Preoperative anaemia in distal pancreatectomy: a propensity-score matched analysis.

BACKGROUND: Preoperative anaemia is a prevalent morbidity predictor that adversely affects short- and long-term outcomes of patients undergoing surgery. This analysis aimed to investigate preoperative anaemia and its detrimental effects on patients after distal pancreatectomy. MATERIAL AND METHODS: The present study was a propensity-score match analysis of 286 consecutive patients undergoing distal pancreatectomy. Patients were screened for preoperative anaemia and classified according to WHO recommendations. The primary outcome measure was overall morbidity. The secondary endpoints were in-hospital mortality and rehospitalization. RESULTS: The preoperative anaemia rate before matching was 34.3% (98 patients), and after matching a total of 127 patients (non-anaemic 42 vs. anaemic 85) were included. Anaemic patients had significantly more postoperative major complications (54.1% vs. 23.8%; p < 0.01), a higher comprehensive complication index (26.2 vs. 4.3; p < 0.01), and higher in-hospital mortality rate (14.1% vs. 2.4%; p = 0.04). Multivariate regression analysis confirmed these findings and identified preoperative anaemia as a strong independent risk factor for postoperative major morbidity (OR 4.047; 95% CI: 1.587-10.320; p < 0.01). CONCLUSION: The current propensity-score matched analysis strongly considered preoperative anaemia as a risk factor for major complications following distal pancreatectomy. Therefore, an intense preoperative anaemia workup should be increasingly prioritised.

Giant splenic artery aneurysm: case report.

True splenic artery aneurysms are exceedingly rare and the medical literature contains only a limited number of reports on this pathology. Presently, there remains a lack of consensus regarding the optimal management and treatment approaches for patients in this category. Over the course of the last century, significant changes have occurred in the realm of surgical options, transitioning from open and endovascular procedures to the more advanced laparoscopic and robotic interventions. The propensity for these aneurysms to rupture underscores the need for timely intervention. The risk of rupture is notably elevated in patients harboring giant splenic artery aneurysms. In this report, we present the case of a 55-year-old woman diagnosed with a giant splenic artery aneurysm measuring 12x12 cm in diameter. She presented with notable weakness, discomfort, and pain in the left subcostal area. In response to her complaints and after thorough evaluation, we opted for a surgical procedure encompassing distal pancreatic resection in conjunction with splenectomy and resection of the giant splenic artery aneurysm.

Os aneurismas verdadeiros da artéria esplênica são extremamente raros, e há um número limitado de relatos sobre essa condição na literatura médica. Atualmente, não há consenso sobre as abordagens ideais de manejo e tratamento para pacientes que se enquadram nessa categoria. Ao longo do século passado, ocorreram mudanças significativas no domínio das opções cirúrgicas, passando de procedimentos abertos e endovasculares para intervenções laparoscópicas e robóticas mais avançadas. A propensão à ruptura do aneurisma ressalta a necessidade de intervenção em tempo oportuno. O risco de ruptura é notavelmente elevado em pacientes com aneurismas gigantes da artéria esplênica. Neste relato, apresentamos o caso de uma mulher de 55 anos diagnosticada com aneurisma gigante de artéria esplênica medindo 12x12 cm de diâmetro. A paciente apresentava fraqueza notável, desconforto e dor na região subcostal esquerda. Em resposta às suas queixas e após avaliação minuciosa, optamos por um procedimento cirúrgico que incluiu pancreatectomia distal associada a esplenectomia e ressecção do aneurisma gigante da artéria esplênica.

Giant splenic artery aneurysm: case report / Aneurisma gigante da artéria esplênica: relato de caso

Abstract True splenic artery aneurysms are exceedingly rare and the medical literature contains only a limited number of reports on this pathology. Presently, there remains a lack of consensus regarding the optimal management and treatment approaches for patients in this category. Over the course of the last century, significant changes have occurred in the realm of surgical options, transitioning from open and endovascular procedures to the more advanced laparoscopic and robotic interventions. The propensity for these aneurysms to rupture underscores the need for timely intervention. The risk of rupture is notably elevated in patients harboring giant splenic artery aneurysms. In this report, we present the case of a 55-year-old woman diagnosed with a giant splenic artery aneurysm measuring 12x12 cm in diameter. She presented with notable weakness, discomfort, and pain in the left subcostal area. In response to her complaints and after thorough evaluation, we opted for a surgical procedure encompassing distal pancreatic resection in conjunction with splenectomy and resection of the giant splenic artery aneurysm.

