External validation of the Japanese difficulty scoring system for minimally-invasive distal pancreatectomies.

INTRODUCTION: Preoperative prediction of the difficulty of surgery would be useful for surgeons embarking on MIDP. A novel difficulty scoring system(DSS) was recently developed in Japan but has not been externally validated. This study aims to externally validate the DSS determine its association with important clinical outcome parameters. METHODS: Retrospective review of 90 patients who underwent MIDP from 2006 to 2018. The patients were stratified into 3 groups (low, intermediate and high difficulty) according to the DSS with some minor modifications. RESULTS: Difficulty of MIDP was classified as low in 45(50%), intermediate in 32(35.5%) and high in 13(14.4%). Comparison between the baseline characteristics across the 3 difficulty groups demonstrated a significant difference in the frequency of malignant tumors, larger tumor size, frequency of extended pancreatectomies and use of robotic assistance. There was statistically significant increase in operation time, blood loss and blood transfusion rate across the 3 groups from low to high difficulty. CONCLUSION: The DSS correlated significantly with operation time, blood loss and blood transfusion rate. These findings support the validity of the system.

Clinical impact of margin status on survival and recurrence pattern after curative-intent surgery for pancreatic cancer.

BACKGROUND/OBJECTIVE: The definition of R0 resection for invasive pancreatic ductal carcinoma (IPDC) is important. However, there are different definitions among several countries in the world. METHODS: From 2001 to 2015, 100 consecutive patients with IPDC who underwent pancreatic resection in our hospital were enrolled. We compared survival and recurrence patterns between the R0 group and R1 group based on the UICC (Union for International Cancer Control) classification (current-R0 vs. current-R1) and based on our revised classification, which defines R0 as a surgical margin of >1 mm (revised-R0 vs. revised-R1). RESULTS: The 100 patients comprised 58 males and 42 females, and their median age was 70 [32-87]. There were 84 patients in the current-R0 group and 43 in the revised-R0 group. There was no difference in overall survival (OS) or recurrence-free survival (RFS) between the current-R0 group and current-R1 group. However, there was a tendency toward a higher OS rate in the revised-R0 than revised-R1 group (log-rank p = 0.065), and RFS was significantly better in the revised-R0 than revised-R1 group (log-rank p = 0.002). There was no significant difference in the recurrence patterns between the current-R0 and current-R1 groups. In contrast, the local recurrence rate was significantly lower in the revised-R0 than revised-R1 group (21% vs. 42%, respectively; p = 0.026). CONCLUSION: The revised classification of surgical resection may be more useful than the current UICC classification for prediction of prognosis and local recurrence of IPDC.

Standardizing terminology for minimally invasive pancreatic resection.

BACKGROUND: There is a growing body of literature pertaining to minimally invasive pancreatic resection (MIPR). Heterogeneity in MIPR terminology, leads to confusion and inconsistency. The Organizing Committee of the State of the Art Conference on MIPR collaborated to standardize MIPR terminology. METHODS: After formal literature review for "minimally invasive pancreatic surgery" term, key terminology elements were identified. A questionnaire was created assessing the type of resection, the approach, completion, and conversion. Delphi process was used to identify the level of agreement among the experts. RESULTS: A systematic terminology template was developed based on combining the approach and resection taking into account the completion. For a solitary approach the term should combine "approach + resection" (e.g. "laparoscopic pancreatoduodenectomy); for combined approaches the term must combine "first approach + resection" with "second approach + reconstruction" (e.g. "laparoscopic central pancreatectomy" with "open pancreaticojejunostomy") and where conversion has resulted the recommended term is "first approach" + "converted to" + "second approach" + "resection" (e.g. "robot-assisted" "converted to open" "pancreatoduodenectomy") CONCLUSIONS: The guidelines presented are geared towards standardizing terminology for MIPR, establishing a basis for comparative analyses and registries and allow incorporating future surgical and technological advances in MIPR.

Systematic Review and Meta-Analysis of Enucleation Versus Standardized Resection for Small Pancreatic Lesions.

