Validating biologic age in selecting elderly patients with pancreatic cancer for surgical resection.

BACKGROUND AND OBJECTIVES: Selecting frail elderly patients with pancreatic cancer (PC) for pancreas resection using biologic age has not been elucidated. This study determined the feasibility of the deficit accumulation frailty index (DAFI) in identifying such patients and its association with surgical outcomes. METHODS: The DAFI, which assesses frailty based on biologic age, was used to identify frail patients using clinical and health-related quality-of-life data. The characteristics of frail and nonfrail patients were compared. RESULTS: Of 242 patients (median age, 75.5 years), 61.2% were frail and 32.6% had undergone pancreas resection (surgery group). Median overall survival (mOS) decreased in frail patients (7.13 months, 95% confidence interval [CI]: 5.65-10.1) compared with nonfrail patients (16.1 months, 95% CI: 11.47-34.40, p = 0.001). In the surgery group, mOS improved in the nonfrail patients (49.4%; 49.2 months, 95% CI: 29.3-79.9) compared with frail patients (50.6%, 22.1 months, 95% CI: 18.3-52.4, p = 0.10). In the no-surgery group, mOS was better in nonfrail patients (54%; 10.81 months, CI 7.85-16.03) compared with frail patients (66%; 5.45 months, 95% CI: 4.34-7.03, p = 0.02). CONCLUSIONS: The DAFI identified elderly patients with PC at risk of poor outcomes and can identify patients who can tolerate more aggressive treatments.

Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients.

BACKGROUND: While emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown. METHODS: ACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DP - distal pancreatectomy, PD - pancreaticoduodenectomy, or TP- total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of > 4 units RBCs in 72 h prior to resection. Chi-square tests, Fisher's exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types. RESULTS: Of 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p < 0.001) for emergent vs. elective operations. Emergent operations resulted in increased transfusion rates (47.6% vs. 23.4%, p < 0.001), return to OR (14.0% vs. 5.6%, p < 0.001), organ-space infection (14.6 vs. 10.5, p = 0.002), unplanned intubation (9.% vs. 4.1%, p < 0.001), pneumonia (9.6% vs. 4.2%, p < 0.001), length of stay (14 days vs. 8 days, p < 0.001), and discharge to skilled facility (31.1% vs. 13.9%). These differences persisted when stratified by pancreatic resection type. The 30-day operative mortality was higher in the emergent group (9.4%vs. 2.7%, p < 0.001) and highest for emergent TP (20%). CONCLUSION: Emergent pancreatic resection is markedly uncommon in the setting of neoplastic disease. Although these operations result in increased morbidity and mortality compared to elective resections, they can be life-saving in specific circumstances. The results of this large series of modern era national data may assist surgeons as well as patients and their families in making critical decisions in select cases of acutely complicated neoplastic disease.

Influence of sarcopenia in major pancreatic surgery. A systematic review of the literature.

Post-operative morbidity of pancreatectomies occurs in up to 40-50% of patients, even in modern series. There is a need to find a simple scale in order to identify patients with increased risk of developing major post-operative complications after pancreatic resections. Many studies have been published on sarcopenia and surgical outcomes. Aspects of sarcopenia are presented, along with a systematic review using PRISMA guidelines, in order to search for articles about sarcopenia and pancreatic surgery. The impact of sarcopenia on morbidity and mortality in pancreatic resections is still unclear. The studies presented have been carried out over long periods of time, and many of them compare patients with different diseases. There are also different definitions of sarcopenia, and this can influence the results, as some of the reviewed articles have already shown. It is necessary to unify criteria, both in the definition and in the cut-off values. Prospective studies and consensus on sarcopenia diagnosis should be achieved.

Outcome and prognosis after pancreatectomy in patients with solid pseudopapillary neoplasms.

