Intravenous Treprostinil in Severe Inoperable Chronic Thromboembolic Pulmonary Hypertension Using Implantable Pumps-Single-Center Experience over More Than a Decade.

The management of chronic thromboembolic pulmonary hypertension has significantly changed over the last decade with the availability of both specific therapies and interventional treatments. In parallel, implantable pumps for intravenous administration of treprostinil have broadened the spectrum of continuous prostanoid infusion. We evaluated the course of 17 consecutive patients with inoperable chronic thromboembolic pulmonary hypertension treated with treprostinil by means of an implantable infusion pump between 2011 and 2023 at our center. Complications associated with the infusion system were rare, leading to 0.4 unplanned surgical interventions during 17,160 patient days. No additional safety signals were detected, and clinical benefits achieved with subcutaneous treprostinil before pump implantation could be maintained in all patients. No catheter-related infections or thromboembolic events were observed. Implantable infusion pumps offer an attractive alternative to subcutaneous treprostinil for patients intolerant to the subcutaneous route, including those with chronic thromboembolic pulmonary hypertension.

Long-term experience with implantable infusion pumps for intravenous treprostinil in pulmonary arterial hypertension-procedural safety and system-related complications.

Implantable pumps for intravenous treprostinil provide a promising option to overcome drawbacks of parenteral prostanoid administration with external pumps in pulmonary hypertension. We retrospectively analyzed 85 patients undergoing implantation in a single center since 2010. In our cohort, serious complications were rare, and flow rate increase over time warrants careful monitoring.

A Preoperative Clinical Risk Score Including C-Reactive Protein Predicts Histological Tumor Characteristics and Patient Survival after Surgery for Sporadic Non-Functional Pancreatic Neuroendocrine Neoplasms: An International Multicenter Cohort Study.

Background: Oncological survival after resection of pancreatic neuroendocrine neoplasms (panNEN) is highly variable depending on various factors. Risk stratification with preoperatively available parameters could guide decision-making in multidisciplinary treatment concepts. C-reactive Protein (CRP) is linked to inferior survival in several malignancies. This study assesses CRP within a novel risk score predicting histology and outcome after surgery for sporadic non-functional panNENs. Methods: A retrospective multicenter study with national exploration and international validation. CRP and other factors associated with overall survival (OS) were evaluated by multivariable cox-regression to create a clinical risk score (CRS). Predictive values regarding OS, disease-specific survival (DSS), and recurrence-free survival (RFS) were assessed by time-dependent receiver-operating characteristics. Results: Overall, 364 patients were included. Median CRP was significantly higher in patients >60 years, G3, and large tumors. In multivariable analysis, CRP was the strongest preoperative factor for OS in both cohorts. In the combined cohort, CRP (cut-off ≥0.2mg/dL; hazard-ratio (HR):3.87), metastases (HR:2.80), and primary tumor size ≥3.0cm (HR:1.83) showed a significant association with OS. A CRS incorporating these variables was associated with postoperative histological grading, T category, nodal positivity, and 90-day morbidity/mortality. Time-dependent area-under-the-curve at 60 months for OS, DSS, and RFS was 69%, 77%, and 67%, respectively (all p < 0.001), and the inclusion of grading further improved the predictive potential (75%, 84%, and 78%, respectively). Conclusions: CRP is a significant marker of unfavorable oncological characteristics in panNENs. The proposed internationally validated CRS predicts histological features and patient survival.

Exploring the surgical landscape of pancreatic neuroendocrine neoplasia in Austria: Results from the ASSO pNEN study group.

