Recovery of health-related quality of life after laparoscopic versus open distal pancreatectomy.

BACKGROUND: Limited data comparing recovery of health-related quality of life (HRQoL) after laparoscopic (LDP) versus open distal pancreatectomy (ODP) are available. The aim of this study was to assess the impact of laparoscopy on postoperative HRQOL after DP using the Patient-Reported Outcomes Measurement Information System (PROMIS). METHODS: Data from consecutive patients who underwent DP (2020-2022) enrolled in a prospective clinical trial were reviewed. Patients completed PROMIS-29 plus 2 profile preoperatively, at postoperative day (POD) 15, 30, 90, and 180. Linear regression analysis adjusting for confounders including preoperative PROMIS scores, age, gender, ASA score, diagnosis, and multivisceral resection was used to estimate mean between-group differences (MD) in postoperative PROMIS domains T scores. RESULTS: Overall, 202 patients (118 laparoscopic, 86 open) underwent DP (median age 66 years, pancreatic cancer 41%, multivisceral resection 10%, median LOS 6 days). At POD15, LDP was associated with higher physical function (MD 5.6) and participation in social roles and activities scores (MD 3.8), reduced fatigue (MD - 2.7) and sleep disturbance (MD - 3.8) compared to ODP. At POD30, LDP patients had higher physical function (MD 5.2) and participation in social roles and activities scores (MD 6.0), reduced fatigue (MD - 3.5), and anxiety (MD - 4.0) compared to ODP. No between-group differences were found in HRQoL domains at POD90 and 180. Six months after surgery, the proportions of patients who had not recovered to preoperative physical function, participation in social roles and activities, fatigue, pain interference, sleep disturbance, cognitive function, depression, and anxiety were 31%, 31%, 28%, 20%, 15%, 14%, 8%, and 7%, respectively. CONCLUSIONS: According to PROMIS, LDP resulted in improved physical and social functioning and reduced anxiety and fatigue up to 30 days after surgery compared to ODP. At 6 months after surgery, recovery of physical domains is still incomplete in up to 30% of patients.

Validation of the PROMIS-29 Questionnaire as a Measure of Recovery After Pancreatic Surgery.

OBJECTIVE: To contribute evidence for the reliability, construct validity, and responsiveness of the Patient-Reported Outcomes Measurement Information System 29 (PROMIS-29) profile questionnaire as a measure of recovery after pancreatic surgery. BACKGROUND: PROMIS questionnaires have been recommended to evaluate postdischarge recovery after surgery. Evidence supporting their measurement properties in pancreatic surgery is missing. METHODS: An observational validation study designed according to the COSMIN checklist was conducted including data from a prospective clinical trial. Patients undergoing pancreatectomy completed PROMIS-29 preoperatively and on postoperative days (PODs) 15, 30, 90, and 180. Reliability was assessed by internal consistency using Cronbach α. Construct validity was assessed by known-groups comparison. Responsiveness was evaluated hypothesizing that scores would be higher (1) preoperatively versus POD15, (2) on POD30 versus POD15, (3) on POD90 versus POD30, and (4) on POD180 versus POD90. RESULTS: Overall, 510 patients were included in the study. Reliability was good to excellent (α values ranged from 0.82 to 0.97). Data supported 4 of 5 hypotheses tested for construct validity for 5 domains (physical function, anxiety, depression, fatigue, and ability to participate in social roles) at most time points. Responsiveness hypotheses 1, 2, and 3 were supported by the data for physical function, fatigue, sleep disturbance, pain interference, and ability to participate in social roles domains. CONCLUSIONS: PROMIS had excellent reliability, discriminated between most groups expected to have different recovery trajectories and was responsive to the expected trajectory of recovery up to 90 days after surgery. Our findings support the use of PROMIS-29 profile as a patient-reported outcome measure of postdischarge recovery after pancreatectomy.

Development of a predictive model for unplanned intensive care unit admission after pancreatic resection within an enhanced recovery pathway.