BACKGROUND: The appropriate surgical strategy in patients with small pancreatic lesions of low malignant potential, such as pancreatic neuroendocrine tumors, remains unknown. Increasing reports suggest limited pancreatic surgery may be a safe option for parenchymal preservation. METHODS: PubMed and MEDLINE were searched in the English literature for studies from January 2000 to February 2015 examining enucleation for pancreatic lesions that were single-arm and comparative studies (versus resection). Single-arm enucleation studies were systematically reviewed. Comparative studies were included for meta-analysis. Endpoints include safety, complications, mortality, survival, and parenchymal-related outcomes. RESULTS: Thirteen studies comprising of 1101 patients undergoing enucleation were included. Seven studies were comparative studies of enucleation and standardized pancreatic resection. Enucleation was a shorter procedure (pooled mean differences (MD) = 109, 95 % confidence interval (CI) 105-114; Z = 46.37; P < 0.001) associated with less blood loss (pooled MD = 314, 95 % CI 297-330; Z = 37.47; P < 0.001). Both enucleation and resection had similar mortality and complication rates, but the rate of pancreatic fistula (all grades) (pooled odds ratio (OR) = 1.99; 95 % CI 1.2-3.4; Z = 2.57; P = 0.01] and rate of pancreatic fistula (grade B/C) (pooled OR = 1.58; 95 % CI 1.0-2.5; Z = 2.06; P = 0.04) was higher in the enucleation group. Enucleation resulted in lower rates of endocrine (pooled OR = 0.22; 95 % CI 0.1-0.5; Z = 3.21; P = 0.001) and exocrine (pooled OR = 0.07; 95 % CI 0.02-0.2; Z = 5.08; P < 0.001) insufficiency. The median 5-year survival was 95 % (range 93-98) and 84 % (range 79-90). CONCLUSIONS: Enucleation appears to be a safe procedure and achieves parenchymal preservation for small pancreatic lesions of low malignant potential. Its oncologic efficacy compared with standardized pancreatic resection with respect to long-term survival and recurrences have not been reported adequately and hence may not be concluded as being comparable.

[REMOTE RESULTS OF SURGICAL TREATMENT IN PATIENTS, SUFFERING LOCALLY SPREAD FORMS OF MALIGNANT PANCREATIC TUMORS].

Remote results of surgical treatment of patients, suffering locally spread forms of pancreatic malignancies (PM), using different approaches, were analyzed. In retrospective investigation were included 84 patients with PM and invasion of the main vessels. In the group І patients palliative operations were performed, including in a subgroup Іа­ cryoablation of PM, in a subgroup Іb ­ palliative pancreatic resection with leaving the tumor on the main vessels intact; and in patients of group ІІ the tumor was resected radically, including in a sub* group ІІа­pancreatic resection or total pancreatectomy with resection of the main vessels, and in subgroup ІІb ­ pancreatic resection or total pancreatectomy with cryoablation of tumor, which was left on the main vessel. The one­year, three­years and five­years survival indices have constituted in a subgroup Іа, accordingly 74, 17 and 0% (survival median 16 mo); in a subgroup Іb ­ 70, 20 and 0% (survival median 20 mo); in a subgroup ІІа ­ 83, 49 and 21% (survival median 29 mo); in a subgroup ІІb ­ 73, 41 and 18% (survival median 26 mo). Difference between the general survival indices in subgroups Іа and ІІа, Іb and ІІа is statistically significant. Application of aggressive surgical tactics have permitted to improve the general survival indices of the patients.

A comprehensive classification of invasive procedures for treating the local complications of acute pancreatitis based on visualization, route, and purpose.

BACKGROUND/AIMS: The lack of a system to classify invasive procedures to treat local complications of acute pancreatitis is an obstacle to comparing interventions. This study aimed to develop and validate a comprehensive multidisciplinary classification. METHODS: Standardized terminology was used to develop a classification of procedures based on three key components: how the lesion is visualized, the route used during the procedure, and the procedure's purpose. Gastroenterologists, radiologists, and surgeons (n = 22) from three New Zealand centers independently classified 15 published technique descriptions. Inter-rater reliability was calculated for each component. The classification's clarity, ease of use, and potential to achieve its objectives were rated on a Likert scale. RESULTS: The classification's clarity, ease of use, and potential to achieve its objectives had median scores of 4/5. Inter-rater reliability for visualization, route, and purpose components was substantial at 0.73 (95% CI 0.63-0.82), 0.79 (95% CI 0.70-0.87), and 0.64 (95% CI 0.53-0.74), respectively. CONCLUSIONS: This article describes the development and validation of a comprehensive classification for the wide range of procedures used to treat the local complications of acute pancreatitis. It has substantial inter-rater reliability and high acceptability, which should enhance communication between clinicians and facilitate comparison between procedures.

