Textbook outcome in distal pancreatectomy: A multicenter study.

BACKGROUND: Textbook outcome is an interesting quality metrics tool. Information on textbook outcomes in distal pancreatectomy is very scarce. In this study we determined textbook outcome in a distal pancreatectomy multicenter database and propose a specific definition of textbook outcome-distal pancreatectomy that includes pancreatic fistula. METHODS: Retrospective multicenter observational study of distal pancreatectomy performed at 8 hepatopancreatobiliary surgery units from January 1, 2008, to December 31, 2018. The inclusion criteria were any scheduled distal pancreatectomy performed for any diagnosis and age > 18 years. Specific textbook outcome-distal pancreatectomy was defined as hospital stay P < 75, no Clavien-Dindo complications (≥ III), no hospital mortality, and no readmission recorded at 90 days, and the absence of pancreatic fistula (B/C). RESULTS: Of the 450 patients included, 262 (58.2%) obtained textbook outcomes. Prolonged stay was the parameter most frequently associated with failure to achieve textbook outcomes. The textbook outcome group presented the following results. Preoperative: lower American Society of Anesthesiologists score < III, a lower percentage of smokers, and less frequent tumor invasion of neighboring organs or vascular invasion; operative: major laparoscopic approach, and less resection of neighboring organs and less operative transfusion; postoperative: lower percentage of delayed gastric emptying and pancreatic fistula B/C, and diagnosis other an adenocarcinoma. In the multivariate study, the American Society of Anesthesiologists score > II, resection of neighboring organs, B/C pancreatic fistula, and delayed gastric emptying were associated with failure to achieve textbook outcomes. CONCLUSION: The textbook outcome rate in our 450 pancreaticoduodenectomies was 58.2%. In the multivariate analysis, the causes of failure to achieve textbook outcomes were American Society of Anesthesiologists score > II, resection of neighboring organs, pancreatic fistula B/C, and delayed gastric emptying. We believe that pancreatic fistula should be added to the specific definition of textbook outcome-distal pancreatectomy because it is the most frequent complication of this procedure.

Metastasis of Renal Cell Carcinoma to Pancreatic Bile Duct.

Secondary pancreatic neoplasms account for less than 5% of all pancreatic malignancies, with renal cell carcinoma (RCC) being one of the most common primary tumors. Here, we present the case of a patient with obstructive jaundice secondary to an isolated metastatic RCC, to the intrapancreatic portion of the common bile duct, ampulla of Vater, and pancreatic parenchyma. Patient had a history of a left radical nephrectomy due to a primary RCC 10 years prior to presentation, and eventually underwent a pylorus-sparing pancreaticoduodenectomy (PD) with minor morbidity. While metastases of RCC to the pancreatic body and tail have been reported, isolated metastasis to the pancreatic bile duct comprises an even rarer subgroup.

Pancreatic mucinous cystic neoplasms located in the distal pancreas: a multicenter study.

Background: Mucinous cysts of the pancreas (MCN) are infrequent, usually unilocular tumors which occur in postmenopausal women and are located in the pancreatic body/tail. The risk of malignancy is low. The objective is to define preoperative risk factors of malignancy in pancreatic MCN and to assess the feasibility of the laparoscopic approach. Methods: Retrospective multicenter observational study of prospectively recorded data regarding distal pancreatectomies was carried out at seven hepatopancreatobiliary (HPB) Units between 01/01/08 and 31/12/18 (the ERPANDIS Project). Results: Four hundred and forty-four distal pancreatectomies were recorded including 47 MCN (10.6%). Thirty-five were non-invasive tumors (74.5%). In all, 93% of patients were female, and 60% were ASA (American Society of Anaesthesiology) II. The mean preoperative size was 46 mm. Patients with invasive tumors were older (54 vs. 63 years). Invasive tumors were larger (6 vs. 4 cm), although the difference was not significant (P=0.287). Sixty percent was operated via laparoscopic approach, which was used in 74.6% of non-invasive tumors and in 16.7% of the invasive ones. The spleen was not preserved in 93.6% of the patients. R0 resection was obtained in all patients. Two patients with invasive tumors died. Conclusions: In our surgical series of MCN, patients with malignancy were older and presented larger tumors, although the difference was not statistically significant. Laparoscopy is a safe and feasible approach for MCN. Prospective studies are now needed to define risk factors that can guide the decision whether to administer conservative treatment or to operate.