BACKGROUND: Solid pseudopapillary neoplasms (SPN) are rare and represent approximately 4% of all cystic pancreatic tumors. The prognosis is excellent, although 10-15% of SPN patients show metastasis at the time of surgery or tumor recurrence during follow-up after pancreatectomy. Aim of the study was to analyze surgical management, risk factors for malignancy as well as long-term outcome and prognosis of this distinct tumor entity. METHOD: All patients with pancreatic resection for SPN between 10/2001 and 07/2018 in the authors' institution were identified from a prospective database. Clinicopathologic details, perioperative data and long-term follow-up results were retrospectively analyzed. RESULTS: Fifty-two patients were identified, 44 (85%) of them were female and the median age was 29 years (IQR 9-71). Seven (13%) patients showed a malignant behaviour of SPN with N1 (n = 2) or M1 (n = 1) disease at resection; 5 patients developed tumor recurrence, after a median of 21 months. During follow-up time (median 54 months) all patients were alive, the 5- and 10-year rates for disease-free survival were 89.0% and 81.6%, respectively. Significant risk factors for recurrence were age <18 years (p = 0.0087) and parenchyma-preserving surgical approaches (p = 0.0006). The postoperative long-term outcome showed ECOG = 0-1 in all patients, with resection related exocrine insufficiency in 20 (41%) and diabetes mellitus in 2 (4%) patients. CONCLUSIONS: Age < 18 years is a significant risk factor for malignancy in SPN, and parenchyma preserving resections harbor a significant risk for tumor recurrence. As recurrence may occur late, a systematic life-long follow-up should be performed.

Outcome after surgery for solid pseudopapillary pancreatic tumors in children: Report from the TREP project-Italian Rare Tumors Study Group.

BACKGROUND: Solid pseudopapillary pancreatic tumors (SPPT) are an extremely rare entity in pediatric patients. Even if the role of radical surgical resection as primary treatment is well established, data about follow-up after pancreatic resection in children are scant. METHODS: A retrospective review of data from the Italian Pediatric Rare Tumor Registry (TREP) was performed. Short-term (<30 days) and long-term complications of different surgical resections, as well as long-term follow-up were evaluated. RESULTS: From January 2000 to present, 43 patients (male:female = 8:35) were enrolled. The median age at diagnosis was 13.2 years (range, 7-18). Nine children had an incidental diagnosis, whereas 26 complained of abdominal pain and 4 of palpable mass. Tumors arose either from the head of pancreas (n = 14) or from body/tail (n = 29): only one patient presented with metastatic disease. Resection was complete in all patients (cephalic duodenopancreatectomy vs distal resection). At follow-up (median, 8.4 years; range, 0-17 years), one recurrence occurred in a patient with intraoperative rupture. All patients are alive. Three pancreatic fistulas occurred in the body/tail group, whereas four complications occurred in the head group (one ileal ischemia, two stenosis of the pancreatic duct, and one chylous fistula). CONCLUSION: Surgery is the best therapeutic option for these tumors; hence, complete resection is mandatory. Extensive resections, including cephalic duodenopancreatectomy, are safe when performed in specialized centers. Long-term follow-up should be aimed to detect tumor recurrence and to evaluate residual pancreatic function.

Usefulness of indocyanine green-fluorescence imaging for real-time visualization of pancreas neuroendocrine tumor and cystic neoplasm.

We evaluated the usefulness of fluorescence imaging using indocyanine green to identify pancreas tumors in 23 patients undergoing pancreas resection. This technique was useful in visualizing pancreas lesions during surgery, specifically, neuroendocrine tumors as fluorescence and cystic neoplasms as a fluorescence defect.

Management implications of resection margin histology in patients undergoing resection for IPMN: A meta-analysis.

INTRODUCTION: IPMN is a relatively new clinical entity and surgeons are continuing to develop their understanding of this complex pathology. Little is known of the natural disease process post-resection of an IPMN, particularly the impact of gland histology and margin status on the chance of recurrence and survival in benign and invasive IPMN. METHODS: An online search was conducted to evaluate and include those studies which reported on gland histology, margin status and disease recurrence in resected benign and malignant IPMN. A Meta analysis was then performed using a random effects model. RESULTS: The chance of recurrence in non-invasive margin positive IPMN is similar to margin negative IPMN. The chance of recurrence is higher in invasive gland IPMN compared to non-invasive gland. The vast majority of recurrences occurred in patients with positive margins demonstrating invasion. CONCLUSION: All patients with intra- or post-operative evidence of invasive carcinoma at the resection margin should undergo further resection to achieve a negative margin. Patients with evidence of IPMN at the transaction margin (even with changes of high grade dysplasia/CIS) may not achieve any benefit from further resection. Patients with recurrence in benign/non-invasive IPMN should undergo re-resection, whereas patients with recurrence in invasive IPMN should not.

