Perioperative Outcomes of Pancreaticoduodenectomy Compared to Total Pancreatectomy for Neoplasia

Purpose

Total pancreatectomy (TP) eliminates the risk and morbidity of pancreatic leak after pancreaticoduodenectomy (PD). However, TP is a more extensive procedure with guaranteed endocrine and exocrine insufficiency. Previous studies conflict on the net benefit of TP.

Methodology

A comparison of patients undergoing non-emergent, curative-intent TP or PD for pancreatic neoplasia using the National Surgical Quality Improvement Project data from 2005–2011 was done. Main outcome measures were mortality and major and minor morbidities.

Results

Of the 6,314 (97 %) who underwent PD and the 198 (3 %) who underwent TP, malignancy was present in 84 % of patients. The two groups were comparable at baseline. Mortality was higher after TP (6.1 %) than DP (3.1 %), p?=?0.02. Adjusting for differences on multivariable analysis, TP carried increased mortality (OR 2.64, 95 % CI 1.3–5.2, p?=?0.005). TP was also associated with increased rates of major morbidity (38 vs. 30 %, p?=?0.02) and blood transfusion (16 vs. 10 %, p?=?0.01). Infectious and septic complications occurred equally in both groups.

Conclusion

The morbidity of a pancreatic fistula can be eliminated by TP. However, based on our findings, TP is associated with increased major morbidity and mortality. TP cannot be routinely recommended for to reduce perioperative morbidity when pancreaticoduodenectomy is an appropriate surgical option.     

Laparoscopic versus open distal pancreatectomy: a clinical and cost-effectiveness study

Background

Laparoscopic distal pancreatectomy (LDP) is being increasingly performed with some concerns regarding the cost of the minimally invasive approach. The purpose of this study was to assess the cost-effectiveness of LDP versus open distal pancreatectomy (ODP).

Methods

A retrospective clinical and cost-comparison analysis was performed for patients who underwent LDP vs. OPD between 2005 and 2011. Data considered for the comparison analysis were: operative costs (surgical procedure, operative time, blood transfusions), postoperative costs (laboratory testing, hospital stay, complication management, readmissions), and overall costs.

Results

Fifty-one distal pancreatectomies (laparoscopic?=?35, open?=?16) were performed during the study period. The median operative time was 200 (range, 120–420) min for LDP vs. 225 (range, 120–460) min for ODP (p?=?0.93). Median blood loss was 200 (range, 50–900) mL for LDP vs. 394 (range, 75–2000) mL for ODP (p?=?0.038). Median hospital stay was 7 (range, 3–25) days in the laparoscopic group vs. 11 (range, 5–46) days in the open group (p?=?0.007). Complication rate was 40% for LDP vs. 69% in ODP (p?=?0.075). Postoperative intervention was required in 11% of patients after LDP vs. 31% after ODP (p?=?0.12). The average operative, postoperative, and overall cost was ￡6039 (range, ￡4276–￡9500), ￡4547 (range, ￡1299–￡13937), ￡10587 (range, ￡6508–￡20303) vs. ￡5231 (range, ￡3409–￡9330), ￡10094 (range, ￡2665–￡39291), ￡15324 (range, ￡7209–￡47484) for the LDP and ODP groups, respectively (p?=?0.033; p?=?0.006; p?=?0.197).

Conclusions

We showed that LDP is feasible and safe without having a negative impact on cost. Extensive experience in pancreatic and laparoscopic surgery is required to optimize surgical outcomes.     

Is it worthwhile to preserve adult spleen in laparoscopic distal pancreatectomy? Perioperative and patient-reported outcome analysis

Background

Despite the emphasis on its role, the spleen has commonly been removed in distal pancreatectomy. We designed this study to evaluate the efficacy of spleen salvage during laparoscopic distal pancreatectomy for patients with benign and borderline malignant tumors.

Materials and methods

From February 2005 to December 2010, 40 patients underwent spleen-preserving laparoscopic distal pancreatectomy (Sp-Lap DP) and 32 patients underwent laparoscopic distal pancreatosplenectomy (Lap DPS). Medical records were retrospectively reviewed, and a specially designed questionnaire was administered to the patients for the follow-up study.