BACKGROUND: It is unclear whether routine postoperative admission to the intensive care unit (ICU) can improve outcomes for patients undergoing elective pancreatic surgery. Aim of the study was to determine preoperative and intraoperative predictors of unplanned ICU access in patients undergoing pancreatectomy treated within an established enhanced recovery pathway (ERP) and compare outcomes between direct and late ICU admission. METHODS: A retrospective observational study was conducted on adult patients who underwent pancreatic resection (2015-2019) within an ERP. Patients with preoperatively planned ICU admission were excluded from the study. Multiple multivariate logistic regression models were constructed to verify the association of preoperative and intraoperative variables with study outcomes. RESULTS: The study included 1486 consecutive patients (cancer diagnosis 60%, pancreaticoduodenectomy 60%; laparoscopic approach 20%; vascular resection 9%). Sixty-six (4.4%) patients had an unplanned ICU admission. Direct admission occurred in 22 (33%) patients and late ICU admission in 44 (67%) patients. Mortality was significantly lower in direct admission group (n = 3, 14%) compared to late admission (n = 25, 57%; p > 0.001). A comprehensive model including preoperative and intraoperative variables identified ASA score ≥ 3 (OR 5.59, p value < 0.001), history of hypertension (OR 2.29, p = 0.029), chronic obstructive pulmonary disease (OR 3.05, p = 0.026), proximal pancreatic resection (OR 2.79, p value 0.046), multivisceral resection (OR 8.86, p value < 0.001), high intraoperative blood loss (OR 1.01 per ml, p < 0.001), and increased serum lactate at the end of surgery (OR 1.25, p = 0.017) as independent factors associated with ICU admission. Area under the ROC curve was 0.891. CONCLUSION: Patient comorbidities, surgical complexity, and lactic acidosis at the end of surgery were associated with unplanned postoperative ICU admission. Late ICU admission had very high mortality rates compared to direct admission. Our findings suggest that patients with a combination of preoperative and intraoperative risk factors could benefit from upfront postoperative ICU admission to potentially improve postoperative outcomes.

Management of clinically relevant postoperative pancreatic fistula-related fluid collections after distal pancreatectomy.

BACKGROUND: Distal pancreatectomy is burdened by a high rate of clinically relevant postoperative pancreatic fistula (CR-POPF). The presence of a fistula-related abdominal collection often requires additional treatment such as antibiotics, percutaneous drainage, and endoscopic drainage thus prolonging patient recovery. Aim of this study was to describe the management of abdominal collections related to CR-POPF and identify variables associated with the need for invasive procedures. METHODS: A retrospective review of clinical data for patients who underwent distal pancreatectomy between 2015 and 2020 was conducted. All postoperative CT-scan imaging performed for clinical signs related to POPF was reviewed. The main outcome of the study was the need for procedural management (percutaneous or endoscopic) of CR-POPF-related fluid collections at 90 days after surgery. A multivariate regression analysis was adopted to analyze factors influencing procedural management of the collection. RESULTS: Five hundred sixteen patients were included in the study. Laparoscopic resection was performed in 290 patients (56%). At 90 days after surgery, CR-POPF occurred in 207 (40.1%) patients. A symptomatic collection related to fistula was observed in 130 patients (25.2%). Factors associated with fluid collections were increased body mass index (BMI) (25.5 versus 24, p = 0.001) and intraoperative blood loss (median of 250 versus 200 ml, p < 0.001). Procedural management was required in 70 patients (13.6%); 52 patients required interventional radiology and 18 endoscopic drainage. At multivariate analysis, risk factors for invasive procedures were the following CT-scan parameters: fluid collection diameter greater than 5 cm (OR 6.366, 95%CI 2.29-17.66, p = 0.001), presence of blood in the fluid collection (OR 10.618, 95%CI 1.94-58.09, p = 0.006), and enhancement of its walls (OR 4.073, 95%CI 1.22-13.57, p = 0.022). CONCLUSION: CR-POPF-related fluid collections affect about a quarter of patients undergoing distal pancreatectomy. CT-scan provides important information which can guide the management of the collection in a "step-up" fashion.

Noninvasive Ventilation for Acute Respiratory Failure in Pediatric Patients: A Systematic Review and Meta-Analysis.

