Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS): Design and International External Validation.

OBJECTIVE: The aim of this study was to develop an alternative fistula risk score (a-FRS) for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, without blood loss as a predictor. BACKGROUND: Blood loss, one of the predictors of the original-FRS, was not a significant factor during 2 recent external validations. METHODS: The a-FRS was developed in 2 databases: the Dutch Pancreatic Cancer Audit (18 centers) and the University Hospital Southampton NHS. Primary outcome was grade B/C POPF according to the 2005 International Study Group on Pancreatic Surgery (ISGPS) definition. The score was externally validated in 2 independent databases (University Hospital of Verona and University Hospital of Pennsylvania), using both 2005 and 2016 ISGPS definitions. The a-FRS was also compared with the original-FRS. RESULTS: For model design, 1924 patients were included of whom 12% developed POPF. Three predictors were strongly associated with POPF: soft pancreatic texture [odds ratio (OR) 2.58, 95% confidence interval (95% CI) 1.80-3.69], small pancreatic duct diameter (per mm increase, OR: 0.68, 95% CI: 0.61-0.76), and high body mass index (BMI) (per kg/m increase, OR: 1.07, 95% CI: 1.04-1.11). Discrimination was adequate with an area under curve (AUC) of 0.75 (95% CI: 0.71-0.78) after internal validation, and 0.78 (0.74-0.82) after external validation. The predictive capacity of a-FRS was comparable with the original-FRS, both for the 2005 definition (AUC 0.78 vs 0.75, P = 0.03), and 2016 definition (AUC 0.72 vs 0.70, P = 0.05). CONCLUSION: The a-FRS predicts POPF after pancreatoduodenectomy based on 3 easily available variables (pancreatic texture, duct diameter, BMI) without blood loss and pathology, and was successfully validated for both the 2005 and 2016 POPF definition. The online calculator is available at www.pancreascalculator.com.

Laparoscopic parenchymal sparing resections in segment 8: techniques for a demanding and infrequent procedure.

BACKGROUND: Laparoscopic liver resections for lesions in the postero-superior segments are technically demanding due their deep location and relation with the vena cava. However, previous reports have demonstrated the feasibility and safety of these resections in centres with advanced experience in laparoscopic liver surgery. In this case series, we present our results and experience of laparoscopic parenchymal sparing liver resections of lesions in segment 8. METHODS: All patients undergoing laparoscopic liver resections of segment 8 lesions, alone or combined with other liver resections, between August 2003 and July 2016 were included. Analysis of baseline characteristics and perioperative results was performed for the whole cohort. A separate subgroup analysis was performed for isolated segment 8 resections. Long-term results were analyzed in patients with colorectal liver metastases. A video is attached for thorough explanation of surgical technique. RESULTS: A total of 30 patients were included. Among them, 13 patients had isolated segment 8 resections. Operative time for the whole cohort and isolated segment 8 resections were 210 min (range 180-247 min) and 200 min (range 90-300 min), respectively. The conversion rate was 3.4% for the entire cohort and 0 for isolated segment 8 resections. Major morbidity was 7 and 0%, respectively. R0 rates were 96% for the entire cohort and 92% for isolated segment 8 resections. Recurrence free survival in the colorectal liver metastasis subgroup was 82, 71 and 54% at 1, 3 and 5 years. Overall survival was 94, 82 and 65% at 1, 3 and 5 years. CONCLUSIONS: Laparoscopic resection of lesions in segment 8 is feasible and offers the benefits of minimally invasive surgery with parenchyma sparing resections. However, advanced experience in LLR is essential to ensure safety and oncological results.

Elderly patients have similar short term outcomes and five-year survival compared to younger patients after pancreaticoduodenectomy.