Laparoscopic distal pancreatectomy for pancreatic cancer: an overview of evaluation and treatment strategies.

Background: Laparoscopic distal pancreatectomies (LDP) confer benefits over open distal pancreatectomies (ODP). These benefits extend to patients with known malignancies. Despite being a common procedure for pancreatic surgeons, widespread adoption of minimally invasive approaches is still not universal. Improved understanding of the benefits of LDP as well as operative steps can help further spread the use of minimally invasive techniques. Methods: The authors present their approach to LDP with an emphasis on anatomy, intraoperative technique, and pearls/pitfalls. A brief historical overview of the development of LDP and landmark studies is also included. Results: Review of milestones along the evolution of LDP are presented, showcasing the controversies and advantages that are associated with the procedure. Current perspectives and society recommendations are also discussed. Operative steps of LDP are described via the "clockwise technique". This technique outlines a step-wise method that includes wide mobilization for adequate exposure, slow compression of pancreatic parenchyma, and other important pearls such as patient positioning and operative planning. Conclusions: Proper understanding of LDP is crucial to maximizing positive outcomes from the operation. Further education on technical pearls can help increase use of minimally invasive approaches to distal pancreatic resection for cancer.

Minimally Invasive Pancreas Surgery: Is There a Benefit?

Minimally invasive procedures minimize trauma to the human body while maintaining satisfactory therapeutic results. Minimally invasive pancreas surgery (MIPS) was introduced in 1994, but questions regarding its efficacy compared to an open approach were widespread. MIPS is associated with several perioperative advantages while maintaining oncological standards when performed by surgeons with a robust training regimen and frequent practice. Future research should focus on addressing learning curve discrepancies while identifying factors associated with shortening the time needed to attain technical proficiency.

The power of suction: Theory and practice in closed suction vs gravity drains and postoperative pancreatic fistulas.

BACKGROUND: Postoperative pancreatic fistula (POPF) is a feared complication in pancreatic resection. Gravity drainage (GD) is hypothesized to reduce POPF versus closed-suction drainage (CSD). We sought to evaluate this theory. METHODS: Six-hundred-twenty-nine patients undergoing pancreatic resection between 2013 and 2020 were analyzed with multivariable logistic regression for the outcomes of POPF and clinically-relevant POPF (crPOPF). RESULTS: Three-hundred-ninety-seven patients (63.1%) underwent pancreaticoduodenectomy and 232 (36.9%) underwent distal pancreatectomy. Suction drains were placed in 588 patients (93.5%) whereas 41 (6.5%) had GDs. One-hundred-twenty-five (27.6%) experienced a POPF; 49 (10%) crPOPFs. On multivariable analysis, suction drainage was not associated with increased risk of POPF (OR 0.76, 95% CI 0.30-1.93, P = 0.57) or crPOPF (OR 0.99, 95% CI 0.30-3.26, P = 0.98). CONCLUSION: Suction drainage does not promote POPF when compared to GDs. Drain type should be determined by surgeon preference, while taking into account nursing and patient-specific considerations especially when patients are discharged with drains.

Invasive giant pancreatic desmoid-type fibromatosis with curative resection: A case report.