OBJECTIVE: To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) on the use of noninvasive ventilation (NIV) for acute respiratory failure (ARF) in pediatric patients. DATA SOURCES: We searched PubMed, EMBASE, the Cochrane Central Register of Clinical Trials, and Clinicaltrials.gov with a last update on July 31, 2022. STUDY SELECTION: We included RCTs comparing NIV with any comparator (standard oxygen therapy and high-flow nasal cannula [HFNC]) in pediatric patients with ARF. We excluded studies performed on neonates and on chronic respiratory failure patients. DATA EXTRACTION: Baseline characteristics, intubation rate, mortality, and hospital and ICU length of stays were extracted by trained investigators. DATA SYNTHESIS: We identified 15 RCTs (2,679 patients) for the final analyses. The intubation rate was 109 of 945 (11.5%) in the NIV group, and 158 of 1,086 (14.5%) in the control group (risk ratio, 0.791; 95% CI, 0.629-0.996; p = 0.046; I2 = 0%; number needed to treat = 31). Findings were strengthened after removing studies with intervention duration shorter than an hour and after excluding studies with cross-over as rescue treatment. There was no difference in mortality, and ICU and hospital length of stays. CONCLUSIONS: In pediatric patients, NIV applied for ARF might reduce the intubation rate compared with standard oxygen therapy or HFNC. No difference in mortality was observed.

The Impact of CT-Assessed Liver Steatosis on Postoperative Complications After Pancreaticoduodenectomy for Cancer.

INTRODUCTION: Liver steatosis (LS) has been increasingly described in preoperative imaging of patients undergoing pancreaticoduodenectomy (PD). The aim of this study was to assess the impact of preoperative LS on complications after PD and identify possible contributors to LS development in this specific cohort. METHODS: Pancreatic head adenocarcinoma (PDAC) patients scheduled for PD, with preoperative CT-imaging available were included in the study. LS was defined as mean liver density lower than 45 Hounsfield units. Patients showing preoperative LS were matched for patient age, gender, BMI, ASA score, neoadjuvant treatment, and vascular and multivisceral resections, based on propensity scores in a 1:2 ratio to patients with no LS. The primary outcome was postoperative complication severity at 90 days as measured by the comprehensive complication index (CCI) RESULTS: Overall, 247 patients were included in the study. Forty-three (17%) patients presented with LS at preoperative CT-scan. After matching, the LS group included 37 patients, whereas the non-LS group had 74 patients. LS patients had a higher mean (SD) CCI, 29.7 (24.5) versus 19.5 (22.5), p = 0.035, and a longer length of hospital stay, median [IQR] 12 [8-26] versus 8 [7-13] days, p = 0.006 compared with non-LS patients. On multivariate analysis, variables independently associated with CCI were: LS (16% increase, p = 0.048), male sex (19% increase, p = 0.030), ASA score ≥ 3 (26% increase, p = 0.002), fistula risk score (FRS) (28% increase for each point of FRS, p = 0.001) and vascular resection (20% increase, p = 0.019). CONCLUSION: Preliminary evidence suggests that preoperative LS assessed by CT-scan influences complication severity in patients undergoing PD for PDAC.

Early biochemical predictors of clinically relevant pancreatic fistula after distal pancreatectomy: a role for serum amylase and C-reactive protein.

BACKGROUND: Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP. METHODS: Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien-Dindo grade ≥ 3) were performed. RESULTS: At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p < 0.001), followed by serum amylase on POD 1 (0.651, p < 0.001), serum CRP on POD3 (0.644, p < 0.001), and CRP change between POD 2 and POD 3 (0.644, p < 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36-3.86; p = 0.002), DFA ≥ 1500 U/L on POD2 (OR 4.63, 95% CI 2.72-7.89; p < 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01-2.93; p = 0.046), and CRP increase by at least 25 mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11-3.21; p = 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714-0.816, p < 0.001). CONCLUSIONS: Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management.

The impact of preoperative anemia on pancreatic resection outcomes.

BACKGROUND: Preoperative anemia is a risk factor for blood transfusions and delayed postoperative recovery, but few data are available for pancreatic surgery. Aim of the study was to analyze the impact of preoperative anemia on outcomes after pancreatic resection. METHODS: Retrospective review of 1107 patients resected at San Raffaele Hospital (2015-2018). Preoperative anemia was defined as hemoglobin lower than 130 g/L for men and 120 g/L for women. Primary outcome was 90-day comprehensive complication index (CCI). Analysis was stratified according to type of surgery; proximal resections (pancreaticoduodenectomy and total pancreatectomy) versus distal pancreatectomy. RESULTS: In 776 proximal resection patients, preoperative anemia was associated with increased CCI (24 ± 25 vs. 19 ± 23, p = 0.018) and perioperative allogenic blood transfusions (n = 124, 46% vs. n = 129, 26%; p < 0.001). Multivariate analysis showed that anemia was associated with a 7% (95%CI 0.02-0.57 p = 0.047) increase in CCI, and was an independent factor associated with perioperative blood transfusion (OR 2.762, 95%CI 1.72-4.49, p < 0.001). In 331 distal pancreatectomies, anemia was not associated to increased morbidity but only to an increased risk of perioperative blood transfusion. CONCLUSION: Preoperative anemia is an independent risk factor for increased complication severity and blood transfusion in patients undergoing major pancreatic resection.

