The impact of preoperative anemia on pancreatic resection outcomes.

BACKGROUND: Preoperative anemia is a risk factor for blood transfusions and delayed postoperative recovery, but few data are available for pancreatic surgery. Aim of the study was to analyze the impact of preoperative anemia on outcomes after pancreatic resection. METHODS: Retrospective review of 1107 patients resected at San Raffaele Hospital (2015-2018). Preoperative anemia was defined as hemoglobin lower than 130 g/L for men and 120 g/L for women. Primary outcome was 90-day comprehensive complication index (CCI). Analysis was stratified according to type of surgery; proximal resections (pancreaticoduodenectomy and total pancreatectomy) versus distal pancreatectomy. RESULTS: In 776 proximal resection patients, preoperative anemia was associated with increased CCI (24 ± 25 vs. 19 ± 23, p = 0.018) and perioperative allogenic blood transfusions (n = 124, 46% vs. n = 129, 26%; p < 0.001). Multivariate analysis showed that anemia was associated with a 7% (95%CI 0.02-0.57 p = 0.047) increase in CCI, and was an independent factor associated with perioperative blood transfusion (OR 2.762, 95%CI 1.72-4.49, p < 0.001). In 331 distal pancreatectomies, anemia was not associated to increased morbidity but only to an increased risk of perioperative blood transfusion. CONCLUSION: Preoperative anemia is an independent risk factor for increased complication severity and blood transfusion in patients undergoing major pancreatic resection.

Preoperative predictive factors of laparoscopic distal pancreatectomy difficulty.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is a challenging operation due to technical complexity and tumor-related factors. Aim of this study was to identify preoperative risk factors affecting LDP difficulty. METHODS: Consecutive patients who underwent LDP between 2015 and 2018 at San Raffaele Hospital and Policlinico S.Orsola-Malpighi Hospital were enrolled retrospectively. Three variables were used to define surgical difficulty: conversion to open, duration of surgery >3rd quartile and intraoperative blood loss >3rd quartile. The presence of ≥1 of these 3 variables was considered as another measure of difficulty. RESULTS: Overall, 191 patients were included. Conversion to open was required in 25 patients (13%). At multiple regression analysis, tumor proximity to major vessels was the only independent predictor of conversion from laparoscopic to open (p < 0.001). No variables independently predicted an excessive duration of surgery. Male gender (p = 0.033) and increasing parenchymal thickness at resection line (p = 0.018) were independent predictors of excessive blood loss. Increasing parenchymal thickness at resection line (p = 0.014) and tumor proximity to major vessels (p = 0.002) were significant risk factors for the presence of ≥1 outcome of surgical difficulty. CONCLUSION: Male gender, increasing parenchymal thickness at resection line and tumor proximity to major vessels represent preoperative risk factors of LDP difficulty.

Prognostic role of ultrasonography staging in patients with anal cancer.

BACKGROUND: Carcinomas of the anal canal are staged according to the size and extent of the disease; however, we propose including a novel ultrasound (US) staging system, based on depth of tumor invasion. In this study the clinical American Joint Committee on Cancer (AJCC) staging guidelines and the US classificationss in patients with anal cancer were compared. AIM: To evaluate the prognostic role of the US staging system in patients with anal cancer. METHODS: The data of 48 patients with anal canal squamous cells carcinoma, observed at our University Hospital between 2007 and 2017, who underwent pre-treatment assessment with pelvic magnetic resonance imaging (MRI), total body computed tomography (CT) scan and endoanal US were retrospectively reviewed. Anal canal tumors were clinically staged according to AJCC, determined by MRI by measurement of the longest tumor diameter, and CT scan. Endoanal US was performed with a high multi-frequency (9-16 MHz), 360° rotational mechanical probe; US classification was based on depth of tumor penetration through the anal wall, according to Giovannini's study. All patients were treated with definitive radiation combined with 5-fluorouracile and Mitomycin-C. After treatment patients were followed-up regularly. RESULTS: At baseline there were 30 and 32 T1-2, 18 and 16 T3-4, 31 and 19 N+ patients classified according to the clinical AJCC and US staging system respectively. After a mean follow-up of 98 months, 38 patients (79.1%) are alive and 28 (58.3%) are disease free. During follow up 20 patients (41.6%) experienced recurrences. After univariate analysis, American Society of Anesthesiologists (ASA) score (P = 0.00000001) and US staging (P = 0.009) were significantly related to disease-free survival (DFS). When overall survival and DFS functions were compared, a statistically significant difference was observed for DFS survival when the US staging was applied with respect to the clinical AJCC staging. By combining the 2 significant prognostic variables, namely the US staging with the ASA score, four risks groups with different prognoses were identified. CONCLUSION: Our findings suggest that US staging may be superior to traditional clinical staging, since it is significantly associated with DFS in anal cancer patients.