Results

The demographics and final diagnoses were similar between the two groups. The operative time was significantly longer in the Sp-Lap DP group (303.9?±?136.0 versus 239.0?±?94.9?min, p?=?0.024). Patients in the Lap DPS group had more postoperative pancreatic fistulas of higher grade (p?=?0.026). A higher grade of postoperative complications occurred more frequently in the Lap DPS group (p?=?0.003). Consequently, postoperative hospital stay was significantly shorter for Sp-Lap DP than for Lap DPS patients (7.1?±?2.3 versus 12.5?±?10.8?days, p?=?0.004). On the follow-up survey, episodes of common cold or flu were apparently more frequent in the Lap DPS group (p?=?0.026). Despite the similar recovery period between the two groups, significantly more patients who underwent Lap DPS felt fatigue (p?=?0.014) and poorer health condition (p?=?0.042).

Conclusions

In addition to frequent higher-grade complications and prolonged hospital stays, Lap DPS appeared to impair patient quality of life based on follow-up survey. Even an effort to preserve adult spleen in distal pancreatectomy is worthwhile.     

Pulmonary Resection for Isolated Pancreatic Adenocarcinoma Metastasis: an Analysis of Outcomes and Survival

Objectives

This study was conducted to determine if pulmonary metastasectomy (PM) for isolated pancreatic cancer metastases is safe and effective.

Methods

This was a retrospective case?Ccontrol study of patients undergoing PM at our institution from 2000 to 2009 for isolated lung metastasis after resection for pancreatic cancer. Clinical and pathologic data were compared with a matched reference group. Resected neoplasms were immunolabeled for the Dpc4 protein. Kaplan?CMeier analysis compared overall survival and survival after relapse.

Results

Of 31 patients with isolated lung metastasis, 9 underwent 10 pulmonary resections. At initial pancreas resection, all patients were stage I or II. Other baseline characteristics were similar between the two groups. Median time from pancreatectomy to PM was 34 months (interquartile range 21?C49). During the study, 29/31(90.6%) patients died. There were no in-hospital mortalities or complications after PM. Median cumulative survival was significantly improved in the PM group (51 vs. 23 months, p?=?0.04). There was a trend toward greater 2-year survival after relapse in the PM group (40% vs. 27%, p?=?0.2).

Conclusions

In patients with isolated lung metastasis from pancreatic adenocarcinoma, this is the first study to show that pulmonary resection can be performed safely with low morbidity and mortality. The improved survival in the PM group may result in part from selection bias but may also represent a benefit of the procedure.     

Randomized Controlled Single-Center Trial Comparing Pancreatogastrostomy Versus Pancreaticojejunostomy After Partial Pancreatoduodenectomy

Background

The aim of this single-center randomized trial was to compare the perioperative outcome of pancreatoduodenectomy with pancreatogastrostomy (PG) vs pancreaticojejunostomy (PJ).

Methods

Randomization was done intraoperatively. PG was performed via anterior and posterior gastrotomy with pursestring and inverting seromuscular suture; control intervention was PJ with duct?Cmucosa anastomosis. The primary endpoint was postoperative pancreatic fistula (POPF).

Results

From 2006 to 2011, n?=?268 patients were screened and n?=?116 were randomized to n?=?59 PG and n?=?57 PJ. There was no statistically significant difference regarding the primary endpoint (PG vs PJ, 10?% vs 12?%, p?=?0.775). The subgroup of high-risk patients with a soft pancreas had a non-significantly lower pancreatic fistula rate with PG (PG vs PJ, 14 vs 24?%, p?=?0.352). Analysis of secondary endpoints demonstrated a shorter operation time (404 vs 443?min, p?=?0.005) and reduced hospital stay for PG (15 vs 17?days, p?=?0.155). Delayed gastric emptying (DGE; PG vs PJ, 27 vs 17?%, p?=?0.246) and intraluminal bleeding (PG vs PJ, 7 vs 2?%, p?=?0.364) were more frequent with PG. Mortality was low in both groups (<2?%).

Conclusions

Our randomized controlled trial shows no difference between PG and PJ as reconstruction techniques after partial pancreatoduodenectomy. POPF rate, DGE, and bleeding were not statistically different. Operation time was significantly shorter in the PG group.     

Outcomes following radical cystectomy for micropapillary bladder cancer versus pure urothelial carcinoma: a matched cohort analysis

Purpose

Micropapillary (MP) bladder cancer is a rare variant of urothelial carcinoma (UC) which has been associated with an aggressive natural history. We sought to report the outcomes of patients with MP bladder cancer treated with radical cystectomy (RC) and compare survival to patients with pure UC of the bladder.

Methods

We identified 73 patients with MP bladder cancer and 748 patients with pure UC who underwent RC at our institution with median postoperative follow-up of 9.6?years. MP patients were stage-matched 1:2 to patients with pure UC. Survival was estimated using the Kaplan?CMeier method and compared with the log-rank test.

