Laparoscopic Heller Myotomy with Anterior Fundoplication Improves Frequency and Severity of Symptoms of Achalasia, Regardless of Preoperative Severity Determined by Esophagography.

This study was undertaken to determine whether postoperative outcomes after laparoscopic Heller myotomy with anterior fundoplication could be predicted by preoperative findings on esophagography. Preoperative barium esophagograms of 135 patients undergoing laparoscopic Heller myotomy with anterior fundoplication were reviewed. The number of esophageal curves, esophageal width, and angulation of the gastroesophageal junction (GEJ) were determined; correlations between these determined parameters and symptoms were assessed using linear regression analysis. The number of esophageal curves correlated with the preoperative frequency of dysphagia, vomiting, chest pain, regurgitation, and heartburn. The width of the esophagus negatively correlated with the preoperative frequency of regurgitation. The angulation of the GEJ did not correlate with preoperative symptoms. Laparoscopic Heller myotomy with anterior fundoplication significantly reduced the frequency and severity of all symptoms, regardless of the number of esophageal curves, esophageal width, or angulation of the GEJ. Laparoscopic Heller myotomy with anterior fundoplication provides dramatic palliation for achalasia. More esophageal curves on preoperative esophagography correlate well with the frequency of a broad range of preoperative symptoms, including the frequency of dysphagia and regurgitation. Patients experience dramatically improved frequency and severity of symptoms after laparoscopic Heller myotomy with anterior fundoplication for achalasia regardless of the number of esophageal curves, esophageal width, or the angulation of the GEJ. Findings on barium esophagogram, in evaluating achalasia, should not deter the application of laparosocopic Heller myotomy with anterior fundoplication.

Spontaneous splenic artery rupture in a patient with an unclassified malignant spindle cell tumor of the spleen: report of a case.

The purpose of this paper was to describe an unusual manifestation of a sarcoma of the spleen and to raise awareness for spontaneous rupture of the splenic vessels in patients with splenic tumors. A 70-year-old man was admitted to our institution, suffering from left upper quadrant abdominal pain. Upon physical examination, a large and tender abdominal mass was palpated. Abdominal computed tomography showed a heterogenous enlarged spleen with active contrast extravasation from the splenic artery, free intraperitoneal fluid, and a retroperitoneal hematoma. The patient was treated with angioembolization of the splenic artery. Because of rebleeding, splenectomy was performed. Pathology revealed the spleen to be involved with an unclassified malignant spindle cell neoplasm. We concluded that in the case of spontaneous rupture of the splenic artery, accompanied with a radiologic appearance of an enlarged spleen, the diagnosis of sarcoma should be included in the differential diagnosis.

A comparison study of pelvic fractures and associated abdominal injuries between pediatric and adult blunt trauma patients.

PURPOSE: Pelvic fractures are a marker of severe injury, mandating a thorough investigation for the presence of associated injuries. Anatomical and physiological differences between adults and children may lead to a different impact of pelvic fractures on these populations. The purpose of this study is to compare pelvic fractures between pediatric and adult blunt trauma victims, mainly regarding their severity and associated intraabdominal injuries. METHODS: A retrospective study involving blunt trauma patients suffering pelvic fractures, according to the records of the Israeli National Trauma Registry. Patients included children, aged 0-14years, and adults between 15 and 64years. The presence and severity of associated injuries were assessed. RESULTS: Overall, 7621 patients aged 0-64years were identified with pelvic fractures following blunt trauma. The incidence of pelvic fractures in children was (0.8%), as compared to 4.3% in adults, p <0.0001. The most common mechanism of injury was motor vehicle accident (MVA) in adults, and pedestrian hit by car (PHBC) in children. About a quarter of the patients in both groups had an ISS >25. Adults sustained significantly more moderate to severe pelvic fractures (AIS≥3) than children (26.7% vs. 17.4%, p<0.0001). The overall mortality rate was similar among the two groups (5.4% in adults, 5.2% in children, p=0.7554). The only associated injury with statistically significant difference in incidence among the two groups was rectal injury (1.2% among children, 0.2% among adults, p<0.0001). Among adult patients, there was a clear correlation between the severity of pelvic fractures and the severity of concomitant splenic and hepatic injuries (p=0.026, p=0.0004, respectively). Among children, a similar correlation was not demonstrated. CONCLUSIONS: Adults involved in blunt trauma are more likely to sustain pelvic fractures, and these are generally more severe fractures, as compared to children suffering from blunt trauma. Nonetheless, mortality rates were found similar in both groups. The only associated injury with statistically significant difference in incidence among the two groups was rectal injury. In adults, but not in children, higher grade pelvic fractures correlated with more severe concomitant splenic or hepatic injuries. LEVEL OF EVIDENCE: The level of evidence for this study is III (3).

