Different Oncologic Outcomes According to Margin Status (High-Grade Dysplasia vs. Carcinoma) in Patients Who Underwent Hilar Resection for Mid-Bile Duct Cancer.

Margin positivity after hilar resection (HR) for bile duct cancer is commonly observed due to its longitudinal spread along the subepithelial plane; nevertheless, we cannot draw conclusions regarding the prognostic effects of margins with high-grade dysplasia (HGD) or carcinoma. We aimed to investigate the oncologic effect according to the margin status after HR, particularly between the R1 HGD and the R1 carcinoma. From 2008 to 2017, 149 patients diagnosed with mid-bile duct cancer in Samsung Medical Center, South Korea, were divided according to margin status after HR and retrospectively analyzed. Recurrence patterns were also analyzed between the groups. There were 126 patients with R0 margins, nine with R1 HGD, and 14 with R1 carcinoma. The mean age of the patients was 68.3 (±8.1); most patients were male. The mean age was higher in R1 carcinoma patients than in R1 HGD and R0 patients (p = 0.014). The R1 HGD and R1 carcinoma groups had more patients with a higher T-stage than R0 (p = 0.079). In univariate analysis, the prognostic factors affecting overall survival were age, T- and N-stage, CA19-9, and margin status. The survival rate of R0 was comparable to that of R1 HGD, but the survival rate of R0 was significantly better compared to R1 carcinoma (R0 vs. R1 HGD, p = 0.215, R0 vs. R1 carcinoma, p = 0.042, respectively). The recurrence pattern between the margin groups did not differ significantly (p = 0.604). Extended surgery should be considered for R1 carcinoma; however, in R1 HGD, extended operation may not be necessary, as it may achieve oncologic outcomes similar to R0 margins with HR.

Heavy metals in ENDS: a comparison of open versus closed systems purchased from the USA, England, Canada and Australia.

INTRODUCTION: Electronic nicotine delivery systems (ENDS) are known to contain heavy metals such as lead (Pb), nickel (Ni) and chromium (Cr). The presence of heavy metals in ENDS may be due to contamination of e-liquids or leaching from elements of the ENDS device. This study investigates differences in ENDS metal concentrations between product type, year of purchase, country of purchase and e-liquid flavour. METHODS: Various open-system (refill e-liquids; n=116) and closed-system (prefilled with e-liquid; n=120) products were purchased in 2017 and 2018 from the USA, England, Canada and Australia. Electrothermal atomic absorption spectroscopy was used to analyse each product for Pb, Ni and Cr. Multiple linear regression and Kruskal-Wallis non-parametric statistical tests were conducted using GraphPad. RESULTS: Linear regression showed system type, year of purchase (not supported by Kruskal-Wallis), country of purchase and flavour type each had significant impacts on heavy metal concentrations. Open-system e-liquid samples showed no quantifiable levels of heavy metals. Closed-system samples contained concerningly high concentrations of Pb, Ni and Cr. Closed-system samples from the USA commonly displayed higher average heavy metal concentrations than those from England. Some fruit and mint-flavoured closed-system products showed higher heavy metal concentrations than tobacco-flavoured products. CONCLUSION: The presence of heavy metals only in closed-system products suggests that metals may be leaching from ENDS device parts. Highly variable heavy metal concentrations between ENDS products demonstrate that various product characteristics may affect the degree of leaching and that there is a need for further regulation of these products.

Cryopreserved allografts versus end-to-end anastomosis for the reconstruction of a segment-resected portomesenteric vein during advanced pancreatic cancer surgery.