Results

MP cancers were associated with a high rate of adverse pathologic features, as 48/73 patients (66?%) had pT3/4 tumors and 37 (50?%) had pN+ disease. Ten-year cancer-specific survival in MP patients was 31?%, compared with 53?% in the overall cohort with pure UC (p?=?0.001). When patients with MP bladder cancer were then stage-matched to those with pure UC, no significant differences between the groups were noted with regard to 10-year local recurrence-free survival (62 vs. 69?%; p?=?0.87), distant metastasis-free survival (44 vs. 56?%; p?=?0.54), or cancer-specific survival (31 vs. 40?%; p?=?0.41).

Conclusion

MP cancers are associated with a higher rate of locally advanced disease. However, when matched to patients with pure UC, patients with MP tumors did not have increased local/distant recurrence or adverse cancer-specific survival following RC.     

Short-Term but Not Long-Term Loss of Patency of Venous Reconstruction During Pancreatic Resection Is Associated with Decreased Survival

Background

Pancreatic surgery with vascular reconstruction is increasingly performed to offer the benefits of surgical resection to patients with locally advanced disease. The short- and long-term patency rates and the clinical significance of thrombosis of such reconstructions are unknown.

Methods

We reviewed pancreatectomies requiring venous reconstruction from 1994 to 2011. We sought to identify predictors of acute (within 30 days) and late thrombosis. We compared survival of patients with thrombosis to patients with patent reconstructions.

Results

Of 203 pancreatectomies requiring venous reconstruction, acute thrombosis occurred in nine (4.4 %) cases and was associated with increased perioperative mortality (22.2 versus 4.6 %, p?=?0.023). Even when nonfatal, acute thrombosis was associated with decreased median survival (7.1 versus 15.9 months, p?=?0.011) and increased hazard of death (hazard ratio 8.6, confidence interval 3.7–19.9, p?<?0.001). A late loss of patency was seen in 31.2 % of cases at a median of 9.5 months. Later loss of patency was not associated with decreased median survival or increased hazard of death.

Conclusions

Acute thrombosis of the portal venous reconstructions after pancreatectomy is associated with increased perioperative mortality and, even when nonfatal, is associated with decreased survival. Late loss of patency occurs in one-third of patients but does not affect survival.     

Preoperative Chemotherapy Does Not Adversely Affect Pancreatic Structure and Short-Term Outcome after Pancreatectomy

Background

Preoperative chemotherapy (PCHT) has recently been proposed also in patients with resectable pancreatic adenocarcinoma. Few data are currently available on the impact of PCHT on short-term postoperative outcome after pancreatic resection. The objective of this study is to assess the impact of PCHT on pancreatic structure and short-term outcome after surgical resection.

Methods

Fifty consecutive patients successfully underwent resection after PCHT. Each patient was matched with two control patients with pancreatic adenocarcinoma selected from our prospective electronic database. Match criteria were age (±3 years), gender, American Society of Anesthesiologist score, type of resection, pancreatic duct diameter (±1 mm), and tumor size (±5 mm). Primary endpoint was morbidity rate. Secondary endpoints were pancreatic parenchymal structure, mortality rate, and length of hospital stay (LOS).

Results

Both degree of fibrosis and fatty infiltration of the pancreas were similar in the two groups. Overall morbidity rate was 48.0 % in the PCHT group vs. 54.0 % in the control group (p?=?0.37). Pancreatic fistula rate was 18.0 % in the PCHT group vs. 25.0 % in the control group (p?=?0.41). Mortality was 4.0 % in the PCHT group vs. 2.0 % in the control group (p?=?0.60). Mean LOS (days) was 12.7 in the PCHT group vs. 12.4 in the control group (p?=?0.74). There was no difference in resection margin status, while the rate of patients without nodal involvement was higher in the PCHT group (46.0 vs. 23.0 %, p?=?0.004).

Conclusion

PCHT did not induce significant structural changes in pancreatic parenchyma and did not adversely affect short-term outcome after surgery.     

Obesity, But Not High-Fat Diet, Promotes Murine Pancreatic Cancer Growth

Background

Obesity accelerates pancreatic cancer growth; the mechanisms underlying this association are poorly understood. This study evaluated the hypothesis that obesity, rather than high-fat diet, is responsible for accelerated pancreatic cancer growth.

Methods

Male C57BL/6J mice were studied after 19?weeks of high-fat (60?% fat; n?=?20) or low-fat (10?% fat; n?=?10) diet and 5?weeks of Pan02 murine pancreatic cancer growth (flank).