BACKGROUND: Outcomes following pancreaticoduodenectomy (PD) in elderly patients in the United Kingdom (UK) remain uncertain. This study aimed to analyse peri-operative outcomes in the elderly, and investigate the impact of age on five-year survival following PD in a UK tertiary centre. MATERIALS AND METHODS: All patients who underwent PD in a single Hepatobiliary and Pancreatic unit in the UK between January 2007 to December 2015 were analysed from a prospectively collected database. Individuals were divided into two groups (Group A <75 years and Group B ≥ 75 years "elderly") and outcomes compared. RESULTS: Five hundred and twenty-four patients were included (Group A n = 422, Group B n = 102). Post-operative cardiac events and peri-operative mortality were higher in the elderly (10.8 vs 3.6%, p = 0.008 and 5.9 vs 1.9%, 0.037, respectively). Multivariate analysis revealed only ASA score (OR 0.279, 95% CI 0.063-1.130), post-pancreatectomy haemorrhage (OR 0.055, 95% CI 0.006-0.518) and pulmonary embolism (OR 0.03, 95% CI 0.00-0.148) as independent risk factors for peri-operative mortality. Age was not (OR 0.978, 95% CI 0.911-1.049). Median survival was 22 months in Group A and 19 months in Group B (p = 0.165). Predictors of five-year survival included vascular resection (OR 0.171, 95% CI 0.053-0.549), positive margin (OR 0.256, 95% CI 0.102-0.641), lympho-vascular invasion (OR 0.392, 95% CI 0.160-0.958) and lymph node ratio (OR 67.381, 95% CI 3.301-1375.586), but not age (OR 1.012, 95% CI 0.972-1.054). CONCLUSION: Older patients have similar peri-operative outcomes and five-year survival compared to younger counterparts after PD in a UK tertiary centre, and should be considered for surgical resection of pancreatic and periampullary cancers.

Single-Surgeon Learning Curve in 111 Laparoscopic Distal Pancreatectomies: Does Operative Time Tell the Whole Story?

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is becoming the standard treatment for left-sided pancreatic disease. Learning curve identification is essential to ensure a safe and steady expansion. However, large (n > 30) single-surgeon learning curve series are lacking. STUDY DESIGN: Data of all patients undergoing LDP between June 2007 and March 2016 by a single surgeon were collected prospectively. For learning curve analysis, the first 10, 20, 30, 40, and 50 LDPs were compared with LDPs performed thereafter. RESULTS: In total, 111 LDPs were performed, of which 2 (2%) were converted. Median operative time was 200 minutes (interquartile range [IQR] 150 to 245 minutes) and median blood loss was 200 mL (IQR 100 to 300 mL). Learning curve analysis did not show improvements in operative time or blood loss. However, the number of patients with pancreatic ductal adenocarcinoma increased after 30 cases and a significant reduction of Clavien-Dindo grade III or higher complications was seen; from 30% (n = 9) for cases 1 to 30 to 5% (n = 4) for cases 31 to 111 (p < 0.001). Similarly, the International Study Group on Pancreatic Fistula grade B/C fistulas (33% [n = 10] vs 9% [n = 7]; p = 0.001) and percutaneous drainage rate (23% [n = 7] vs 4% [n = 3]; p = 0.001) were lower. Hospital stay was 7 days (IQR 5 to 13 days) for cases 1 to 30 vs 5 days (IQR 4 to 6 days) for cases 31 to 111 (p < 0.001). CONCLUSIONS: Operative outcomes of LDP remained stable with increasing surgical complexity over time. Postoperative outcomes, such as complications and length of hospital stay, improved after the first 30 cases. When describing learning curves, short- and long-term outcomes should be considered.

Preoperative Computed Tomography to Predict and Stratify the Risk of Severe Pancreatic Fistula After Pancreatoduodenectomy.

The aim of this article is to assess whether measures of abdominal fat distribution, visceral density, and antropometric parameters obtained from computed tomography (CT) may predict postoperative pancreatic fistula (POPF) occurrence.We analyzed 117 patients who underwent pancreatoduodenectomy (PD) and had a preoperative CT scan as staging in our center. CT images were processed to obtain measures of total fat volume (TFV), visceral fat volume (VFV), density of spleen, and pancreas, and diameter of pancreatic duct. The predictive ability of each parameter was investigated by receiver-operating characteristic (ROC) curves methodology and assessing optimal cutoff thresholds. A stepwise selection method was used to determine the best predictive model.Clinically relevant (grades B and C) POPF occurred in 24 patients (20.5%). Areas under ROC-curves showed that none of the parameters was per se significantly predictive. The multivariate analysis revealed that a VFV >2334 cm, TFV >4408 cm, pancreas/spleen density ratio <0.707, and pancreatic duct diameter <5 mm were predictive of POPF. The risk of POPF progressively increased with the number of factors involved and age.It is possible to deduce objective information on the risk of POPF from a simple and routine preoperative radiologic workup.