Staged Double Hepatectomy, Double Total Vascular Exclusion, and Double Venous Reconstruction by Peritoneal Patches in One Patient with Colorectal Liver Metastases.

BACKGROUND: Surgical resection is the best treatment for colorectal liver metastases with good response to chemotherapy and in the absence of extrahepatic disease.1 With the amelioration of surgical technique, primary and recurrent colorectal liver metastases with venous invasion can be resected safely under short total vascular exclusion (TVE), and associated right thoracotomy can have a major benefit if resection at the hepato-caval junction is planned.2 The availability of the peritoneum as an autologous graft for venous reconstruction considerably facilitates the task of the surgeon.3 In this video, we present a patient who had staged double liver resection, double TVE, and double venous reconstruction by a peritoneal graft on the vena cava and the hepatic vein. METHODS: In March 2017, a 47-year-old female was diagnosed with rectal cancer and synchronous liver metastases, microsatellite stability, and Kras mutation. The patient received folinic acid, fluorouracil, and oxaliplatin (FOLFOX) chemotherapy, with good response and a decrease in tumor markers. After chemotherapy, a computed tomography (CT) scan showed one lesion located on the right liver with lateral invasion of the vena cava, and another lesion located in segment I. A liver-first strategy was decided and, in October 2017, the patient had a right hepatectomy extended to segment I and partially on the diaphragm, with lateral resection of the vena cava under isolated clampage of the vena cava and reconstruction with a peritoneal graft (60 mm). The patient received FOLFOX adjuvant chemotherapy for 3 months, and, while under radiotherapy for the rectal cancer, recurrence was diagnosed on the left liver lobe (two lesions), with lateral invasion of the left hepatic vein. Chemotherapy was shifted to folinic acid, fluorouracil, and irinotecan (FOLFIRI)-Avastin, with good response, allowing resection of the primary (T3N0M1), followed by adjuvant chemotherapy. In May 2019, the patient underwent two large resections on the left liver, including one under TVE, with opening of the diaphragm and intrathoracic control of the vena cava. The left hepatic vein was reconstructed laterally with a peritoneal graft (30 mm). RESULTS: Postoperative outcome was uneventful and the two hospital stays were 12 and 15 days, respectively. For the first hepatectomy, pathological examination showed two lesions (80 and 50 mm) with a residual tumor at 10% and R0 resection, and, for the second resection, pathological examination showed two lesions (18 and 20 mm) with residual tumor at 40-60% and R0 resection. In both cases, the tumor was in contact with the resected vein without wall infiltration. The reconstructed vena cava and hepatic vein were patent without stenosis. The patient is disease-free 3 years after the diagnosis. CONCLUSION: Improvements in surgical technique combined with short TVE and associated thoracotomy allow some complicated liver resections to be performed safely. The use of the peritoneum for venous reconstruction is of great benefit in relation to safety and availability, especially in 'redo' liver surgery where intense adhesions can be encountered.

Chemopreventive Agents After Pancreatic Resection for Ductal Adenocarcinoma: Legend or Scientific Evidence?