BACKGROUND: Porto-mesenteric vein (PMV) infiltration of pancreatic cancer is classified as borderline resectable cancer. For en-bloc resectability, the probability of PMV resection and reconstruction is the most decisive factor. The purpose of this study was to compare and analyze PMV resection and reconstruction during pancreatic cancer surgery using end-to-end anastomosis (EA) and a cryopreserved allograft (AG) and to verify the effectiveness of reconstruction using an AG. METHODS: Between May 2012 and June 2021, 84 patients (65 underwent EA, and 19 received AG reconstruction) underwent pancreatic cancer surgery with PMV reconstruction. An AG is a cadaveric graft with a diameter of 8-12 mm and is obtained from a liver transplant donor. Patency after reconstruction, disease recurrence, overall survival, and perioperative factors were assessed. RESULTS: The median age was higher in EA patients (p = .022) and neoadjuvant therapy (p = .02) was more in AG patients. Upon histopathological examination, the R0 resection margin did not show a significant difference by reconstruction method. During a 36-month survival analysis, primary patency was significantly superior in EA patients (p = .004), and there was no significant difference in recurrence-free survival (p = .628) or overall survival (p = .638) rates. CONCLUSION: Compared with EA, AG reconstruction after PMV resection during pancreatic cancer surgery showed a lower primary patency, but there was no difference in recurrence-free or overall survival rates. Therefore, the use of AG can be a viable option for borderline resectable pancreatic cancer surgery if the patient is properly followed-up postoperatively.

Intraoperative Positive Pancreatic Parenchymal Resection Margin: Is It a True Indication of Completion Total Pancreatectomy after Partial Pancreatectomy for Pancreatic Ductal Adenocarcinoma?

BACKGROUND: Total pancreatectomy (TP) can be performed in cases with positive resection margin after partial pancreatectomy for pancreatic cancer. However, despite complete removal of the residual pancreatic parenchyme, it is questionable whether an actual R0 resection and favorable survival can be achieved. This study aimed to identify the R0 resection rate and postoperative outcomes, including survival, following completion TP (cTP) performed due to intraoperative positive margin. METHODS: From 1995 to 2015, 1096 patients with pancreatic ductal adenocarcinoma underwent elective pancreatectomy at the Samsung Medical Center. Among these, 25 patients underwent cTP, which was converted during partial pancreatectomy because of a positive resection margin. To compare survival after R0 resection between the cTP R0 and pancreaticoduodenectomy (PD) R0 cases, propensity score matching was conducted to balance the baseline characteristics. RESULTS: The R0 rate of cTP performed due to intraoperative positive margin was 84% (21/25). The overall 5-year survival rate (5YSR) in the 25 cTP cases was 8%. There was no difference in the 5YSR between the cTP R0 and cTP R1 groups (9.5% versus 0.0%, p = 0.963). However, the 5YSR of the cTP R0 group was significantly lower than that of the PD R0 group (9.5% versus 20.0%, p = 0.022). There was no distinct difference in postoperative complications between the cTP R0 versus cTP R1 and cTP R0 versus PD R0 groups. CONCLUSIONS: In cases with intraoperative positive pancreatic parenchymal resection margin, survival after cTP was not favorable. Careful patient selection is needed to perform cTP in such cases.

Realistic Advantages of Early Surgical Drain Removal after Pancreatoduodenectomy: A Single-Institution Retrospective Study.

The latest guidelines from the Enhanced Recovery After Surgery (ERAS®) Society stated that early drain removal after pancreatoduodenectomy (PD) is beneficial in decreasing complications including postoperative pancreatic fistulas (POPFs). This study aimed to ascertain the actual benefits of early drain removal after PD. The data of 450 patients who underwent PD between 2018 and 2020 were retrospectively reviewed. The surgical outcomes were compared between patients whose drains were removed within 3 postoperative days (early removal group) and after 5 days (late removal group). Logistic regression analysis was performed to identify the risk factors for clinically relevant POPFs (CR-POPFs). Among the patients with drain fluid amylase < 5000 IU on the first postoperative day, the early removal group had fewer complications and shorter hospital stays than the late removal group (30.9% vs. 54.5%, p < 0.001; 9.8 vs. 12.5 days, p = 0.030, respectively). The incidences of specific complications including CR-POPFs were comparable between the two groups. Risk factor analysis showed that early drain removal did not increase CR-POPFs (p = 0.163). Although early drain removal has not been identified as apparently beneficial, this study showed that it may contribute to an early return to normal life without increasing complications.