Age and Achalasia: How Does Age Affect Patient Presentation, Hospital Course, and Surgical Outcomes?

Heller myotomy is the "gold-standard" therapy for achalasia, alleviating symptoms by defunctionalizing the lower esophageal sphincter mechanism. Observation has suggested many differences between young and old patients with achalasia, raising the question: is achalasia in younger patients a different disorder than it is in older patients? This study was undertaken to answer this question. With Institutional Review Board approval, 648 patients undergoing laparoscopic Heller myotomy from 1992-2016 were prospectively followed up. Patients self-assessed symptom frequency/severity preoperatively and postoperatively using a Likert scale; 0 (never/not bothersome) to 10 (always/very bothersome). Before myotomy, frequency/severity of many symptoms (e.g., "dysphagia," "chest pain," and "regurgitation") inversely correlated with age (P < 0.01 each). Symptom duration and the number of previous abdominal operations correlated with age, as did intraoperative complications (e.g., gastrotomy), postoperative complications (e.g., atrial fibrillation), and length of stay (P < 0.01 for each). Patients experienced amelioration of all symptoms queried, regardless of age (P < 0.01 each). Age did affect outcome because older patients had less frequent and severe symptoms. Age did not affect improvement of symptoms (e.g., dysphagia) (i.e., differences between preoperative and postoperative scores) (P = 0.88). Age did not influence symptom resolution or patient satisfaction (P = 0.98 and P = 0.15, respectively). The presentation with achalasia, hospital course, and outcome after myotomy are significantly impacted by age, whereas patient improvement after myotomy is constant independent of age. Younger and older patients have different presentations, experiences, and outcomes; these patients seem to have "different disorders", but Heller myotomy provides similar significant amelioration of symptoms independent of age.

Dissatisfaction after laparoscopic Heller myotomy: The truth is easy to swallow.

BACKGROUND: Although laparoscopic Heller myotomy has been shown to well palliate symptoms of achalasia, we have observed a small subset of patients who are "Dissatisfied". This study was undertaken to identify the causes of their dissatisfaction. STUDY DESIGN: Patients undergoing laparoscopic Heller myotomy from 1992 to 2015 were prospectively followed. Using a Likert scale, patients rated their symptom frequency/severity before and after the procedure. Patients graded their experience from "Very Satisfying" to "Very Unsatisfying." RESULTS: 647 patients underwent laparoscopic Heller myotomy. Fifty (8%) patients, median age 57 years and BMI 24 kg/m2 reported dissatisfaction at follow-up subsequent to myotomy. "Dissatisfied" patients were more likely to have undergone prior abdominal operations (p = 0.01) or previous myotomies (p = 0.02). "Dissatisfied" patients had a greater incidence of diverticulectomy (p = 0.03) and had longer postoperative LOS (p = 0.01). Symptom frequency/severity persisted after myotomy for dissatisfied patients (p > 0.05). CONCLUSION: Dissatisfaction after laparoscopic Heller myotomy is directly related to persistent/recurrent symptoms. Previous abdominal operations/myotomies, diverticulectomies, and longer LOS are predictors of dissatisfaction. With this understanding, we can identify patients who might be more prone to dissatisfaction.

Regional differences for pancreaticoduodenectomy in Florida: Location matters.

INTRODUCTION: Regionalization of care raises potential for differences in cost of care and outcome. This study was undertaken to determine if costs and outcome after pancreaticoduodenectomy vary by region in Florida, and whether costs and outcome are related. METHODS: Inpatient data for pancreaticoduodenectomy in Florida during 2010-2012 were obtained from the Florida Agency for Health Care Administration. Seven geographically different regions were designated based on "cost of living index" and "urban to rural population ratio". Hospital costs, LOS, in-hospital mortality, and the frequency with which surgeons performed pancreaticoduodenectomy were evaluated for these regions. RESULTS: Median hospital costs for pancreaticoduodenectomy by region ranged from $101,436-$214,971. Median hospital costs by region correlated positively with LOS (p < 0.0001) and in-hospital mortality (p < 0.0001), and negatively with the frequency of pancreaticoduodenectomies performed by high-volume surgeons (p < 0.0001). CONCLUSIONS: There are regional differences for hospital costs and outcome with pancreaticoduodenectomy in Florida. Regions with lower costs had more pancreaticoduodenectomies performed by high-volume surgeons, shorter LOS, and lower in-hospital mortality rates. Regional differences in cost and quality-of-care need to be studied and abrogated to provide uniform optimal care.

A practical approach to liver metastasis from unknown primary cancer: What surgeons need to know.

