Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries.

BACKGROUND: Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide. METHODS: This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters. RESULTS: A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries. CONCLUSION: Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Pancreatic surgery can sometimes lead to health problems afterwards. Although some top hospitals report good results, it is not clear how patients are doing all over the world. The aim was to find out how people are recovering after pancreatic surgery in different countries, and to see whether where they live affects their health outcomes after pancreatic surgery. The health records of 4223 patients from 67 countries who had pancreatic surgery in a 3-month interval in 2021 were studied, especially looking at how many people faced serious complications or passed away within 90 days of the surgery. Almost 7 in 10 patients faced some health problems after operation. The chance of having a major health issue or dying after the surgery was higher in countries with fewer resources and less developed healthcare. For example, 10 of 100 patients died after the surgery in these countries, but only 5 of 100 patients did in richer countries. What stands out is that countries with fewer resources have a tougher time getting patients back to health when things go wrong after surgery. It is hoped that doctors and medical groups worldwide can work together to improve these outcomes and give everyone the best chance of recovering well after pancreatic surgery.

Too Fat for Transplant? The Impact of Recipient BMI on Pancreas Transplant Outcomes.

BACKGROUND: In many transplant centers, a recipient body mass index (BMI) >30 kg/m2 would be considered a contraindication for pancreas transplantation. This study aims to investigate the impact of recipient BMI on graft outcomes after pancreas transplantation. METHODS: Retrospective data on all UK solid organ pancreas transplants from 1994 to 2016 were obtained from the National Health Service Blood and Transplant UK Transplant Registry, n = 2618. Cases missing BMI data were excluded, resulting in a final cohort of n = 1452. Graft and patient survival analysis were conducted using Kaplan-Meier plots and Cox regression models. RESULTS: The mean recipient BMI was 24.8 kg/m2 (±2.4). There were 507 overweight (BMI 25-29.9) and 146 obese (>30) recipients receiving pancreas transplants. Univariate analysis showed no statistically significant difference between overweight BMI categories compared with normal BMI (18.5-24.9 kg/m2). Multivariate analysis revealed increasing recipient BMI had a significant impact on graft survival (P = 0.03, hazard ratio 1.04, 95% confidence interval, 1.00-1.08). Receiver operating characteristic curve analyses revealed no value of BMI that provided both specific and sensitive discrimination between death and survival of both grafts or patients. Recipients on dialysis with a BMI >30 kg/m2 had a statistically significant decrease in both graft (P = 0.002) and patient survival (P = 0.015). CONCLUSIONS: Analysis of available UK Pancreas data has shown recipient BMI is an independent risk factor for patient survival after transplantation. However, we have been unable to define a specific cutoff value above which patients have poorer outcomes. Obese patients on hemodialysis had the poorest graft survival, and preemptive transplantation may be beneficial in this cohort.

Nutritional treatment is associated with longer survival in patients with pancreatic disease and concomitant risk of malnutrition.

BACKGROUND: Pancreatic diseases involve complex nutritional challenges. Despite this, conflicting evidence exists regarding the clinical relevance of detecting the risk of malnutrition and implementing systematic nutrition support for these patients. Thus, our aims were to investigate whether screening for malnutrition risk and initiating nutrition support are predictive of mortality for hospitalized patients with pancreatic diseases. DESIGN: From 2008 to 2018, 34 prevalence surveys of nutrition were conducted at Haukeland University Hospital (HUH), Norway. Risk of malnutrition was defined by a score of ≥3 in Nutritional Risk Screening 2002 (NRS 2002). Primary outcomes included overall, one-year, and one-month mortality, and were compared according to malnutrition risk and nutrition support for adult patients with ICD-10 codes of K85: acute pancreatitis, K86: other diseases of pancreas, and C25: malignant neoplasm of pancreas. Length of hospital stay (LOS) was included as a secondary outcome. RESULTS: Of the 283 patients investigated, risk of malnutrition was present in 61.5%. Risk of malnutrition was associated with higher overall mortality (Hazard Ratio (HR) = 1.67, 95% confidence interval (CI): 1.2-2.4, P = 0.003) and one-year mortality (HR = 1.89, 95% CI: 1.2-2.9, P = 0.004) compared to patients not at risk. Not receiving nutrition support for at-risk patients was associated with higher overall mortality (HR = 1.60, 95% CI: 1.1-2.4, P = 0.019) and one-year mortality (HR = 1.64, 95% CI: 1.04-2.6, P = 0.034) compared to patients at risk who received nutrition support. Patients at risk of malnutrition had increased LOS (20.5 nights vs 15.2 nights, P = 0.044) compared to patients not at risk of malnutrition. CONCLUSION: This study of hospitalized patients with pancreatic disease suggests that risk of malnutrition may be associated with higher mortality rates, whereas nutrition support may decrease mortality rates. CLINICAL TRIAL REGISTRY: Not registered.