Comparison of Oncologic Outcomes between Transduodenal Ampullectomy and Pancreatoduodenectomy in Ampulla of Vater Cancer: Korean Multicenter Study.

This study used multicenter data to compare the oncological safety of transduodenal ampullectomy (TDA) with that of pylorus-preserving pancreatoduodenectomy (PPPD) in early ampulla of Vater (AoV) cancer. Data for patients who underwent surgical resection for AoV cancer (pTis-T2 stage) from January 2000 to September 2019 were collected from 15 institutions. The clinicopathologic characteristics and survival outcomes were compared between the PPPD and TDA groups. A total of 486 patients were enrolled (PPPD, 418; TDA, 68). The oncologic behavior in the PPPD group was more aggressive than that in the TDA group at all T stages: larger tumor size (p = 0.034), advanced T stage (p < 0.001), aggressive cell differentiation (p < 0.001), and more lymphovascular invasion (p = 0.002). Five-year disease-free survival (DFS) and overall survival (OS) did not differ between the two groups when considering all T stages or only the Tis+T1 group. Among T1 patients, PPPD produced significantly better DFS (PPPD vs. TDA, 84.8% vs. 66.6%, p = 0.040) and superior OS (PPPD vs. TDA, 89.1% vs. 68.0%, p = 0.056) than TDA. Lymph node dissection (LND) in the TDA group did not affect DFS or OS (TDA + LND vs. TDA-only, DFS, p = 0.784; OS, p = 0.870). In conclusion, PPPD should be the standard procedure for early AoV cancer.

Clinicopathologic analysis of intraductal papillary neoplasm of bile duct: Korean multicenter cohort study.

BACKGROUND: IPNB is very rare disease and most previous studies on IPNB were case series with a small number due to low incidence. The aim of this study is to validate previously known clinicopathologic features of intraductal papillary neoplasm of bile duct (IPNB) based on the first largest multicenter cohort. METHODS: Among 587 patients previously diagnosed with IPNB and similar diseases from each center in Korea, 387 were included in this study after central pathologic review. We also reviewed all preoperative image data. RESULTS: Of 387 patients, 176 (45.5%) had invasive carcinoma and 21 (6.0%) lymph node metastasis. The 5-year overall survival was 80.9% for all patients, 88.8% for IPNB with mucosal dysplasia, and 70.5% for IPNB with invasive carcinoma. According to the "Jang & Kim's modified anatomical classification," 265 (68.5%) were intrahepatic, 103 (26.6%) extrahepatic, and 16 (4.1%) diffuse type. Multivariate analysis revealed that tumor invasiveness was a unique predictor for survival analysis. (p = 0.047 [hazard ratio = 2.116, 95% confidence interval 1.010-4.433]). CONCLUSIONS: This is the first Korean multicenter study on IPNB through central pathologic and radiologic review process. Although IPNB showed good long-term prognosis, relatively aggressive features were also found in invasive carcinoma and extrahepatic/diffuse type.

Excess intraoperative fluid volume administration is associated with pancreatic fistula after pancreaticoduodenectomy: A retrospective multicenter study.