Efficacy of 4D CT Scan in Re-operative Parathyroid Surgery.

Parathyroidectomy is the only cure for primary hyperparathyroidism and is effective in more than 95% of cases at initial surgical intervention. However, 2.5-5% of cases have recurrent or persistent disease. Pre-operative imaging is recommended in patients undergoing redo parathyroidectomy to localize the diseased gland. Parathyroid 4D CT scan is now widely used for localization and has been reported to have improved accuracy when compared to other imaging modalities. We conducted a retrospective study of all redo parathyroidectomies from 2017 to 2021 at a single tertiary parathyroid referral center. We evaluated pre-operative 4D CT scan results and compared them to intra-operative findings to determine if 4D CT scan correctly predicted the location of the diseased gland. 4D CT scan had a concordance of 87% with intra-operative findings. 4D CT scan is highly effective identifying parathyroid pathology in re-operative cases and can be used as a pre-operative tool to guide surgical management.

Distal pancreatectomy with multivisceral resection: A retrospective multicenter study - Case series.

BACKGROUND: Multivisceral resection (MVR) is sometimes necessary to achieve disease-free margins in cancer surgery. In certain patients with pancreatic tumors that invade neighboring organs these must be removed to perform an appropriate oncological surgery. In addition, there is an increasing need to perform resections of other organs like liver not directly invaded by the tumor but which require synchronous removal. The results of MVR in pancreatic surgery are controversial. MATERIAL AND METHODS: A distal pancreatectomy retrospective multicenter observational study using prospectively compiled data carried out at seven HPB Units. The period study was January 2008 to December 2018. We excluded DP with celiac trunk resection. RESULTS: 435 DP were performed. In 62 (14.25%) an extra organ was resected (82 organs). Comparison of the preoperative data of MVR and non-MVR patients showed that patients with MVR had lower BMI, higher ASA and larger tumor size. In the MVR group, the approach was mostly laparotomic and spleen preservation was performed only in 8% of the cases, Blood loss and the percentage of intraoperative transfusion were higher in MVR group. Major morbidity rates (Clavien > IIIa) and mortality (0.8vs.4.8%) were higher in the MVR group. Pancreatic fistula rates were practically the same in both groups. Mean hospital stay was twice as long in the MVR group and the readmission rate was higher in the MVR group. Histology study confirmed a much higher rate of malignant tumors in MVR group. CONCLUSIONS: In order to obtain free margins or treat pathologies in several organs we think that DP + MVR is a feasible technique in selected patients; the results obtained are not as good as those of DP without MVR but are acceptable nonetheless. CLINICALTRIALS. GOV IDENTIFIER: NCT04317352.

A Rare Case of Congenital Adrenal Hyperplasia with Giant Adrenal Myelolipoma.

Adrenal incidentalomas are tumors located in the adrenal glands and found on imaging done for purposes not related to adrenal disease. In other cases adrenal mases can be radiologically found when an adrenal hormone secreting tumor is suspected, such as a pheochromocytoma or Cushing's diseases. Adrenal incidentalomas may be classified as functional or non-functional based on whether they produce hormones, such as aldosterone, cortisol, and androgens, or catecholamines. Studies indicate that around 8% of adrenal incidentalomas are adrenal gland myelolipomas (AGMs). AGMs are non-malignant masses that can cause the compression of vital organs and vessels if said masses become large enough. In patients with congenital adrenal hyperplasia (CAH), adrenocorticotropic hormone (ACTH) levels tend to be elevated due to the lack of adrenal-hormone production. Patients with CAHs are treated with steroids that suppress ACTH levels and prevent adrenal gland hyperplasia. Around 10% of AGMs are found in untreated CAHs. Our patient was a 36-year-old male who was on steroids due to CAH and intermittent abdominal pain; a CT scan revealed a large left adrenal mass that was displacing organs towards the right. Pathological analysis revealed an AGM exceeding 30 x 23.6 x 16.7 cm. This AGM is one of the largest ever to be reported in the literature.