Identification of genetic loci associated with higher resistance to pancreas disease (PD) in Atlantic salmon (Salmo salar L.).

BACKGROUND: Pancreas disease (PD) is a contagious disease caused by salmonid alphavirus (SAV) with significant economic and welfare impacts on salmon farming. Previous work has shown that higher resistance against PD has underlying additive genetic components and can potentially be improved through selective breeding. To better understand the genetic basis of PD resistance in Atlantic salmon, we challenged 4506 smolts from 296 families of the SalmoBreed strain. Fish were challenged through intraperitoneal injection with the most virulent form of the virus found in Norway (i.e., SAV3). Mortalities were recorded, and more than 900 fish were further genotyped on a 55 K SNP array. RESULTS: The estimated heritability for PD resistance was 0.41 ± 0.017. The genetic markers on two chromosomes, ssa03 and ssa07, showed significant associations with higher disease resistance. Collectively, markers on these two QTL regions explained about 60% of the additive genetic variance. We also sequenced and compared the cardiac transcriptomics of moribund fish and animals that survived the challenge with a focus on candidate genes within the chromosomal segments harbouring QTL. Approximately 200 genes, within the QTL regions, were found to be differentially expressed. Of particular interest, we identified various components of immunoglobulin-heavy-chain locus B (IGH-B) on ssa03 and immunoglobulin-light-chain on ssa07 with markedly higher levels of transcription in the resistant animals. These genes are closely linked to the most strongly QTL associated SNPs, making them likely candidates for further investigation. CONCLUSIONS: The findings presented here provide supporting evidence that breeding is an efficient tool for increasing PD resistance in Atlantic salmon populations. The estimated heritability is one of the largest reported for any disease resistance in this species, where the majority of the genetic variation is explained by two major QTL. The transcriptomic analysis has revealed the activation of essential components of the innate and the adaptive immune responses following infection with SAV3. Furthermore, the complementation of the genomic with the transcriptomic data has highlighted the possible critical role of the immunoglobulin loci in combating PD virus.

Outcome of interventional radiology for delayed postoperative hemorrhage in hepatobiliary and pancreatic surgery.