Pancreatectomía central en tumores benignos del cuello del páncreas / Central pancreatectomy in benign tumors of the neckof the pancreas

El tratamiento quirúrgico de los tumores benignos del cuello del páncreas ha sido clásicamente la enucleación o la pancreatectomía estándar. La pancreatectomía central se ha propuesto por su menor tasa de complicaciones y por la posibilidad de preservar la función endocrina y exocrina. Entre enero de 1999 y marzo de 2003 se realizaron en nuestro centro 3 pancreatectomías centrales por patología benigna en el cuello del páncreas. En todos los casos se realizó tomografía computarizada, ecografía intraoperatoria y estudio anatomopatológico. El examen de las piezas quirúrgicas mostró 2 cistoadenomas mucinosos y 1 cistoadenoma seroso. Ninguno de los pacientes presentó complicaciones quirúrgicas mayores, recurrencia local de la enfermedad o diabetes, con un seguimiento medio de 34 meses. Podemos decir, por tanto, que la pancreatectomía central es una técnica útil para un grupo seleccionado de pacientes con lesiones benignas en el cuello del páncreas o de bajo grado de malignidad (AU)

The surgical treatment of benign tumors of the neck of the pancreas usually consists of enucleation or formal pancreatectomy. Central pancreatectomy has been put forward because it has fewer major complications and can preserve endocrine and exocrine function. Between January 1999 and march 2003, three patients with benign tumors of the neck of the pancreas underwent central pancreatectomy. all patients underwent computed tomography scans, intraoperative ultrasound and frozen-section analysis. pathologic examination showed two mucinous cystadenomas and one serous cystadenoma. after a mean follow-up of 34 months, none of the patients has shown major complications or local recurrence, or has developed diabetes. In conclusion, central pancreatectomy is a useful technique for selected benign or low-grade malignant pancreatic tumors of the neck of the pancreas (AU)

[The pancreatic segmental classification and segmental resection of the head of the pancreas].

Based on embryologic anatomy and clinical practice, the pancreas can be divided into four segments: the posterior, anterior, medial, and distal segments. The embryologically termed ventral pancreas is now retermed the posterior segment. The posterior segment is drained by the duct of Wirsung, and the anterior segment is drained by the duct of Santorini. According to this segmental classification, independent resection of each segment can be performed systematically. This concept will contribute to establishing more ration and anatomic operative procedures. Recent anatomic study in autopsies has revealed a persistent embryologic fusion plane between the anterior and posterior segments. To establish new operative procedures based on to this pancreatic segmental classification, further investigations on the blood supply of each segment and the embryologic fusion plane are required.

Outcome after surgical resection of intraductal papillary and mucinous tumors of the pancreas.

OBJECTIVE: Treatment of intraductal papillary and mucinous tumors of pancreas (IPMT) usually requires surgery. The objective of this study was to evaluate the risk of recurrence in patients after surgery according to the histological nature of the neoplasm and the type of surgery. METHODS: The outcome of 45 patients who underwent partial pancreatectomy (n = 35) or total pancreatectomy (n = 10) for IPMT was studied according to the nature of the neoplasm (invasive carcinoma or noninvasive neoplasm), type of surgery (partial or total pancreatectomy), and lymph nodes status. RESULTS: The overall 3-yr actuarial survival rate was 83%. Death occurred in seven of 20 (35%) patients with invasive carcinoma and in one of 26 (4%) patients with noninvasive tumors (p<0.05). There were two recurrences in the seven patients with noninvasive neoplasm who underwent partial pancreatectomy with involved resection margins, and none in the 13 patients with disease-free margins. In patients with invasive carcinoma, there was one recurrence after total pancreatectomy, six after partial pancreatectomy with disease-free margins and six after partial pancreatectomy with involved margins. In patients with invasive carcinoma, total pancreatectomy and the absence of lymph nodes involvement were independently associated with a low risk of recurrence. CONCLUSIONS: IPMT may be managed as follows: 1) in patients with noninvasive neoplasms, partial pancreatic resection should be guided by frozen section examination until disease-free margins are obtained; and 2) in patients with invasive carcinoma, total pancreatectomy seems most likely to cure the patient, but should be discussed according to the general status and the age.

Technique of regional subtotal and total pancreatectomy.

The technique of regional pancreatectomy as detailed is divided into five phases. The procedure includes en bloc regional lymph node dissection, peripancreatic soft tissue resection, and resection with reconstruction of the pancreatic segment of portal vein. The pancreatic resection can be subtotal or total.