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is currently the fourth leading cause of cancer-related death in the USA. A wealth of evidence has demonstrated the chemopreventive activity of aspirin, statins, and metformin against PDAC. The aim of this study is to investigate the effect of aspirin, statins, and metformin on disease-free survival (DFS) and disease-specific survival (DSS) in a large population of PDAC patients undergoing pancreatic resection. PATIENTS AND METHODS: All patients who underwent pancreatic resections between January 2015 and September 2018 were retrospectively reviewed. The potentially "chemopreventive agents" considered for the analysis were aspirin, statins, and metformin. Drug use was defined in case of regular assumption at least 6 months before diagnosis and regularly after surgery along the follow-up period. RESULTS: A total of 430 patients were enrolled in this study, with median DFS and DSS of 21 months (IQR 13-30) months and 34 (IQR 26-52) months, respectively. On multivariable analysis, use of aspirin was associated with better DFS (HR: 0.62; p = 0.038). Metformin was associated with better DFS, without reaching statistical significance (p = 0.083). Use of statins did not influence DFS in the studied population. Aspirin, metformin, and statins were not associated with better DSS on multivariable analysis. Factors influencing DSS were pT3/pT4, N1, N2, no adjuvant treatment, G3, and ASA score > 3. CONCLUSIONS: The results suggest that chronic use of aspirin is associated with increased DFS but not with better DSS after surgical resection in patients with PDAC.

Prognostic Role of Examined and Positive Lymph Nodes after Distal Pancreatectomy for Non-Functioning Neuroendocrine Neoplasms.

BACKGROUND: The most appropriate nodal staging system for non-functioning pancreatic neuroendocrine tumours (NF-PanNETs) remains unclear. Despite some evidence is available for pancreaticoduodenectomy, the adequate nodal staging is still unknown for distal pancreatectomy (DP). The aim of the present study was to evaluate the prognostic impact of the number of positive lymph nodes (PLNs) after DP for NF-PanNETs and to define the minimal number of lymph nodes to be harvested for an appropriate nodal staging. METHODS: Data were retrospectively collected from patients who underwent DP with curative intent (R0-R1) for sporadic well-differentiated NF-PanNETs in 4 European high-volume centres. NF-PanNETs with nodal involvement (N+) were subclassified into N1 (1-3 PLNs) and N2 (4 or more PLNs). Univariate and multivariate analyses of disease-free survival (DFS) were performed. RESULTS: Of 271 patients in the study, 62 (23%) had nodal involvement (N+). A higher probability of N+ was associated with the following factors: grading, resection margin status, perineural and microvascular invasion, and the number of examined lymph nodes. Three-year DFS rate for N0, N1, and N2 patients was 92, 72, and 50%, respectively (p < 0.001). At multivariate analysis, independent predictors of DFS were grading, T stage, presence of necrosis, and nodal status. For patients with ≥12 examined/resected lymph nodes, the N status remained a significant predictor of disease recurrence (p < 0.001), while it failed to predict recurrence in patients with <12 lymph nodes examined/resected (p = 0.116). CONCLUSIONS: A minimal number of 12 nodes should be harvested in case of DP for NF-PanNET for an appropriate nodal staging. The number of positive lymph nodes is an independent predictor of DFS after DP for NF-PanNET, and the N0/N1/N2 nodal classification seems to be more relevant than the current N0/N+ staging.

The impact of minimally invasive surgery on hospital readmissions, emergency department visits and functional recovery after distal pancreatectomy.

BACKGROUND: A recent RCT showed similar postoperative outcomes and a reduced time to functional recovery in patients undergoing minimally invasive distal pancreatectomy (DP) compared to open approach. However, it reported very-high post-discharge readmission rates, calling for further investigation. The aim of our study was to evaluate the extent to which minimally invasive surgery impacts on postoperative readmissions following DP. METHODS: Clinical data for patients undergoing DP between 2011 and 2018 were reviewed. Primary outcome was hospital readmission at 90 days after surgery. Secondary outcomes included post-discharge emergency department (ED) visits and time to functional recovery. Regression analyses were performed to evaluate the impact of the laparoscopic approach and other perioperative factors. RESULTS: Overall, 376 consecutive patients underwent DP during the study period. Laparoscopy was successfully performed in 219 (58%) patients. Overall, 62 patients (16.5%) returned to the ED after discharge, 41 (18.7%) of laparoscopically operated patients, and 21 (13.4%) of those undergoing open surgery (p = 0.162). Forty-six (12.2%) of them required readmission, 31 (14.2%) after laparoscopic, and 15 (9.6%) after open procedures (p = 0.179). At multivariate regression, a low preoperative physical status (OR 2.3, 95% CI 1.2-4.7; p = 0.017), occurrence of pancreatic fistula (OR 6.8, 95% CI 2.9-15.9; p < 0.001), and post-pancreatectomy hemorrhage (OR 3.9, 95% CI 1.2-13.1; p = 0.025) were significantly associated with 90-day readmission, while laparoscopy had no impact. Median time to reach functional recovery was 5 (IQR 4-6) days. At multivariate analysis, laparoscopy reduced time to functional recovery by 13% (95% CI - 19 to - 6%; p < 0.001), time to adequate oral intake by 19% (95% CI - 27 to - 10%; p < 0.001), and time to adequate pain control by 12% (95% CI - 18 to - 5%; p < 0.001). CONCLUSION: Hospital readmissions and ED visits following DP were not influenced by the surgical approach. A low preoperative physical status, occurrence of postoperative pancreatic fistula and hemorrhage were significantly associated with post-discharge readmission within 90 days. Laparoscopy reduced time to functional recovery.