BACKGROUND AND AIM: Postoperative hemorrhage is a rare but potentially lethal complication of hepatobiliary and pancreatic surgeries. This study aimed to retrospectively evaluate the clinical outcome of patients with delayed postoperative hemorrhage and compare the results according to the surgical procedure. METHODS: Overall, 4220 patients underwent surgery for hepatobiliary and pancreatic diseases. Delayed postoperative hemorrhage (observed more than 24 h postoperatively) occurred in 62 patients. Of these, 61 underwent interventional radiology to achieve hemostasis. Patients' clinical data were analyzed retrospectively. The chi-squared or Fisher's exact test was used in data analysis. RESULTS: A total of 62 patients (1.5%) developed delayed postoperative hemorrhage; 61 (1.4%) of them underwent interventional radiology to achieve hemostasis. Median duration from surgery to interventional radiology was 19 days (range: 5-252 days). Sentinel bleeding was detected in 31 patients; Clinical success was achieved in 54 patients (88.5%) by interventional radiology. Overall mortality rate was 26.2%. Causes of 16 in-hospital deaths were uncontrollable hemorrhage (n = 4) and worsening of general condition after hemostasis (n = 12). Mortality rates were 50.0% (11/22) and 12.8% (5/39) after hepatobiliary surgery and pancreatic resection, respectively. Mortality rate was significantly higher after hepatobiliary surgery than after pancreatic surgery (P = 0.002). CONCLUSIONS: Interventional radiology can be successfully performed to achieve hemostasis for delayed hemorrhage after hepatobiliary and pancreatic surgeries. Because successful interventional radiology does not necessarily lead to survival, particularly after hepatobiliary surgery, meticulous attention to prevent surgical complications and intensive treatments before and after interventional radiology are required to improve outcomes.

Management of Pancreatic Injuries Following Nephrectomy.

BACKGROUND: Pancreatic injuries during nephrectomy are rare, despite the relatively close anatomic relation between the kidneys and the pancreas. The data regarding the incidence and outcome of pancreatic injuries are scarce. OBJECTIVES: To assess the frequency and the clinical significance of pancreatic injuries during nephrectomy. METHODS: A retrospective analysis was conducted of all patients who underwent nephrectomy over a period of 30 years (1987-2016) in a large tertiary medical center. Demographic, clinical, and surgical data were collected and analyzed. RESULTS: A total of 1674 patients underwent nephrectomy during the study period. Of those, 553 (33%) and 294 patients (17.5%) underwent left nephrectomy and radical left nephrectomy, respectively. Among those, four patients (0.2% of the total group, 0.7% of the left nephrectomy group, and 1.36% of the radical left nephrectomy) experienced iatrogenic injuries to the pancreas. None of the injuries were recognized intraoperatively. All patients were treated with drains in an attempt to control the pancreatic leak and one patient required additional surgical interventions. Average length of stay was 65 days (range 15-190 days). Mean follow-up was 23.3 months (range 7.7-115 months). CONCLUSIONS: Pancreatic injuries during nephrectomy are rare and carry a significant risk for postoperative morbidity.

Response of the Salmon Heart Transcriptome to Pancreas Disease: Differences Between High- and Low-Ranking Families for Resistance.

Pancreas disease caused by salmonid alphaviruses leads to severe losses in Atlantic salmon aquaculture. The aim of our study was to gain a better understanding of the biological differences between salmon with high and low genomic breeding values (H-gEBV and L-gEBV respectively) for pancreas disease resistance. Fish from H- and L-gEBV families were challenged by intraperitoneal injection of salmonid alphavirus or co-habitation with infected fish. Mortality was higher with co-habitation than injection, and for L- than H-gEBV. Heart for RNA-seq and histopathology was collected before challenge and at four- and ten-weeks post-challenge. Heart damage was less severe in injection-challenged H- than L-gEBV fish at week 4. Viral load was lower in H- than L-gEBV salmon after co-habitant challenge. Gene expression differences between H- and L-gEBV manifested before challenge, peaked at week 4, and moderated by week 10. At week 4, H-gEBV salmon showed lower expression of innate antiviral defence genes, stimulation of B- and T-cell immune function, and weaker stress responses. Retarded resolution of the disease explains the higher expression of immune genes in L-gEBV at week 10. Results suggest earlier mobilization of acquired immunity better protects H-gEBV salmon by accelerating clearance of the virus and resolution of the disease.

Facing the surgeon's nightmare: Incidence and management of postoperative pancreatic fistulas grade C after pancreaticoduodenectomy based on the updated definition of the International Study Group of Pancreatic Surgery (ISGPS).