Recent studies on perioperative fluid administration in patients undergoing pancreaticoduodenectomy (PD) have suggested that increased fluid loads are associated with worse perioperative outcomes. The purpose of this study was to investigate the relationship between intraoperative fluid (IOF) administration and postoperative pancreatic fistula (POPF), and to determine additional risk factors affecting pancreatic fistula in patients undergoing PD.From 2005 to 2014, a total of 182 patients with various periampullary diseases after PD were reviewed retrospectively at Dongguk University Ilsan Hospital, Chung-Ang University Hospital, and Dongnam Institute of Radiological and Medical Sciences. Patients were assigned to high or low IOF groups based on more or less fluid administration for supplementation of estimated blood loss and maintenance volume (12.5 mL/kg/h) than planned, respectively. The associations between IOF administration, pancreatic fistula development, and perioperative outcomes were evaluated.A total of 98 patients were assigned to the high-IOF group, and 84 to the low-IOF group. Risk factors for pancreatic fistula after univariate analysis were assignment to the high-IOF group, higher preoperative serum hemoglobin level, ampullary or bile duct cancer, pylorus preserving PD, small pancreatic duct, duct-to-mucosa pancreatojejunostomy, use of a stent, and mesh application to pancreatojejunal anastomosis. Among these, assignment to the high-IOF group (hazard ratio [HR] = 5.501, 95% CI 1.624-18.632, P = .006) and a small (<4 mm) pancreatic duct (HR = 4.129, 95% CI 1.569-14.658, P = .035) were identified as independent risk factors for the development of pancreatic fistula after multivariate analysis. However, long-term survival rate did not differ according to IOF group or duct size.Excessive IOF volume administration is associated with an increased incidence of pancreatic fistula after pancreaticoduodenectomy.

Use of TachoSil(®) patches to prevent pancreatic leaks after distal pancreatectomy: a prospective, multicenter, randomized controlled study.

BACKGROUND: We performed a prospective, multicenter, randomized controlled study to investigate the clinical outcomes, including postoperative pancreatic fistulas (POPF), after using the TachoSil® patch in distal pancreatectomy (NCT01550406). METHODS: Between June 2012 and September 2014, 101 patients at five centers were randomized into Control (n = 53) and TachoSil (n = 48) groups. In all patients, the pancreas was resected using a stapler with Endo-GIA™ staples. The TachoSil patch was wrapped around the pancreatic stump only in the TachoSil group, not in Control group. RESULTS: The patient characteristics, including age and diagnosis, were comparable in both groups. The mean operation time (159.4 vs. 172.3 min, P = 0.081) and postoperative hospital stay (10.0 vs. 9.7 days, P = 0.279) were similar in the Control and TachoSil groups, respectively. The overall incidence of POPF was 62.4% (n = 63). The distribution of grades A, B, and C POPF was similar in the Control (n = 14/14/1) and TachoSil (n = 23/11/0) groups, as were the overall incidence (54.7% vs. 70.8%, P = 0.095) and the incidence of grade B and C POPF (28.3% vs. 22.9%, P = 0.536). CONCLUSION: This study showed that the TachoSil® patch did not reduce the incidence of POPF after distal pancreatectomy.

Pathologic T1 subclassification of ampullary carcinoma with perisphincteric or duodenal submucosal invasion: Is it T1b?

CONTEXT: In ampullary carcinoma staging, T1 is defined as a tumor limited to the ampulla of Vater or the sphincter of Oddi, and T2 is defined as invasion into the duodenal wall. However, the definition of duodenal wall invasion is vague. Ampullary carcinoma that invades beyond the sphincteric of Oddi (perisphincteric invasion) or into the duodenal submucosa could be considered pT1b because submucosal invasion is classified as pT1b in gastrointestinal tract tumors. However, there are no data regarding T subclassifications for ampullary carcinoma with perisphincteric or duodenal submucosa invasion. OBJECTIVE: To determine the T subclassification of ampullary carcinoma that invades into perisphincteric or duodenal submucosa. DESIGN: Pathologically proven ampullary carcinomas with T1 or T2 were reviewed (n = 105). We reclassified tumors as pT1a that were limited to within the sphincter of Oddi (n = 40; 38%), as pT1b for tumors that invaded beyond the sphincter of Oddi or into the duodenal submucosa (n = 25; 24%), and as pT2 for tumors that invaded into duodenal proper muscle (n = 40; 38%). RESULTS: Lymph node metastasis and recurrence were absent in ampullary carcinoma with pT1a, whereas nodal metastasis were noted in 24% (6 of 25) and 40% (16 of 40) of the ampullary carcinomas with pT1b and pT2, respectively. Tumor recurrence/metastasis rate of ampullary carcinoma with pT1b and pT2 was 44% (11 of 25) and 40% (16 of 40), respectively. The 5-year disease-free-survival rates from ampullary carcinoma with pT1a, pT1b, and pT2 were 95% (38 of 40), 56% (14 of 25), and 58% (23 of 40), respectively (P = .003). The 5-year overall survival from ampullary carcinoma with pT1a, pT1b, and pT2 was 98% (39 of 40), 72% (18 of 25), and 60% (24 of 40), respectively. CONCLUSIONS: The clinicopathologic outcome of ampullary carcinoma with a pT1b subclassification was worse than it was for T1a and approached the outcome for pT2.