The liver is a site of metastasis in 25% of metastatic cancers (Abbruzzese et al., 1995). In Western countries, metastases are the most common type of malignant neoplasms in the liver. The majority of liver metastases arise from carcinomas, but other primary tumor types should also be considered, such as lymphomas, sarcomas, melanomas, and germ cell tumors. Of primary liver malignancies, hepatocellular carcinoma is the most common (Hertz et al., 2000). The differentiation between metastatic carcinoma to the liver and primary hepatocellular carcinoma is sometimes challenging. In the last decade, newer technologies have emerged and are being used to reinforce the existing traditional pathologic staining and immunohistochemistry techniques, thus increasing the accuracy of primary site detection, and suggesting new targeted treatment options. The purpose of this review is to present and summarize, in a practical and simplified manner, the current literature regarding the clinically challenging entity of liver metastasis from carcinomas of unknown primary.

Does Severity of Pelvic Fractures Correlate with the Incidence of Associated Intra-Abdominal Injuries in Children?

Background Pelvic fractures are considered a marker of injury severity, especially in the pediatric population. However, the correlation between the severity of pelvic fractures and incidence of associated abdominal injuries is not clear. Methods A retrospective cohort study involving blunt trauma patients up to the age of 14 years, who suffered from pelvic fractures, with or without associated intra-abdominal injuries. Results A total of 812 trauma patients were included in this study. Overall, 671 of them suffered from pelvic fractures with abbreviated injury scale (AIS) of 2, 103 with AIS of 3, and 38 with AIS of 4 to 5. Overall mortality was found to be 5.2%, strongly correlating with the severity of the pelvic fractures (p value < 0.0001). There was no correlation between the incidence of most extrapelvic abdominal organ injuries (liver, spleen, small bowel, and pancreas) and the severity of pelvic fractures. A significant correlation was found with intrapelvic organ injuries (p value < 0.0001) and kidney injuries (p = 0.03). Conclusions Mortality of pediatric trauma patients with pelvic fractures is correlated with the severity of the fractures. An increase in the severity of pelvic fractures in this population is associated with an increased incidence of pelvic organ injury, but is not associated with the presence of extrapelvic abdominal injuries, except for kidney injuries.

Aorta Balloon Occlusion in Trauma: Three Cases Demonstrating Multidisciplinary Approach Already on Patient's Arrival to the Emergency Room.

PURPOSE: To describe the usage of aortic balloon occlusion (ABO), based on a multidisciplinary approach in severe trauma patients, emphasizing the role of the interventional radiologist in primary trauma care. METHODS: We briefly discuss the relevant literature, the technical aspects of ABO in trauma, and a multidisciplinary approach to the bleeding trauma patient. We describe three severely injured trauma patients for whom ABO was part of initial trauma management. RESULTS: Three severely injured multi-trauma patients were treated by ABO as a bridge to surgery and embolization. The procedures were performed by an interventional radiologist in the early stages of trauma management. CONCLUSIONS: The interventional radiologist and the multidisciplinary team approach can be activated already on severe trauma patient arrival. ABO usage and other endovascular methods are becoming more widely spread, and can be used early in trauma management, without delay, thus justifying the early activation of this multidisciplinary approach.

Can pancreatic cancer behavior be predicted based on computed tomography measurements of fat and muscle mass?

Many studies purport that obesity, and specifically visceral fat, impact survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. However, these studies involve crude measures of obesity [eg, body mass index (BMI)] or visceral fat [eg, linear measurements on computed tomographic (CT) scans]. Some studies purport that weight loss and muscle wasting (ie, sarcopenia) presage poor survival in these patients. This study was undertaken to accurately measure and reexamine the impact of visceral fat, subcutaneous fat, and sarcopenia on pancreatic cancer. MATERIALS AND METHODS: CT scans of 100 patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma were reviewed using specialized software to precisely determine the cross-sectional area (CSA) of subcutaneous fat, visceral fat, and psoas muscles at the level of L5 vertebra. In addition, linear measurements of subcutaneous fat and visceral fat were undertaken. Measures of cancer progression included tumor (T) status, nodal (N) status, American Joint Committee on Cancer stage, and overall survival after resection. Regression analysis was utilized, with and without standardization of all measurements to body size. Median data are presented. RESULTS: The median patient age was 67 years, with a BMI of 24 kg/m2. Cancer stage was IIB for 60% of patients. BMI, CSA of visceral fat, CSA for subcutaneous fat, CSA for psoas muscles, and linear measurements of visceral and subcutaneous fat were not significantly related to any measures of cancer progression or survival. Standardization to body size did not demonstrate any relationships with cancer progression or survival. CONCLUSIONS: Precise and reproducible measures of visceral fat, subcutaneous fat, and muscle mass, even when standardized to body size, do not predict cancer progression or survival in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma. Pancreatic cancer biology and behavior is too complex to predict with a CT scanner. The main focus of pancreatic cancer research should continue to be at the molecular, genetic, and immunologic levels.