INTRODUCTION: Pancreatic neuroendocrine neoplasia (pNEN) show increasing incidence and management is complex due to biological heterogeneity. Most publications report isolated high-volume single-centre data. This Austrian multi-centre study on surgical management of pNENs provides a comprehensive real-life picture of quality indicators, recurrence-patterns, survival factors and systemic treatments. METHODS: Retrospective, national cohort-study from 7 medium-/high-volume centres in Austria, coordinated under the auspices of the Austrian Society of Surgical Oncology (ASSO). RESULTS: Two-hundred patients underwent resection for pNEN, 177 had non-functioning tumours and 31 showed stage 4 disease. Participating centres were responsible for 2/3 of pNEN resections in Austria within the last years. The mean rate of completeness of variables was 98.6%. Ninety-days mortality was 3.5%, overall rate of complications was 42.5%. Morbidity did not influence long-term survival. The 5-year overall-survival (OS) was 81.3%, 10-year-OS 52.5% and 5-year recurrence-free-survival (RFS) 69.8%. Recurrence was most common in the liver (68.1%). Four out of five patients with recurrence underwent further treatment, most commonly with medical therapy or chemotherapy. Multivariable analysis revealed grading (HR:2.7) and metastasis (HR:2.5) as significant factors for relapse. Tumours-size ≥2 cm (HR:5.9), age ≥60 years (HR:3.1), metastasis (HR:2.3) and grading (HR:2.0) were associated with OS. Tumours <2 cm showed 93.9% 10-year-OS, but 33% had G2/G3 grading, 12.5% positive lymph-nodes and 4.7% metastasis at diagnosis, each associated with significant worse survival. CONCLUSION: Resection of pNENs in Austria is performed with internationally comparable safety. Analysed factors allow for risk-stratification in clinical treatment and future prospective trials. A watch-and-wait strategy purely based on tumour-size cannot be recommended.

Surgical quality data and survival after pancreatic cancer resections: a comparison of results for octogenarians and younger patients.

BACKGROUND: Although age is no contraindication for pancreatic cancer resections, there are conflicting reports of morbidity and mortality rates and only few data showing direct comparisons of survival for octogenarians and patients younger than 80 years. METHODS: Comparison of complication, reintervention, reoperation, and 30-day in-hospital mortality rates, length of stay, and survival of all octogenarians and patients younger than 80 years undergoing pancreatectomy for ductal adenocarcinoma during the study period from 2001 to 2010 was done. All resectable patients with suspected ductal adenocarcinoma who deemed to be fit for surgery in an interdisciplinary assessment (anesthesiology, gastroenterology, oncology, surgery) were offered pancreatectomy. The only exceptions were Eastern Cooperative Oncology Group (ECOG) performance score 3 and 4 or advanced dementia patients. Resectability was determined according to contrast-enhanced computed tomography scans (pancreas protocol). The database was prospectively maintained. For survival analysis, a first follow-up was made on December 31, 2010, by a query of the national register of residents with retrieval of corresponding International Classification of Diseases (ICD) death diagnoses by the Austrian Institute of Statistics. For surviving octogenarians, a second follow-up was made by telephone interview on August 21, 2013. RESULTS: We identified 9 octogenarians and 99 patients younger than 80 years. Median age in the two groups was 83 and 67 years, respectively. The predominant procedure in both groups was pylorus-preserving pancreaticoduodenectomy (55.6 and 68.7 %, respectively). Complications occurred in 33.3 and 28.3 % of patients, respectively. Reintervention, reoperation, and 30-day in-hospital mortality rates of patients younger than 80 years were 9.1, 6.1, and 5.1 %, respectively. In the octogenarian group, there were no pancreatic fistulas, one transient ischemic attack after stenting of an intraoperatively detected stenosis of the celiac trunk, one infected hematoma that was managed with intravenous antibiotics, and one wound infection. There were no reoperations or postoperative reinterventions. Median length of stay was 18 days, and postoperative 30-day mortality was nil. Median survival was comparable for both age-groups (10.5 vs. 12.1 months, respectively). CONCLUSION: In an interdisciplinary setting, surgical quality data and survival after pancreatic cancer resections are comparable in octogenarians and patients younger than 80 years.

Clinical approach to the patient with a solid pancreatic mass.

Diagnosis and clinical work-up of a solid pancreatic mass is a challenging problem. Patients' history, laboratory parameters, computed tomography magnetic resonance imaging, and endosonography are the cornerstones in diagnosis. Biopsy is indicated in selected patients. The main goal of surgical indication is to select patients with suspected malignancy who are resectable, but avoid unnecessary resections. About 5 % of patients resected due to suspicion of malignancy finally present with a benign histology. Autoimmune pancreatitis is the most frequent cause of such unnecessary resections.