BACKGROUND: Postoperative pancreatic fistulas (POPF) grade C represent a rare but feared complication following pancreaticoduodenectomy (PD). They can contribute significantly to postoperative morbidity and mortality. METHODS: We performed a retrospective chart review for all patients who had undergone pancreatic head resection between 2007 and 2016 to identify those who suffered from POPF grade C according to the updated definition of the International Study Group of Pancreatic Surgery (ISGPS). RESULTS: A total of 722 patients underwent PD. Twenty-three patients (3.19%) developed a POPF grade C. Cardiovascular diseases, soft pancreatic texture and main pancreatic duct diameter were identified as risk factors (P < .05). Reoperation was necessary in all affected patients on postoperative day 12 ± 9 on average. Mortality was significantly associated with POPF grade C (P < .05) being present in 39.1% (9/23). CONCLUSIONS: POPF grade C after PD remains a serious complication with a high level of morbidity and mortality. Surgical treatment is the sole curative therapy and thus the treatment of choice.

Robotic-assisted Pancreaticoduodenectomy: Technique Description and Performance Evaluation After 60 Cases.

PURPOSE: Robotic pancreaticoduodenectomy (RPD) remains one of the most challenging abdominal operations. During the implementation of new surgical technologies, safety and efficacy outcomes must be rigorously monitored and the learning curve clearly identified. MATERIALS AND METHODS: The authors investigated their experience during the adoption of RPD, analyzing the outcomes of our first 60 consecutive cases, divided into group A (1 to 30) and group B (31 to 60). The cumulative sum (CUSUM) analysis was used to define the learning curve. RESULTS: The authors observed a reduction in operative time (125 min) and estimated blood loss (185 mL) between the firsts 1 to 30 and the latest 30 cases. The overall rate of complications showed the tendency to decrease during the experience (46.7% vs. 23.3%, P=0.02), conversely, severe complications and the rate of clinically relevant postoperative pancreatic fistula did not show a significant reduction in the incidence (P=0.37 and P=0.67, respectively). The mean number of lymph nodes harvested improved significantly after 30 cases (P=0.004). CONCLUSION: Surgical performance improved significantly after the first 30 cases.

Outcomes After Minimally-invasive Versus Open Pancreatoduodenectomy: A Pan-European Propensity Score Matched Study.

OBJECTIVE: To assess short-term outcomes after minimally invasive (laparoscopic, robot-assisted, and hybrid) pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) among European centers. BACKGROUND: Current evidence on MIPD is based on national registries or single expert centers. International, matched studies comparing outcomes for MIPD and OPD are lacking. METHODS: Retrospective propensity score matched study comparing MIPD in 14 centers (7 countries) performing ≥10 MIPDs annually (2012-2017) versus OPD in 53 German/Dutch surgical registry centers performing ≥10 OPDs annually (2014-2017). Primary outcome was 30-day major morbidity (Clavien-Dindo ≥3). RESULTS: Of 4220 patients, 729/730 MIPDs (412 laparoscopic, 184 robot-assisted, and 130 hybrid) were matched to 729 OPDs. Median annual case-volume was 19 MIPDs (interquartile range, IQR 13-22), including the first MIPDs performed in 10/14 centers, and 31 OPDs (IQR 21-38). Major morbidity (28% vs 30%, P = 0.526), mortality (4.0% vs 3.3%, P = 0.576), percutaneous drainage (12% vs 12%, P = 0.809), reoperation (11% vs 13%, P = 0.329), and hospital stay (mean 17 vs 17 days, P > 0.99) were comparable between MIPD and OPD. Grade-B/C postoperative pancreatic fistula (POPF) (23% vs 13%, P < 0.001) occurred more frequently after MIPD. Single-row pancreatojejunostomy was associated with POPF in MIPD (odds ratio, OR 2.95, P < 0.001), but not in OPD. Laparoscopic, robot-assisted, and hybrid MIPD had comparable major morbidity (27% vs 27% vs 35%), POPF (24% vs 19% vs 25%), and mortality (2.9% vs 5.2% vs 5.4%), with a fewer conversions in robot-assisted- versus laparoscopic MIPD (5% vs 26%, P < 0.001). CONCLUSIONS: In the early experience of 14 European centers performing ≥10 MIPDs annually, no differences were found in major morbidity, mortality, and hospital stay between MIPD and OPD. The high rates of POPF and conversion, and the lack of superior outcomes (ie, hospital stay, morbidity) could indicate that more experience and higher annual MIPD volumes are needed.