INTRODUCTION: Desmoid-type Fibromatoses (DTF) tumours are rare, benign fibrous tumours with aggressive invasive behaviour that account for approximately 0.03% of all neoplasms. We report the success in curing a rare, invasive, and huge pancreatic intraabdominal DTF. PRESENTATION OF CASE: A 42 years old male was medically free apart from recurrent left upper abdominal pain, anorexia, and nausea for more than ten years and no significant past surgeries, trauma, or family history of cancer. The patient has a non-tender large abdominal mass at the left hypochondria area extending down to the pelvis below the umbilicus with a rigid and smooth surface. The computed tomography scan showed a huge heterogeneous mass appears to be of pancreatic origin, measuring about 23 cm by 15 cm by 11 cm. The patient underwent radical antegrade modular pancreato-splenectomy, segmental transverse colectomy, adrenalectomy, and subsequent colo-colic anastomosis. The accurate gross size of the tumour specimen was 26 × 17 × 9 cm, and the weight was found to be 3.6 kg. Immunohistochemistry confirmed the diagnosis of pancreas DTF. The follow up to 5 years confirmed no recurrence reported clinically or by imaging. DISCUSSION: The Pancreas origin of DTF is a rarely reported subset with an incidence of around 5% of all DTF. Establishing the diagnosis is fundamentally based on the characteristic pathological and immunohistochemical studies, for the only available cure modality by complete radical resection to be promptly offered. CONCLUSION: Our case is rare and uniquely the largest pancreatic DTF reported in the literature with curative resection despite being locally invasive.

Comparison of Clinical Outcomes of Single-Incision Versus Conventional Multiport Laparoscopic Distal Pancreatectomy: A Single Institution Experience.

OBJECTIVES: Single-incision laparoscopic procedures have been gaining popularity in recent years due to their minimal incisional morbidity and improved cosmetic outcomes. Herein, we will compare the feasibility and outcomes of single-incision and conventional multiport laparoscopic distal pancreatectomy. METHODS: This study involves consecutive patients who underwent either single-incision or conventional multiport laparoscopic distal pancreatectomy from March 2007 to February 2014. The patients were divided into two groups, based on the surgical approach: single-incision laparoscopic surgery (Group 1) and conventional multiport laparoscopic surgery (Group 2). The parameters evaluated included estimated blood loss, operative time, postoperative pain, duration of hospital stay, complications, conversion, and final pathology. RESULTS: There were a total of 20 patients, 10 in each study group. Baseline characteristics were similar, and there was no mortality in either of the groups. The low-flow pancreatic fistula was the most commonly seen morbidity, but it was ceased spontaneously in each group by a ratio of 30%. The operative time was significantly shorter in Group 2, with a mean of 116 minutes versus a mean of 180 minutes for Group 1 (p<0.001). One of the procedures in Group 2 was converted to open surgery due to peroperative bleeding. The median follow-up periods of the patients were 22 months and 56 months. The spleen was preserved in only 1 patient from Group 1, whereas in Group 2, the spleen preservation was achieved in 5 patients. CONCLUSION: The single-incision laparoscopic technique is a safe and effective alternative to standard laparoscopic distal pancreatectomy.

[Perioperative antibiotic prophylaxis for pancreas resections with and without preoperative bile drainage : Is there room for improvement?] / Perioperative Antibiotikaprophylaxe bei Pankreasresektionen mit und ohne präoperative Galleableitung : Gibt es Verbesserungspotenzial?

BACKGROUND: Whether an immediate surgical treatment or preoperative bile drainage (PBD) should be performed in cases of obstructive jaundice caused by a pancreatic carcinoma has been a matter of controversy for decades. The aim of this study based on in-house patient data was to evaluate both the influence of PBD on septic complications and to analyze intraoperative bile samples in patients with PBD in order to formulate current recommendations for antibiotic treatment. MATERIAL AND METHODS: Relevant data from all pancreatic resections performed in this hospital from January 2013 to December 2017 were collected in a prospective database and were retrospectively analyzed. Depending on the presence of a PBD the collected data were checked for postoperative complications. In addition, the spectrum of bacteria on bile duct swabs was analyzed in patients with PBD and the sensitivity to ampicillin-sulbactam was tested according to the resistogram. Subsequently, an antibiotics recommendation for the practice was compiled. RESULTS: Within the period under consideration 197 pancreas resections were performed in this hospital, 122 of which were duodenopancreatectomies and 20 total pancreatectomies (n = 142). A PBD was performed in 28.2% (40/142) of the patients. There were no significant differences in mortality, intra-abdominal abscesses, post-pancreatectomy hemorrhages (PPH) or postoperative pancreatic fistulas (POPF) depending on a PBD. On the other hand, a significantly higher rate of postoperative wound infections was found in patients with PBD (+PBD 18/40, 45.0% vs. -PBD 13/102, 12.7%, P < 0.0001). Bacteriobilia was found in 86.8% (33/38) of patients with PBD. In 47.4% (18/38) of patients with PBD at least 1 detected bacterium of the bile duct culture was not sensitive to ampicillin-sulbactam. Regarding the antibiotics piperacillin-tazobactam 8 patients (21%) and ciprofloxacin or imipenem 4 patients each (10.5%) showed a bacterium with resistance. CONCLUSION: In general, the indications for a PBD should be strictly applied. If a PBD needs to be performed, perioperative antibiosis should be optimized to minimize subsequent complications. A hospital adjusted perioperative antibiotic prophylaxis should be developed and preoperatively obtained swab results, e. g. within endoscopic retrograde cholangiopancreatography (ERCP) can be used to increase the effectiveness of perioperative antibiotics. Based on an internal analysis of intraoperative bile duct swabs, ciprofloxacin is used in this hospital for the perioperative antibiotic treatment of patients with PBD.