Long-term effects of pancreaticoduodenectomy on glucose metabolism.

BACKGROUND: To analyse the association between pancreatogenic diabetes and the volume of the remnant pancreas after pancreaticoduodenectomy and to identify clinicopathologic factors correlated with pancreatogenic diabetes. METHODS: Among the patients who underwent pancreaticoduodenenctomy from 2003 to 2004, 55 patients who survived by 2009 and were able to measure the volume of the pancreas pre- and post-operatively by CT volumetry were included in this study. Twelve patients had diabetes before surgery. Median follow-up duration was 55.2 and 67.3 months for CT volumetry, pancreatogenic diabetes, respectively. RESULTS: Among 43 patients without preoperative diabetes, nine patients (21%) developed newly diabetes after surgery. Among 12 patients with diabetes, 10 patients had worsened glucose control. The immediate post-operative Vol% was 46.5% and the last Vol% was 31.5% (P < 0.001). Preoperative diabetes, malignant pathology, absence of post-operative pancreatic fistula, chemotherapy and radiotherapy were correlated with a lower Vol%. Atrophic changes were observed in 29 patients and hypertrophic changes in 13 patients. Comparative analysis according to the change in the Vol% revealed no differences in the clinicopathological factors associated with new-onset pancreatogenic diabetes or aggravation of preoperative diabetes. CONCLUSIONS: While some patients had a hypertrophic pancreas at the last follow-up, which reflected the capacity for pancreatic regeneration and some factors were associated with a lower volume of the remnant pancreas, the volume of the remnant pancreas seem not to be associated with pancreatogenic diabetes. There were no clinicopathologic factors identified associated with the risk for pancreatogenic diabetes.

Safety and efficacy of adjuvant chemoradiation therapy with capecitabine after resection of pancreatic ductal adenocarcinoma: a retrospective review.

PURPOSE: To evaluate clinical outcomes and safety of adjuvant chemoradiation therapy (CRT) with capecitabine after resection of pancreatic adenocarcinoma at a single institution. PATIENTS AND METHODS: A retrospective analysis of patients undergoing adjuvant CRT with capecitabine after resection of pancreatic ductal adenocarcinoma between 2004 and 2007 yielded a total of 55 patients. Capecitabine was administered at 850 mg/m(2) twice daily every day per week radiotherapy (45 Gy in 25 fractions) over the 5 weeks. Sixteen percent of patients (N=9) went on to receive gemcitabine. RESULTS: Of 55 patients, 42 had curative (R0) resection and 13 had incomplete resection (R1). Median overall survival (OS) and progression free survival were 18.3 and 8.0 months for all patients, respectively. Patients receiving additional gemcitabine after adjuvant CRT with capecitabine showed better OS and progression free survival than those not receiving additional gemcitabine (P<0.05). In multivariate analysis, lymphovascular invasion (present vs. absent) and addition gemcitabine therapy (yes vs. no) were significant independent prognostic factors for OS (P<0.05). Local recurrence was observed in 10 patients, and distant recurrence in 26 patients, synchronously accounting for 6 recurrences. Ten patients (18.2%) had severe grade 3 toxicities. CONCLUSIONS: Capecitabine-based CRT after resection of pancreatic adenocarcinoma showed favorable outcomes and tolerable toxicity profiles.