Association between Aortic Calcification, Cardiovascular Events, and Mortality in Kidney and Pancreas-Kidney Transplant Recipients.

BACKGROUND: Cardiovascular (CV) disease is the leading cause of death in kidney and simultaneous pancreas-kidney (SPK) transplant recipients. Assessing abdominal aortic calcification (AAC), using lateral spine x-rays and the Kaupilla 24-point AAC (0-24) score, may identify transplant recipients at higher CV risk. METHODS: Between the years 2000 and 2015, 413 kidney and 213 SPK first transplant recipients were scored for AAC at time of transplant and then followed for CV events (coronary heart, cerebrovascular, or peripheral vascular disease), graft-loss, and all-cause mortality. RESULTS: The mean age was 44 ± 12 years (SD) with 275 (44%) having AAC (26% moderate: 1-7 and 18% high: ≥8). After a median of 65 months (IQR 29-107 months), 46 recipients experienced CV events, 59 died, and 80 suffered graft loss. For each point increase in AAC, the unadjusted hazard ratios (HR) for CV events and mortality were 1.11 (95% CI 1.07-1.15) and 1.11 (1.08-1.15). These were similar after adjusting for age, gender, smoking, transplant type, dialysis vintage, and diabetes: aHR 1.07 (95% CI 1.02-1.12) and 1.09 (1.04-1.13). For recipients with high versus no AAC, the unadjusted and fully-adjusted HRs for CV events were 5.90 (2.90-12.02) and 3.51 (1.54-8.00), for deaths 5.39 (3.00-9.68) and 3.38 (1.71-6.70), and for graft loss 1.30 (0.75-2.28) and 1.94 (1.04-3.27) in age and smoking history-adjusted analyses. CONCLUSION: Kidney and SPK transplant recipients with high AAC have 3-fold higher CV and mortality risk and poorer graft outcomes than recipients without AAC. AAC scoring may be useful in assessing and targeted risk-lowering strategies.

Regional versus metropolitan pancreaticoduodenectomy mortality in Australia.

BACKGROUND: This retrospective, population-based cohort study aims to determine if differences in the regional distribution of procedures or variation in regional mortality contributes to the variable pancreaticoduodenectomy (PD) mortality between Australian states and territories. METHODS: De-identified procedural data from public hospitals between 1 July 2005 and 30 June 2015 from the Australian Institute of Health and Welfare were analysed. The regional distribution of procedures and variation in perioperative mortality rate (POMR) were investigated in New South Wales (NSW), Victoria and Queensland (QLD) using logistic regression analysis. RESULTS: NSW performed the highest proportion of city-based procedures (93.8%) while QLD performed the highest proportion of regional procedures (15.3%). QLD demonstrated the lowest city mortality (1.9%) and lowest POMR overall (2.0%). City, regional and state-wide mortality was highest in NSW (5.0%, 8.4% and 5.3%). No significant difference in POMR was demonstrated between regional and city hospitals in each of the states (P = 0.46) or across all states (P = 0.50). CONCLUSION: This study demonstrates comparable regional PD distribution across Australia. The difference in PD POMR between city and regional areas was not found to be statistically significant. NSW exhibited the highest city, regional and overall PD POMR, potentially warranting further investigation.

Short-term outcomes of pancreaticoduodenectomy in the state of Victoria: hospital resources are more important than volume.