Minimally Invasive Techniques for Resection of Pancreatic Neuroendocrine Tumors.

Surgical resection remains the treatment of choice for primary pancreatic neuroendocrine tumors (PNETs), because it is associated with increased survival. Minimally invasive procedures are a safe modality for the surgical treatment of PNETs. In malignant PNETs, laparoscopy is not associated with a compromise in terms of oncologic resection, and provides the benefits of decreased postoperative pain, better cosmetic results, shorter hospital stay, and a shorter postoperative recovery period. Further prospective, multicenter, randomized trials are required for the analysis of these minimally invasive surgical techniques for the treatment of PNETs and their comparison with traditional open pancreatic surgery.

Laparoscopic surgery for benign and malign diseases of the digestive system: indications, limitations, and evidence.

The laparoscopic technique was introduced in gastrointestinal surgery in the mid 1980s. Since then, the development of this technique has been extraordinary. Triggered by technical innovations (stapling devices or coagulation/dissecting devices), nowadays any type of gastrointestinal resection has been successfully performed laparoscopically and can be performed laparoscopically dependent on the patient's condition. This summary gives an overview over 30 years of laparoscopic surgery with focus on today's indications and evidence. Main indications remain the more common procedures, e.g., appendectomy, cholecystectomy, bariatric procedures or colorectal resections. For all these indications, the laparoscopic approach has become the gold standard with less perioperative morbidity. Regarding oncological outcome there have been several high-quality randomized controlled trials which demonstrated equivalency between laparoscopic and open colorectal resections. Less common procedures like esophagectomy, oncological gastrectomy, liver and pancreatic resections can be performed successfully as well by an experienced surgeon. However, the evidence for these special indications is poor and a general recommendation cannot be given. In conclusion, laparoscopic surgery has revolutionized the field of gastrointestinal surgery by reducing perioperative morbidity without disregarding surgical principles especially in oncological surgery.

Laparoscopic distal pancreatectomy: up-to-date and literature review.

Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffusion. Additional researches are necessary to determine the best technique to improve the procedure results.

Combined vascular reconstruction in the treatment of chronic pancreatitis with lump in the head / 国际外科学杂志

Objective To discuss the necessity and rationality of regional pancreatoduodenectomy combined vas-cular reconstruction in the treatment of chronic pancreatitis with lump in the head. Methods Thirteen patients who suffered from pancreas with lump in the head, were operated in our department from January 2000 to March 2006. The clinical data were analyzed retrospectively,there were 10 men and 3 women with an age ranging from 37 to 71 (mean = 51 ), all the patients underwent pancreatoduodenectomy combined PV and SMV reconstruction. Results All thirteen patients were pathologically confirmed chronic pancreatitis without postoperative deaths, in which stom-ach empty disorder and pancreatic fistula occurred and were cured conservatively in one case. All the 13 patients who were followed up 19～86 months had no pain and jaundice at all after the operation. Conclusion Combined vascular reconstruction to treat the lump in the head of the pancreas that packages blood vessel and hard to separa-tion is proved to be a safe and reliable method, being capable of raising lump resection rate, which can improve quality of life of patients remarkably to avoid omit minimum cancer in lump to result in lose the curative opportunity.