A prognostic model to predict clinical outcomes with first-line gemcitabine-based chemotherapy in advanced pancreatic cancer.

OBJECTIVE: Our aim was to devise a prognostic model for advanced pancreatic cancer based on clinical parameters. METHODS: We retrospectively analyzed the medical records of 298 patients who received gemcitabine-based chemotherapy from January 1999 to November 2008. RESULTS: The median survival of all patients was 7 months [95% confidence interval (CI) 6.2-7.8]. Multivariate analysis revealed poor prognostic factors for overall survival such as the presence of liver metastasis [p < 0.001, hazard ratio (HR) 2.628, 95% CI 1.620-4.264], the presence of ascites or peritoneal carcinomatosis (p = 0.005, HR 1.783, 95% CI 1.194-2.661), serum C-reactive protein levels >1.2 mg/dl (p = 0.021, HR 1.568, 95% CI 1.070-2.300), and serum albumin levels <3.5 g/dl (p = 0.021, HR 1.701, 95% CI 1.085-2.667). Of 298 patients, 168 patients (56.4%) were categorized as low-risk with 0 or 1 risk factor, 80 patients (26.8%) were categorized as intermediate-risk with 2 risk factors, and 50 patients (16.8%) were categorized as high-risk with 3 or 4 risk factors. The median survival duration for the low-, intermediate-, and high-risk groups was 10.0 months (95% CI 8.7-11.3), 6.7 months (95% CI 5.7-7.7), and 4.4 months (95% CI 3.2-5.6), respectively. CONCLUSIONS: This prognostic model could help to select treatment for patients in clinical practice, and these risk-adapted treatment strategies should be further investigated in prospective studies in such patient populations.

A mechanosensitive ion channel regulating cell volume.

Cells respond to a hyposmotic challenge by swelling and then returning toward the resting volume, a process known as the regulatory volume decrease or RVD. The sensors for this process have been proposed to include cationic mechanosensitive ion channels that are opened by membrane tension. We tested this hypothesis using a microfluidic device to measure cell volume and the peptide GsMTx4, a specific inhibitor of cationic mechanosensitive channels. GsMTx4 had no effect on RVD in primary rat astrocytes or Madin-Darby canine kidney (MDCK) cells but was able to completely inhibit RVD and the associated Ca(2+) uptake in normal rat kidney (NRK-49F) cells in a dose-dependent manner. Gadolinium (Gd(3+)), a nonspecific blocker of many mechanosensitive channels, inhibited RVD and Ca(2+) uptake in all three cell types, demonstrating the existence of at least two types of volume sensors. Single-channel stretch-activated currents are present in outside-out patches from NRK-49F, MDCK, and astrocytes, and they are reversibly inhibited by GsMTx4. While mechanosensitive channels are involved in volume regulation, their role for volume sensing is specialized. The NRK cells form a stable platform from which to screen drugs that affect volume regulation via mechanosensory channels and as a sensitive system to clone the channel.

The efficacy of frontline platinum-based combination chemotherapy in advanced adenocarcinoma of the ampulla of Vater.