Resumo Os aneurismas verdadeiros da artéria esplênica são extremamente raros, e há um número limitado de relatos sobre essa condição na literatura médica. Atualmente, não há consenso sobre as abordagens ideais de manejo e tratamento para pacientes que se enquadram nessa categoria. Ao longo do século passado, ocorreram mudanças significativas no domínio das opções cirúrgicas, passando de procedimentos abertos e endovasculares para intervenções laparoscópicas e robóticas mais avançadas. A propensão à ruptura do aneurisma ressalta a necessidade de intervenção em tempo oportuno. O risco de ruptura é notavelmente elevado em pacientes com aneurismas gigantes da artéria esplênica. Neste relato, apresentamos o caso de uma mulher de 55 anos diagnosticada com aneurisma gigante de artéria esplênica medindo 12x12 cm de diâmetro. A paciente apresentava fraqueza notável, desconforto e dor na região subcostal esquerda. Em resposta às suas queixas e após avaliação minuciosa, optamos por um procedimento cirúrgico que incluiu pancreatectomia distal associada a esplenectomia e ressecção do aneurisma gigante da artéria esplênica.

Identifying Hospital Cost Savings Opportunities by Optimizing Surgical Approach for Distal Pancreatectomy.

BACKGROUND: The economic implications of relevant clinicopathologic factors on the surgical approach to distal pancreatectomy (DP) should be clearly defined and understood to potentially allow the implementation of cost reduction strategies. METHODS: Administrative and clinical datasets of patients undergoing a DP between 2012 and 2016 were merged and queried. Univariate and multivariate analyses were used to identify clinicopathologic predictors of cost differentials for minimally invasive DP (MIDP) relative to open DP (ODP). Time trends in cost were also assessed to identify opportunities for cost containment. RESULTS: Among two hundred and twenty five patients, 128 underwent an ODP (57%) and 97 a MIDP (43%). The DP groups were comparable with regard to relevant perioperative and disease characteristics. Total hospitalization and total OR costs for MIDP were significantly lower (- 12%, P = 0.0048) and higher (+ 16%, P < 0.0001) respectively, compared to ODP. On univariate analysis, age > 60 (- 12%, P = 0.0262), BMI > 25 (- 10%, P = 0.0222), ASA class ≥ 3 (- 11%, P = 0.0045), OpTime > 230 min (- 16%, P = 0.0004), and T stage ≥ 3 (- 8%, P = 0.0452) were associated with decreased total costs after MIDP compared to ODP. Linear regression analysis revealed that BMI > 25 (Estimate - 0.31, SE 0.15, P = 0.0482), ASA class ≥ 3 (Estimate - 0.36, SE 0.17, P = 0.0344), and T stage ≥ 3 (Estimate - 0.57, SE 0.26, P = 0.0320) were associated with decreased hospitalization costs after MIDP compared to ODP. Overtime, total hospitalization cost for MIDP increased from - 21 to 1% (P = 0.0197), while OR costs for MIDP decreased from + 41% to - 2% (P = 0.0049), nearly equalizing the cost differences between ODP and MIDP. CONCLUSIONS: Relevant clinicopathologic factors predicted decreased hospitalization costs after MIDP relative to ODP. In equivalent stages of disease, optimizing the surgical approach to DP based on specific clinicopathologic characteristics may afford significant cost-saving opportunities.

Surgical treatment of pancreatic cancer.