BACKGROUND: Pancreaticoduodenectomy (PD) is a high-risk procedure. Australian hospitals perform a relatively low volume of PD. This study sought to gain an understanding of hospital volume and short-term outcomes of the procedure in the Australian state of Victoria. METHODS: The Dr Foster Quality Investigator tool was used to interrogate the Victorian Admitted Episodes Database for the Australian Classification of Health Intervention code for PD (30584) from July 2010 to June 2016. The data set included patients from a peer group of 14 hospitals that included all the public hospitals performing PD during this period. Patient characteristics, inpatient mortality, 30-day readmission rates and median length of stay were reported for each de-identified hospital. RESULTS: There were 547 PD conducted over 6 years in 10 public hospitals. The median patient age was 65 years. Inpatient mortality was 2.7%. There was a significant risk adjusted difference in mortality between principal referral and other public hospitals. Annual hospital volume ranged from 3 to 20 PD, and there was no significant relationship between mortality, readmission rates or length of stay and hospital volume. CONCLUSION: The inpatient mortality associated with PD in Victorian public hospitals is comparable to that seen in overseas studies. While hospital volume is relatively low, there does not seem to be a relationship between volume and short-term outcomes. Variability between hospital peer groups suggests that resource availability is more important than volume. The development of a procedure specific registry would be useful to test the outcomes of this study and determine long-term PD outcomes.

Endoscopic retrograde cholangiopancreatography (ERCP): lessons learned from population-based national registries: a systematic review.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) was introduced more than four decades ago as a diagnostic tool for biliary and pancreatic diseases. Currently, ERCP is mainly used as a therapeutic approach to relieve biliary or pancreatic duct obstruction. Clinical practice has been based on a few large reports and some randomized controlled trials. These data are valuable and important, but the external validity of these reports is limited. Implementation into routine practice should be balanced with the knowledge that these studies were conducted under very specific circumstances. This review was undertaken to describe ERCP results from population-based national registries recorded during routine clinical practice. METHODS: A systematic literature search of the electronic databases Medline Ovid and Embase was conducted. Eligible papers were selected and data were recorded according to the PRISMA criteria. RESULTS: Thirty-one studies were included: 15 true national population-based and 16 population-level studies. Most studies originated from countries with a governmental public health care system. At least three-quarters of the ERCP procedures are currently therapeutic, and the technical success rate is high (> 90%). The postprocedure 30-day mortality rate ranged between 1 and 5% and was strongly correlated with older age, male sex, emergency admission, and noncancer comorbidities, but exhibited a lower correlation with the annual ERCP volume. Patients with primary sclerosing cholangitis or liver cirrhosis should receive particular attention. The risk of developing a bile duct, liver, or pancreas malignancy after ERCP tended to increase, but endoscopic sphincterotomy did not affect this risk. CONCLUSION: ERCP is currently mainly used as a therapeutic approach, and the results are generally likely to improve patients' conditions. A nationwide registry enables better monitoring of routine clinical practice. The collection of valuable information from routine clinical practice in population-based databases may help to improve patient care from best evidence to best practice.

Outcomes of Infected versus Symptomatic Sterile Walled-Off Pancreatic Necrosis Treated with a Minimally Invasive Therapy.

Background/Aims: Acute pancreatitis complicated by walled-off necrosis (WON) is associated with high morbidity and mortality, and if infected, typically necessitates intervention. Clinical outcomes of infected WON have been described as poorer than those of symptomatic sterile WON. With the evolution of minimally invasive therapy, we sought to compare outcomes of infected to symptomatic sterile WON. Methods: We performed a retrospective cohort study examining patients who were undergoing dual-modality drainage as minimally invasive therapy for WON at a high-volume tertiary pancreatic center. The main outcome measures included mortality with a drain in place, length of hospital stay, admission to intensive care unit, and development of pancreatic fistulae. Results: Of the 211 patients in our analysis, 98 had infected WON. The overall mortality rate was 2.4%. Patients with infected WON trended toward higher mortality although not statistically significant (4.1% vs 0.9%, p=0.19). Patients with infected WON had longer length of hospitalization (29.8 days vs 17.3 days, p<0.01), and developed more spontaneous pancreatic fistulae (23.5% vs 7.8%, p<0.01). Multivariate analysis showed that infected WON was associated with higher odds of spontaneous pancreatic fistula formation (odds ratio, 2.65; 95% confidence interval, 1.20 to 5.85). Conclusions: This study confirms that infected WON has worse outcomes than sterile WON but also demonstrates that WON, once considered a significant cause of death, can be treated with good outcomes using minimally invasive therapy.