Adenocarcinoma arising from the ampulla of Vater is a rare neoplasm that accounts for only 0.2% of all gastrointestinal tract malignancies and has limited data regarding its frontline therapy. We investigated the treatment outcomes in patients with advanced adenocarcinoma of the ampulla of Vater receiving frontline cisplatin-based combination chemotherapy. We analyzed 29 patients with advanced adenocarcinoma of the ampulla of Vater who had been treated by frontline cisplatin-based combination chemotherapy between June 2003 and April 2008. The chemotherapeutic agent added to cisplatin was gemcitabine in 9 patients and fluorouracil (FU) in 20 patients (11; intravenous 5-FU and 9; oral 5-FU (capecitabine)). The median age of patients was 56 years (range, 36-78), and the median ECOG performance status was 1 (0-1). The confirmed overall response rate was 27.5%, and the disease control rate was 72.4%. In all patients, no complete responses and 8 partial responses were observed (overall response rate, 27.5%). Stable disease was observed in 13 patients (44.8%), and progressive disease in 5 patients (17.2%). The median time to progression (TTP) was 4.9 months (95% CI, 3.4-6.4), and the median overall survival (OS) was 12.5 months (95% CI, 10.6-14.4). There were no significant differences for TTP and OS according to the different chemotherapeutic agents added to cisplatin. Grade 3 or 4 hematologic toxicities included leukopenia in seven patients and thrombocytopenia in one patient. There were no grade 3 or 4 nonhematologic toxicities or treatment-related deaths. The cisplatin-based combination chemotherapy showed moderate activity and a favorable toxicity profile as a frontline treatment for patients with advanced adenocarcinoma of the ampulla of Vater.

Carcinoma of the middle bile duct: is bile duct segmental resection appropriate?

AIM: To compare survival between bile duct segmental resection (BDSR) and pancreaticoduodenectomy (PD) for treating distal bile duct cancers. METHODS: Retrospective analysis was conducted for 45 patients in a BDSR group and for 149 patients in a PD group. RESULTS: The T-stage (P < 0.001), lymph node invasion (P = 0.010) and tumor differentiation (P = 0.005) were significant prognostic factors in the BDSR group. The 3- and 5-year overall survival rates for the BDSR group and PD group were 51.7% and 36.6%, respectively and 46.0% and 38.1%, respectively (P = 0.099). The BDSR group and PD group did not show any significant difference in survival when this was adjusted for the TNM stage. The 3- and 5-year survival rates were: stage Ia [BDSR (100.0% and 100.0%) vs PD (76.9% and 68.4%) (P = 0.226)]; stage Ib [BDSR (55.8% and 32.6%) vs PD (59.3% and 59.3%) (P = 0.942)]; stage IIb [BDSR (19.2% and 19.2%) vs PD (31.9% and 14.2%) (P = 0.669)]. CONCLUSION: BDSR can be justified as an alternative radical operation for patients with middle bile duct in selected patients with no adjacent organ invasion and resection margin is negative.

Comparison of different pancreatic anastomosis techniques using the definitions of the International Study Group of Pancreatic Surgery: a single surgeon's experience.

OBJECTIVES: We aimed to compare different techniques using the definitions of the International Study Group of Pancreatic Surgery for postoperative complications after pancreaticoduodenectomy. METHODS: The perioperative data of 119 patients that underwent pancreaticoduodenectomy by a single surgeon were retrospectively analyzed. Pancreaticojejunal anastomosis was performed using the dunking method (n = 39), the duct-to-mucosa anastomosis method (n = 40), and the duct-to-mucosa adaptation (n = 40). RESULTS: The most frequent complication was postoperative pancreatic fistula (POPF; grades A, 21%; B, 8%; and C, 3%), postpancreatectomy hemorrhage (PPH; grades B, 7% and C, 1%), and delayed gastric emptying (DGE; grades A, 1% and B, 6%). No significant differences in POPF were found between patients who underwent different types of pancreatic anastomoses. Only pancreatic ductal adenocarcinoma (P = 0.001) and pancreatic texture (P = 0.012) were potentially related to POPF. Patients with or without POPF grade A had shorter postoperative stays than patients with grade B or C POPF (P < 0.001), and similar findings were obtained for DGE and PPH. CONCLUSIONS: The successful management of pancreatic anastomoses depends more on a meticulous surgical technique and appropriate experience rather than on the type of technique. Furthermore, the International Study Group of Pancreatic Surgery definitions of POPF, DGE, and PPH seem objective and universally acceptable.

Delayed improvement of insulin secretion after autologous islet transplantation in partially pancreatectomized patients.