The only way to cure the patient with adenocarcinoma of the pancreas (RT) is surgical excision of the tumor. The standard surgical treatment of resectable pancreatic carcinoma is considered the classic pancreatoduodenectomy (PD) with the Kausch- Whipple procedure, or the pylorus-preserving PD with the Traverso-Longmire method. The most difficult technically and at the same time the most important PD stage from an oncological point of view is the separation of the head of the pancreas from the superior mesenteric artery. Over the last decades several PD modifications have been developed, focusing on this maneuver in the early phase of the operation, i.e. before the pancreas is cut (an irreversible stage of the procedure). These procedures in the English literature are called "artery-first approach" or "SMA-first approach". The term "mesopancreas" was created. Complete removal of the mesopancreas together with the proximal part of the jejunum is considered an R0 resection in the case of a tumor of the head of the pancreas with direct or indirect vascular invasion, or metastases to regional lymph nodes, and in English literature it is referred to as pancreatoduodenectomy with systematic mesopancreas dissection (SMDPD). Distal resection of the pancreas (DRT) due to cancer, is associated with a high percentage of positive margins, insufficient number of removed lymph nodes, low survival rates. A new technique was developed - a radical proximal-distal modular pancreatosplenectomy (RAMPS). In RAMPS, surgical operations proceed from the side of the pancreas head towards the tail, the pancreas is cut early, and the splenectomy is performed at the final stages of the procedure. Currently, following the PD model, attempts are made to further modify the original RAMPS technique, especially in the direction of SMA-first approach. In patients with borderline resectable pancreatic tumors or locally advanced tumors, after neoadjuvant treatment, a technique of radical resection with preservance of arterial vessels - "the TRIANGLE operation" has been elaborated. Despite the tremendous progress of surgical techniques, RT is still detected too late in the phase preventing effective resection.

[Early endocrine neoplasia of the pancreas]. / Kleine neuroendokrine Neoplasien des Pankreas.

Pancreatic endocrine neoplasias (pNENs) are uncommon but fascinating tumors with a rising incidence. In accordance to its location, size and grading, the decision to operate the patient should always be made in an interdisciplinary approach. This article provides a comprehensive review of the current literature addressing the current challenges in pNEN surgery and shows that patients with completely resected small pNENs generally have an excellent prognosis, but also that surveillance may be a powerful tool.

Risk factors for delayed gastric emptying following distal pancreatectomy.

PURPOSE: Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy and other types of upper gastrointestinal surgery with published incidences as high as 60 %. The present study examines the incidence of DGE following distal pancreatic resection (DPR). METHODS: Between 2002 and 2014, 100 patients underwent conventional DPR at our department. DGE was classified according to the 2007 International Study Group of Pancreatic Surgery definition. Patients were analyzed regarding severity of DGE, morbidity and mortality, length of hospital stay, and demographic factors. RESULTS: Overall incidence of DGE was 24 %. No difference in age, gender, or other demographic factors was observed in patients with DGE. Perioperative characteristics (splenectomy rate, closure technique of the pancreatic remnant, operation time, blood loss and transfusion, ICU, ASA score) were comparable. Major complications were associated with DGE (11/24 patients (46 %) vs. 19/76 patients (25 %) without DGE) and the rate of pancreatic fistula was significantly higher in the group of patients with DGE (14/24 patients (58 %) vs. 27/76 patients (36 %), P = 0.047). In multivariate analysis, a periampullary malignancy was shown to be a significant factor for DGE development. DGE significantly prolonged hospital stay (14 vs. 22 days). CONCLUSIONS: DGE is a substantial complication not only after pancreatoduodenectomy, but it also occurs frequently after DPR. Prevention of pancreatic fistula might reduce its incidence, especially in patients with malign pathology.

Laparoscopic versus open distal pancreatectomy for benign or premalignant pancreatic neoplasms: a two-center comparative study.

OBJECTIVE: To compare the peri-operative outcomes for laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) for benign or premalignant pancreatic neoplasms in two institutions. METHODS: This prospective comparative study included 91 consecutive patients who underwent LDP (n=45) or ODP (n=46) from Jan. 2010 to Dec. 2012. Demographics, intra-operative characteristics, and post-operative outcomes were compared. RESULTS: The median operating time in the LDP group was (158.7±38.3) min compared with (92.2±24.1) min in the ODP group (P<0.001). Patients had lower blood loss in LDP than in the ODP ((122.6±61.1) ml vs. (203.1±84.8) ml, P<0.001). The rates of splenic conservation between the LDP and ODP groups were similar (53.3% vs. 47.8%, P=0.35). All spleen-preserving distal pancreatectomies were conducted with vessel preservation. LDP also demonstrated better post-operative outcomes. The time to oral intake and normal daily activities was faster in the LDP group than in the ODP group ((1.6±0.5) d vs. (3.2±0.7) d, P<0.01; (1.8±0.4) d vs. (2.1±0.6) d, P=0.02, respectively), and the post-operative length of hospital stay in LDP was shorter than that in ODP ((7.9±3.8) d vs. (11.9±5.8) d, P=0.006). No difference in tumor size ((4.7±3.2) cm vs. (4.5±1.8) cm, P=0.77) or overall pancreatic fistula rate (15.6% vs. 19.6%, P=0.62) was found between the groups, while the overall post-operative complication rate was lower in the LDP group (26.7% vs. 47.8%, P=0.04). CONCLUSIONS: LDP is safe and effective for benign or premalignant pancreatic neoplasms, featuring lower blood loss and substantially faster recovery.