Robotic pancreatic surgery: old concerns, new perspectives.

BACKGROUND: Described for the first time in 2003, the robotic pancreatic surgery shows interesting results. The evaluation of post-operative outcomes is necessary once we describe an innovative surgical approach. METHODS: We have performed a retrospective analysis of a prospectively maintained database on robotic pancreatic surgery including malignant and benign indications for surgery. RESULTS: A total of 50 consecutive patients underwent robotic pancreatic surgery (26 pancreatico duodenectomy and 24 distal pancreatectomy) between January 2012 and July 2015 in a single centre. The overall operative time was 425 (390-620) min. In a subgroup of highly selected malignant tumours, we were able to achieve 88% of R0 resection with robotic approach. A number of lymphnodes rose significantly with growing experience (p = .025). The overall major complication rate (15%), as well as pancreatic fistula rate (16%) were acceptable. The two-year overall survival for the whole group was 65%. CONCLUSION: The robotic pancreatic surgery in a highly selected group of patients seems safe and feasible. The cost-effectiveness and long-term oncologic outcomes need further investigations.

Increased dietary protein-to-lipid ratio improves survival during naturally occurring pancreas disease in Atlantic salmon, Salmo salar L.

This study demonstrated that increased dietary protein-to-lipid ratio (P/L-ratio) improved survival of farmed Atlantic salmon naturally affected by pancreas disease (PD). In addition to diet, body weight (BW) and delousing mortality prior to the PD outbreak also contributed significantly (p < 0.05) to explain the observed variation in PD-associated mortality. Subsequent to the PD outbreak, large amount of fish failed to grow and caused thin fish with poor condition (runts). At the end of the trial, significantly (p < 0.05) lower amounts of runt fish and increased amount of superior graded fish where detected among fish fed increased P/L-ratio and within the fish with the largest BWs prior to PD. Diet, BW and delousing mortality contributed significantly (p < 0.05) to explain the variation in the amount of superior graded fish, whereas BW and diet explained the variation in the amount of runt fish. A significant (p < 0.01) negative linear relationship was observed between the amount of superior graded fish and the total mortality, whereas a positive linear relationship was detected between percentage of fillets with melanin and the total mortality. Thus, increased dietary P/L-ratio seem to reduce the mortality and impaired slaughter quality associated with PD.

African-Americans and Indigenous Peoples Have Increased Burden of Diseases of the Exocrine Pancreas: A Systematic Review and Meta-Analysis.

Ethnic health disparity is a well-acknowledged issue in many disease settings, but not diseases of the exocrine pancreas. A systematic review and meta-analysis was conducted to explore the race- and ethnicity-specific burden of diseases of the exocrine pancreas. Studies that compared health-related endpoints between two or more ethnicities were eligible for inclusion. Proportion meta-analyses were conducted to compare burden between groups. A total of 42 studies (24 on pancreatic cancer, 17 on pancreatitis, and one on pancreatic cyst) were included in the systematic review, of which 19 studies were suitable for meta-analyses. The incidence of pancreatic cancer was 1.4-fold higher among African-Americans, while the incidence of acute pancreatitis was 4.8-fold higher among an indigenous population (New Zealand Maori) compared with Caucasians. The prevalence of post-pancreatitis diabetes mellitus was up to 3.0-fold higher among certain ethnicities, including Asians, Pacific Islanders, and indigenous populations compared with Caucasians. The burden of diseases of the exocrine pancreas differs between ethnicities, with African-Americans and certain indigenous populations being at the greatest risk of developing these diseases. Development of race- and ethnicity-specific screening as well as protocols for lifestyle modifications may need to be considered with a view to reducing the disparities in burden of diseases of the exocrine pancreas.

