Outcome of superior mesenteric-portal vein resection during pancreatectomy for borderline ductal adenocarcinoma: results of a prospective comparative study.

BACKGROUND: Approximately 20 % of patients affected by pancreatic ductal adenocarcinoma are amenable to surgical resection. Several tumours are reported as "borderline resectable" because of their proximity to the major vessels. In the effort to achieve a radical tumour removal, vein resection has been proposed, but its oncological benefits remain debated. METHODS: Our aim is to investigate morbidity, mortality and survival after pancreatectomy with vein resection. RESULTS: Forty patients underwent pancreatectomy and vein resection (group A), and 20 patients (group B) underwent bilio-enteric and/or gastro-entero bypass. In group A, cancer vein invasion was microscopically proven in 14 cases (35 %). Vein infiltration, tumour differentiation and node-positive disease were not adverse prognostic variables. No difference in survival was seen over a 1-year follow-up. After this period, group A showed significant survival benefits with a longer stabilisation of the disease (p = 0.005). Tumour-free resection margins and adjuvant chemoradiotherapy were the most important prognostic factors (p < 0.05). CONCLUSIONS: Suspicion of vein infiltration should not be a contraindication to resection. Pancreatectomy can be safely performed with an acceptable morbidity and better survival trend.

Long-term results of Frey's procedure for chronic pancreatitis: a longitudinal prospective study on 40 patients.

Only limited prospective data are available regarding the long-term outcome of local resection of the pancreatic head in combination with longitudinal pancreaticojejunostomy in patients with chronic pancreatitis. From 1997 to 2001, 40 patients affected by chronic pancreatitis were subjected to the Frey's procedure. Preoperative selection criteria included confirmed diagnosis of chronic pancreatitis, dilation of Wirsung's duct to a diameter greater than 6 mm, and the absence of obstructive chronic pancreatitis secondary to fibrotic stenosis at the pancreatic body or tail. Preoperative pain was present in 38 cases (95%), and follow-up was performed in all patients at least once yearly up to 2003 (median 60 months, inter percentile range 20.1-79.6). Postoperative morbidity occurred in three cases (7.5%). The percentage of pain-free patients was 94.7%, 93.7%, 87.5%, and 90% at 1, 2, 3, and 4/5 years after surgical operation, respectively. After surgery, three patients developed diabetes. Both the body mass index and quality of life showed statistically significant improvements at all follow-up intervals. Whenever surgery is indicated, the short-term and long-term outcomes confirm that Frey's procedure is an appropriate means of management for patients with chronic pancreatitis in the absence of doubts of neoplasia and/or distal ductal obstruction.

Assessment of a complication risk score and study of complication profile in laparoscopic distal pancreatectomy.

OBJECTIVE: This study assessed the patient-specific risk for major postoperative morbidity in a series of 100 laparoscopic distal pancreatectomies (LDP). METHODS: A previously established complication risk score (CRS), identifying body mass index (BMI), estimated blood loss (EBL), and pancreatic specimen length as determinants of postoperative morbidity were examined against the observed outcomes. In addition, multivariate analyses were performed to investigate risk factors specific to our study population. RESULTS: The postoperative morbidity rate was 49 %, major complication accounted for 12 %, and clinically relevant pancreatic fistulae (PF) were 13 %. The incidence of any complications, major complications, any PF, and clinically relevant PF did not vary appreciably when the CRS increased. The multivariate analysis indicated that male sex and an EBL ≥150 mL were independent predictors of major morbidity and clinically relevant PF. CONCLUSION: In conclusion, the previously published CRS based on pre- and intraoperative factors was not able to predict the postoperative risk in our population. This is probably because risk scores may not be able to adjust for the case-mix (heterogeneity in baseline patient characteristics). According to our data, men and patients with EBL ≥150 mL are more likely to develop major postoperative complications after LDP.

Drain management after pancreatic resection: state of the art.

BACKGROUND: Placement of intraperitoneal drain (ID) after abdominal surgery is a common practice. Postoperative pancreatic fistula (POPF), incidence of which ranges from 2% to more than 30%, represents the most common major complication after pancreatic resection. The goal of this paper is to review the state of the art in ID management after pancreatic resection. METHODS: Data from randomized controlled trials (RCT) are reported together with data from our institution in the period before and after the start of the two reported RCTs. RESULTS: One thousand five hundred eighty patients underwent surgical resection for pancreatic lesions at our institution from 1990 to 2010. The overall rate of POPF was 23% before and 19.5% after (p = 0.24) the performance of the RCTs. Both postoperative morbidity and average in-hospital stay were higher in the period before the RCTs (13.6 ± 11.4 versus 13.4 ± 10.3 days, respectively). CONCLUSIONS: POPF is a complex and multifactorial complication after pancreatic surgery. On the basis of the present results and review of the RCTs, the value of ID and its management after pancreatic surgery remain unclear.

Complications after pancreaticoduodenectomy: the problem of current definitions.

Pancreaticoduodenectomy nowadays represents a complex procedure and a challenge for the surgeon. Even though mortality is reported to be below 5% for experienced surgeons, morbidity is still around 30%-50%, often leading to prolongation of hospital stay, demanding postoperative investigations and procedures, and outpatient monitoring of the patients with complications. In the literature there is no agreement on the definitions of postoperative complications following pancreaticoduodenectomy, leading to a wide range of complication rates in different specialist units, particularly regarding the source of every complication, postoperative pancreatic fistula, and others such as delayed gastric emptying. Some authors have demonstrated that applying different definitions in homogeneous, single-center series, the incidence of a complication varied with statistical significance, implying the impossibility of correctly comparing different experiences. It seems essential to organize a Consensus Meeting among expert surgeons to prepare world-wide accepted definitions. The aim of this article is to review the current controversial definitions and to suggest a new clinical-based approach to the problem of the feasibility and reliability of the definitions themselves.

Pancreatic fistula rate after pancreatic resection. The importance of definitions.

BACKGROUND: Pancreatic fistula (PF) is still regarded as a serious complication both in terms of frequency and sequelae. The incidence varies greatly in different reports because of the different definitions used. The aim of this study was to compare several definitions of PF encountered in the current literature and to demonstrate that the PF rate in the same group of patients treated in a high volume center is dependent upon the definition applied. METHODS: A Medline search of the last 10 years was performed as regards the definition of PF. A score was assigned to the reproducible definitions based upon two basic parameters: daily output (cm3) and duration of the fistula represented by the number of days between the postoperative day of onset and the duration of the complication. Four definitions were formulated and were then applied to a group of 242 patients that underwent pancreatic head or intermediate resections with pancreatico-jejunal anastomosis in our Pancreatic Unit between November 1996 and December 2000. Statistical analysis was carried out using the Yates correct chi2 test with statistical significance set at p < 0.05. RESULTS: Among 26 different definitions identified, 14 were found suitable for the applied score. We formulated four final definitions summarizing the current concepts of PF. The incidence of PF ranged between 9.9 and 28.5% according to the different definitions applied with highly statistical differences between them. CONCLUSIONS: The PF rate after pancreatic resections is strictly dependent upon the definition used. An overall general agreement for an internationally accepted definition is urgently needed to correctly compare different experiences.