PolysorbR (an absorbable lactomer) staples, a safe closure technique for distal pancreatic resection.

AIM: To investigate twenty-year experience evaluated the use of the Polysorb(R) (an absorbable lactomer) staples for distal pancreatic resection. METHODS: The data on 150 patients [92 men, 58 women, mean age 52 (24-72) years] who underwent distal pancreatectomy (DP) in the last 20 years were collected prospectively from an electronic database. The diagnosis was confirmed by endoscopic retrograde cholangiopancreatography, sonography, computed tomography and/or magnetic resonance imaging. The indications for DP were focal pancreatic necrosis, spontaneous pancreatic fistulas, abscesses, pseudocysts, segmental chronic obstructive pancreatitis in the tail, traumatic disruption, and benign (cystadenomas, insulinomas, or glucagonomas) or malignant tumours. The distal resections were performed without splenectomy in 29 of the 150 patients (19%). In the event of splenectomy, the splenic artery and vein were individually ligated, the TA-55 Auto Suture stapler, loaded with Premium Polysorb(R) 55 staples (5.5 mm), was placed across the gland, and the trigger was pulled, the action of which produced two staggered absorbable suture lines. The gland distal to the stapler was then amputated with a scalpel on the TA-55 stapler and the two rows of staples were left in the proximal pancreatic stump. After the distal resection, a drainage tube was inserted into the pancreatic bed. RESULTS: The average duration of the operation was 150 min (range: 90-210 min) and no transfusion was indicated during the operation. After DP in one patient a type B fistula was diagnosed, which was treated successfully by conservative treatment comprising of 12-d octreotide medication (3 × 0.1 mg/d) and jejunal feeding. The incidence of postoperative pancreatic fistula was therefore 0.6%. Another 2 patients suffered postoperative pancreatitis, which was also conservatively treated. Reoperations were performed in 2 patients on the first or second postoperative day, necessitated by bleeding from the retroperitoneal region. The morbidity was 3.3% (5 patients), but no mortality occurred in the postoperative period. Overall, the postoperative period was uneventful without any complications (pancreatic fistula, abscess, bleeding or wound infection) in 145 patients. The length of the postoperative stay ranged between 8 and 16 d. For the 145 patients who had no any postoperative complications, the hospital stay was 8 or 9 d. No mortality occurred in the follow-up period (6 or 12 mo postoperatively); but 6 mo after surgery one patient suffered a pseudocyst following recurrent pancreatitis and was treated with cystojejunostomy. CONCLUSION: Our clinical results demonstrated that the application of absorbable lactomer staples for distal pancreatic resection is a safe alternative to the standard closure technique.

Arguments for an individualized closure of the pancreatic remnant after distal pancreatic resection.

AIM: To analyze risk factors for postoperative pancreatic fistula (POPF) rate after distal pancreatic resection (DPR). METHODS: We performed a retrospective analysis of 126 DPRs during 16 years. The primary endpoint was clinically relevant pancreatic fistula. RESULTS: Over the years, there was an increasing rate of operations in patients with a high-risk pancreas and a significant change in operative techniques. POPF was the most prominent factor for perioperative morbidity. Significant risk factors for pancreatic fistula were high body mass index (BMI) [odds ratio (OR) = 1.2 (CI: 1.1-1.3), P = 0.001], high-risk pancreatic pathology [OR = 3.0 (CI: 1.3-7.0), P = 0.011] and direct closure of the pancreas by hand suture [OR = 2.9 (CI: 1.2-6.7), P = 0.014]. Of these, BMI and hand suture closure were independent risk factors in multivariate analysis. While hand suture closure was a risk factor in the low-risk pancreas subgroup, high BMI further increased the fistula rate for a high-risk pancreas. CONCLUSION: We propose a risk-adapted and indication-adapted choice of the closure method for the pancreatic remnant to reduce pancreatic fistula rate.