Unplanned reoperation and reintervention after pancreatic resections: an analysis of risk factors.

BACKGROUND: The purpose of the study was to determine the incidence of any unplanned reoperation or reintervention procedure after pancreatic resection and to identify the underlying risk factors. METHODS: A total of 189 consecutive pancreatic resections performed from 2001-2008 were searched for any unplanned reoperation, percutaneous drainage, or angiographic reintervention. A retrospective analysis of a prospectively maintained database, including patient characteristics, comorbidities, details of surgery, specific complications, incidence of reoperation/reintervention, and mortality was performed. RESULTS: Overall rates of reoperation, reintervention, and mortality were 6.3% (12/189), 7.9% (15/189), and 1.6% (3/189), respectively. Four patients underwent reintervention and reoperation, so the combined reoperation/reintervention rate was 12.2% (23/189). Reoperation (P < 0.001) and reintervention (P = 0.002) correlated with mortality. Hemorrhage (relative risk [RR], 58; P = 0.0017) and the combination of hemorrhage and pancreatic fistula (RR, 117; P < 0.0001) were identified as risk factors for unplanned reoperation, hemorrhage (RR, 82; P = 0.005), pancreatic fistula (RR, 42; P < 0.001), and the combination of both complications (RR, 246; P < 0.001) for reoperation and/or reintervention. Other patient- or procedure-related factors did not influence the reoperation and/or reintervention rates significantly. CONCLUSIONS: Pancreatic fistula and hemorrhage are the predominant factors that afford unplanned reoperation/reintervention. Although reporting the incidence of unplanned reoperation will include the most severe postoperative complications, a considerable number of reinterventions are missed. Therefore, in outcome analyses of pancreatic surgery, not only reoperations but also any interventional therapies should be included.

Unplanned reoperations for infection complications: a survey for quality control.

BACKGROUND: Unplanned reoperation is perceived as a quality indicator for surgical procedures. However, there is a lack of data regarding the extent to which infections add to the reoperation rate. We studied the role of infection as an indication for unplanned reoperation. METHODS: The setting was a surgical department at an academic teaching hospital performing a spectrum of general, vascular, thoracic (lung), and transplant (kidney) procedures. Between January, 2003 and September, 2004, data on operations, unplanned reoperations, and complications were documented prospectively. Unplanned reoperation was defined as unexpected reoperation within 30 days of the primary procedure. Endpoints were the number of unplanned reoperations attributable to infection, the site of the infection, the type of the primary operation, and deaths. RESULTS: A total of 6,287 operations were performed during the study period. The rate of unplanned reoperations was 1.34% (84/6287), and 15 (17.9%) of these 84 patients had to undergo reoperation because of an infection. The primary operations in these cases were general surgical procedures in 11 patients, kidney transplant in two patients, and vascular surgery and lung resection in one patient each. Leakage of a gastrointestinal anastomosis was the predominant cause in the general surgical group (8/11). The most frequent initial procedure was colon resection (n = 4) followed by ileostomy closure (n = 2) and kidney transplant (n = 2). One unplanned reoperation had to be done after esophagectomy, pancreatoduodenectomy, pneumonectomy, incisional hernia repair, appendectomy, femoro-femoral bypass, and resection of a soft tissue tumor. The mortality rate after unplanned reoperation for infection was 20% (3/15), a significantly higher rate than in patients not having reoperation (p < 0.00001). Subgroup analysis did not show any significant difference in mortality according to whether the unplanned reoperation was indicated by infection, bleeding, or other reason (p = 0.28). Patients who required operation because of an infection stayed significantly longer in the intensive care unit (p = 0.018) and underwent more reoperations (p = 0.003) than those with other indications for reoperation. CONCLUSION: Infections add considerably to the rate of unplanned reoperation. The mortality rate is high, but not significantly different from that in patients having reoperation for other indications. A longer stay in the intensive care unit and a higher number of reoperations indicate a greater use of resources by these patients.