A four-step method to centralize pancreatic surgery, accounting for volume, performance and access to care.

BACKGROUND: Adequate criteria for pancreatic surgery centralization are debated. This retrospective study aimed to define a reproducible method for complex care centralization, accounting for hospital performance and access to care. METHODS: The method consisted in: 1. Analysis of overall outcome and mortality-related factors. 2. Assessment of volume and adjusted mortality of each hospital. 3. Definition of different centralization models. 4. Final adjustments to guarantee access to care, evaluating travel times and waiting lists. This method was tested on Lombardy, the most populous Italian region (about 10 million inhabitants, 24 000 km2). RESULTS: According to Ministry of Health data, 79 hospitals performed 3037 resections in 2014-2016. Mean overall mortality was 5.0%, increasing from 2.3%, of seven high-volume facilities (>30 resections/year) to 10.7% of 56 low-volume facilities (<10 resections/year). Five centralization models were tested (range: 7-23 hospitals): the best performing model included seven high-volume facilities, providing both low mortality (<2%), and easy access to care, namely reasonable travel time (≤60 min for >90% of the population), and limited impact on waiting list (1.1 extra-resection/hospital/week). CONCLUSION: The four-step method appears as a flexible tool to centralize pancreatic surgery, allowing regulatory institutions to estimate the effect of different models.

Impact of care pathway adherence on recovery following distal pancreatectomy within an enhanced recovery program.

BACKGROUND: In bowel surgery, adherence to enhanced recovery program (ERP) has been associated with improved recovery. The objective of this study was to evaluate the impact of adherence to ERP elements on outcomes, and identify factors associated with successful recovery following distal pancreatectomy (DP). METHODS: Data for 376 patients who underwent DP managed within an ERP including 16 perioperative elements were reviewed. Primary endpoint was successful recovery, a composite outcome defined as length of hospital stay≤7 days, no severe complications nor readmissions. RESULTS: Patients had a mean (SD) overall adherence of 76 (14)%. Overall, 166 (44%) patients had a successful recovery. There was a positive association between overall adherence and successful recovery (OR 1.19, 95%CI 1.08-1.31 for every additional element, p = 0.001), while an inverse relationship was found with comprehensive complication index (8% reduction, 95%CI -15 to -2%, p = 0.011). Adherence to postoperative phase interventions had the greatest impact on recovery (OR 1.29, 95%CI 1.13-1.47 for every additional postoperative element; p < 0.001). At multivariable regression, early termination of IV fluids was the only ERP element associated with successful recovery (OR 2.80, 95%CI 1.73-4.54; p < 0.001). CONCLUSION: Increased adherence to ERP elements was associated with successful early recovery and reduction of postoperative complication severity.

O-positive blood type is associated with prolonged recurrence-free survival following curative resection of pancreatic neuroendocrine tumors.