Non-inferiority of open passive drains compared with closed suction drains in pancreatic surgery outcomes: A prospective observational study.

BACKGROUND: Policies concerning the management of operatively placed drains after pancreatic surgery are still under debate. Open passive drains and closed-suction drains are both used currently in clinical practice worldwide, but there are no reliable data regarding potential differences in the postoperative outcomes associated with each drain type. The aim of the present study was to compare open passive drains and closed-suction drains with regard to postoperative contamination of the drainage fluid and overall morbidity and mortality. METHODS: This study was a prospective, observational analysis of 320 consecutive, standard, partial resections (pancreaticoduodenectomy and distal pancreatectomy at a single institution from April 2016 to April 2017. Either open passive drains (n = 189, 51%) or closed-suction drains (n = 131) were used according to the operating surgeon's choice. Postoperative outcomes, including samples of drainage fluid collected on postoperative day V and sent for microbiologic analysis, were registered. RESULTS: The open passive drain and closed-suction drain cohorts did not differ in terms of their clinical features, use of neoadjuvant chemotherapy or preoperative biliary drainage, fistula risk zone, and type of operative procedure. The overall rate of postoperative day V drainage fluid contamination (27.5% vs. 20.6%, P = .1) was similar between the groups. The same results were obtained for each specific procedure. The postoperative outcomes, namely, overall 30-day morbidity, postoperative pancreatic fistula, intra-abdominal fluid collections, percutaneous drainage, wound infections, reintervention, mean duration of hospital stay, and mortality did not differ between the 2 groups. Qualitative microbiologic analysis revealed that after pancreaticoduodenectomy, 61.5% of the bacteria contaminating the drainage fluid were attributable to human gut flora, while after distal pancreatectomy, 84.8% of the bacteria belonged to skin and mucous flora (P < .01), however, the spectrum of bacterial contamination did not significantly differ between the open passive drain and closed-suction drain cohorts. CONCLUSION: The use of open passive drains and closed-suction drains for major pancreatic resection does not significantly impact the postoperative outcome. The spectrum of drain contamination depends on the specific operative procedure rather than on the type of drain used.

Robotic Versus Laparoscopic Pancreaticoduodenectomy: a NSQIP Analysis.

BACKGROUND: An increasing body of literature is supporting the safety of minimally invasive pancreaticoduodenectomy compared to open pancreaticoduodenectomy, but there are limited comparative studies between laparoscopic and robotic pancreaticoduodenectomy. The aim of this study was to compare the rate of postoperative 30-day overall complications between laparoscopic and robotic pancreaticoduodenectomy. METHODS: Patients who underwent laparoscopic and robotic pancreaticoduodenectomy were abstracted from the 2014-2015 pancreas-targeted American College of Surgeons National Surgical Quality Improvement Program. A multivariable logistic regression model was developed to determine if the type of minimally invasive approach was associated with 30-day overall complications. RESULTS: We identified 428 minimally invasive pancreaticoduodenectomy cases, of which 235 (55%) were performed laparoscopically and 193 (45%) robotically. Patients who underwent the robotic approach were more likely to be white compared to those who underwent the laparoscopic approach and were less likely to have pulmonary disease, undergo preoperative radiotherapy, and have vascular and multivisceral resection. On multivariable analysis, we found that the type of minimally invasive approach, whether laparoscopic or robotic, was not associated with overall complications. The predictors of 30-day overall complications were higher body mass index (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.09), vascular resection (OR, 2.10; 95% CI, 1.23-3.58), and longer operative time (OR, 1.002; 95% CI, 1.001-1.004). CONCLUSIONS: Robotic pancreaticoduodenectomy was associated with a similar 30-day overall complication rate to laparoscopic pancreaticoduodenectomy. Further studies are needed to corroborate these findings and to establish the best approach to perform this complex operation.