The purpose of this study was to evaluate the effects of autologous islet transplantation (ITx) on glucose homeostasis and insulin secretory function after partial pancreatectomy (Px). Fourteen nondiabetic patients who underwent distal Px and autologous ITx for benign pancreatic tumors were enrolled in the study (Px + ITx group). Fourteen normal glucose-tolerant controls and 6 Px without ITx controls were recruited, and all groups were followed over a 24-month period. They performed the 75-g oral glucose tolerance test and the 1-mg glucagon stimulation test. Hemoglobin A(1c) was measured, and indices of insulin secretion were calculated. In the Px + ITx group, insulin secretion increased after a nadir at 6 months. Glucose tolerance, which had been abruptly impaired immediately after Px, recovered until 6 months and stabilized thereafter. As a result, differences in glucose intolerance emerged between the subjects in the Px group and those in the Px + ITx group at 24 months after Px. Characteristic variables in the better insulin secretory subjects in the Px + ITx group included younger age, less extensive pancreas resection, and a greater number of total islets. In summary, delayed amelioration of glucose intolerance was induced by autologous ITx after partial Px, even with a small number of islets.

Clinical outcomes of hepatic resection and radiofrequency ablation in patients with solitary colorectal liver metastasis.

BACKGROUND: The role of the radiofrequency ablation (RFA) in treatment of solitary liver metastasis has not been established yet. Both hepatic resection (HR) and RFA have been used increasingly in the treatment of colorectal liver metastases. STUDY: A systemic review was performed to determine the impact of treatment modality of solitary liver metastasis on recurrence patterns, disease-free survival, and overall survival (OS) rates. RESULTS: Solitary liver metastases were treated by HR in 116 patients (75.8%) and 37 patients (24.2%) were treated with RFA. Prognostic factors, recurrence rate, recurrence patterns, and survival rates were analyzed. The cumulative 3-year and 5-year local recurrence free survival rates were markedly higher in the HR group (88.0% and 84.6%) as compared with those in the RFA group [53.3% and 42.6%, respectively (P

Risk factor stratification after simultaneous liver and colorectal resection for synchronous colorectal metastasis.

BACKGROUND/AIM: This study was conducted to devise a prognostic model for patients undergoing simultaneous liver and colorectal resection. MATERIALS AND METHODS: A retrospective analysis was performed on 138 colorectal patients who underwent simultaneous liver and colorectal resection between September 1994 and September 2005. The primary endpoint of the study was overall survival. Three patients with positive liver resection margin were excluded from the analysis. RESULTS: At multivariate level, poor prognostic factors were liver resection margin < or =5 mm (P = 0.047; relative risk, 1.684; 95% CI = 1.010-2.809), CEA greater than 5 ng/ml (P = <0.001; relative risk, 2.507; 95% CI = 1.499-4.194), number of liver metastasis > 1 (P = <0.042; relative risk, 1.687; 95% CI = 1.020-2.789), and lymph node > or = 4 (P = <0.012; relative risk, 1.968; 95% CI = 1.158-3.347). The risk stratification grouping of the 135 patients was performed according to the following criteria: low risk group, 0-1 factor; intermediate risk group, 2 factors; high-risk group, 3-4 factors. Of 135 patients, 86 patients (63.0%) were categorized as low-risk group, 36 patients (26.6%) as intermediate risk group, and 14 patients (10.4%) as high-risk group. Median survival times for low, intermediate, high-risk groups were 68.0, 43.6 (95% CI, 24.7-62.4), and 23.5 months (95% CI, 9.4-31.5), respectively. The high-risk group demonstrated an approximately threefold (relative risk, 3.1; 95% CI, 1.6-6.0) increased risk of death. CONCLUSIONS: A simple risk factor stratification system was proposed to evaluate the chances of cure of patients after simultaneous resection of liver metastases and primary colorectal carcinoma. The risk factor stratification showed three groups with distinct survival. The risk stratification may help to predict patient survival after simultaneous liver and colorectal resection. This system needs further prospective validation.