BACKGROUND: The ABO blood group may influence the development and progression of cancer. In particular, the prognosis of patients with blood type O is better for pancreatic adenocarcinoma, although this has not been extensively explored in pancreatic neuroendocrine tumors (PanNET). OBJECTIVE: To assess the influence of the ABO and Rhesus blood types on the risk of recurrence in patients who underwent curative intent PanNET surgical resection. METHODS: All consecutive patients operated on for well-differentiated panNET in an expert center from 2003 to 2018 were retrospectively included. Blood group, Rhesus system, demographic and clinical data were collected. The primary endpoint was recurrence free survival (RFS). Factors associated with RFS were explored using Cox proportional hazard models. RESULTS: Overall, 300 patients (male 43%) were included, median age 54 years old (IQR 45-64). The ABO blood group distribution was similar to that of the French population. There was no association between blood group and tumor features. The median postoperative follow-up was 43.9 months (17.0-77.8). The 5- and 10-year RFS rates were 85 ± 4% and 71 ± 13% in O RhD + patients, versus 72 ± 4% and 63 ± 6% otherwise, respectively (p = 0.035). The O RhD + blood group was associated with a decreased risk of recurrence (HR 0.34, 95% CI [0.15-0.75]), p = 0.007 in multivariable analysis adjusted for age, ki67, functioning syndrome, resection margins, tumor size, lymph node status, oncogenetic syndrome. CONCLUSIONS: After curative-intent surgical resection for PanNET, patients with a non-O RhD + blood group may have an increased risk of recurrence and could benefit from closer follow-up.

Surgical Principles in the Management of Pancreatic Neuroendocrine Neoplasms.

OPINION STATEMENT: Pancreatic neuroendocrine neoplasms (PanNENs) are increasingly recognized entities, whose incidence has dramatically grown during the last two decades. Surgery plays a pivotal role in their management as it represents the only chance of cure. Since PanNENs display a wide range of aggressiveness, their surgical management needs to be tailored on tumor's and patient's characteristics. Currently, there are several open questions and burning issues in the field of PanNEN, such as the management of asymptomatic nonfunctioning pancreatic neuroendocrine tumors (NF-PanNET) ≤ 2 cm. An active surveillance of these small lesions has been demonstrated to be safe although the available evidences are only based on retrospective studies. On the other hand, formal pancreatic resection associated with lymphadenectomy represents the gold standard for patients with localized NF-PanNEN > 2 cm or NF-PanNEN ≤ 2 cm in the presence of symptoms, dilation of the main pancreatic duct or suspicion of nodal metastases. Surgery plays also an important role in the setting of metastatic disease. In particular, surgery is generally recommended in the presence of low-grade, resectable, metastatic disease, but several series have reported also a survival benefit of palliative primary tumor resection in patients with unresectable liver metastases. The role of surgery in PanNEN G3 is still controversial. Indeed, surgery is associated with an improved survival in patients with well-differentiated PanNET G3, whereas there is almost no survival benefit in case of poorly differentiated lesions.

Renal Resistance Trend During Hypothermic Machine Perfusion Is More Predictive of Postoperative Outcome Than Biopsy Score: Preliminary Experience in 35 Consecutive Kidney Transplantations.

Hypothermic machine perfusion (HPM) grants a better postoperative outcome in transplantation of organs procured from extended criteria donors (ECDs) and donors after cardiac death (DCD). So far, the only available parameter for outcome prediction concerning those organs is pretransplant biopsy score. The aim of this study is to evaluate whether renal resistance (RR) trend during HPM may be used as a predictive marker for post-transplantation outcome. From December 2015 to present, HMP has been systematically applied to all organs from ECDs and DCD. All grafts underwent pretransplantation biopsy evaluation using Karpinski's histological score. Only organs that reached RR value ≤1.0 within 3 hours of perfusion were transplanted. Single kidney transplantation (SKT) or double kidney transplantation (DKT) were performed according to biopsy score results. Sixty-five HMPs were performed (58 from ECDs and 7 from DCD/ECMO donors). Fifteen kidneys were insufficiently reconditioned (RR > 1) and were therefore discarded. Forty-nine kidneys were transplanted, divided between 21 SKT and 14 DKT. Overall primary nonfunction (PNF) and delayed graft function (DGF) rate were 2.9 and 17.1%, respectively. DGF were more common in kidneys from DCD (67 vs. 7%; P = 0.004). Biopsy score did not correlate with PNF/DGF rate (P = 0.870) and postoperative creatinine trend (P = 0.796). Recipients of kidneys that reached RR ≤ 1.0 within 1 hour of HMP had a lower PNF/DGF rate (11 vs. 44%; P = 0.033) and faster serum creatinine decrease (POD10 creatinine: 1.79 mg/dL vs. 4.33 mg/dL; P = 0.019). RR trend is more predictive of post-transplantation outcome than biopsy score. Hence, RR trend should be taken into account in the pretransplantation evaluation of the organs.