Results

By two-way ANOVA, diet did not (p?=?0.58), but body weight, significantly influenced tumor weight (p?=?0.01). Tumor weight correlated positively with body weight (R ²?=?0.562; p?<?0.001). Tumors in overweight mice were twice as large as those growing in lean mice (1.2?±?0.2?g vs. 0.6?±?.01?g, p?<?0.01), had significantly fewer apoptotic cells than those in lean mice (0.8?±?0.4 vs 2.4?±?0.5; p?<?0.05), and greater adipocyte volume (3.7 vs. 2.2?%, p?<?0.05). Apoptosis (R ²?=?0.472; p?=?0.008) and serum adiponectin correlated negatively with tumor weight (R?=?0.45; p?<?0.05).

Conclusions

These data suggest that body weight, and not high-fat diet, is responsible for accelerated murine pancreatic cancer growth observed in this model of diet-induced obesity. Decreased tumor apoptosis appears to play an important mechanistic role in this process. The concept that decreased apoptosis is potentiated by hypoadiponectinemia (seen in obesity) deserves further investigation.     

Stapler and Nonstapler Closure of the Pancreatic Remnant After Distal Pancreatectomy: Multicenter Retrospective Analysis of 388 Patients

Background

The pancreatic fistula rate following distal pancreatectomy ranges widely, from 13.3 to 64.0?%. The optimal closure method of the pancreatic remnant remains controversial, especially regarding whether to use a stapler.

Methods

All patients who underwent distal pancreatectomy in five Japanese hospitals from January 2001 to June 2009 were included in this study. All relevant, anonymized medical records were entered into an electronic case report form. Complications and pancreatic fistulas were classified according to the Clavien–Dindo classification and the International Study Group of Pancreatic Surgery grading system, respectively.

Results

Of the 388 patients, stapler closure and nonstapler closure were used after distal pancreatectomy in 224 patients (57.7?%) and 164 patients (42.3?%), respectively. Clinically relevant pancreatic fistulas (grades B and C) occurred in 47 patients (21.0?%) treated by stapler closure, which was a significantly lower rate than that for the 83 patients (50.6?%) treated by nonstapler closure. There were no surgical mortalities or in-hospital deaths. The distribution of postoperative complications was grade 1, 30.7?% (n?=?119); grade 2, 40.2?% (n?=?156); grade 3a, 0.1?% (n?=?5); grade 3b, 0.3?% (n?=?1); grade 4a, 0.3?% (n?=?1). In the multivariate analysis, diabetes mellitus, previous laparotomy, operating time, and method of stump closure were found to be independently associated with the development of a clinical pancreatic fistula.

Conclusions

Stapler closure is a safe, efficient alternative to standard suture closure techniques because the clinical fistula rate is significantly lower.     

Pancreatic Enucleation: Improved Outcomes Compared to Resection

Introduction

Pancreatic enucleation is associated with a low operative mortality and preserved pancreatic parenchyma. However, enucleation is an uncommon operation, and good comparative data with resection are lacking. Therefore, the aim of this analysis was to compare the outcomes of pancreatic enucleation and resection.

Material and Methods

From 1998 through 2010, 45 consecutive patients with small (mean, 2.3 cm) pancreatic lesions underwent enucleation. These patients were matched with 90 patients undergoing pancreatoduodenectomy (n = 38) or distal pancreatectomy (n = 52). Serious morbidity was defined in accordance with the American College of Surgeons?CNational Surgical Quality Improvement Program. Outcomes were compared with standard statistical analyses.

Results

Operative time was shorter (183 vs. 271 min, p < 0.01), and operative blood loss was significantly lower (160 vs. 691 ml, p < 0.01) with enucleation. Fewer patients undergoing enucleation required monitoring in an intensive care unit (20% vs. 41%, p < 0.02). Serious morbidity was less common among patients who underwent enucleation compared to those who had a resection (13% vs. 29%, p = 0.05). Pancreatic endocrine (4% vs. 17%, p = 0.05) and exocrine (2% vs. 17%, p < 0.05) insufficiency were less common with enucleation. Ten-year survival was no different between enucleation and resection.

Conclusion

Compared to resection, pancreatic enucleation is associated with improved operative as well as short- and long-term postoperative outcomes. For small benign and premalignant pancreatic lesions, enucleation should be considered the procedure of choice when technically appropriate.     

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.     

Preoperative Chemoradiation for Pancreatic Adenocarcinoma Does Not Increase 90-Day Postoperative Morbidity or Mortality

Background

The impact of preoperative chemoradiation on postoperative morbidity and mortality of patients with pancreatic adenocarcinoma remains controversial.

Methods

Consecutive pancreatectomies for adenocarcinoma performed between 2011 and 2015 were prospectively monitored for 90 days by using a previously reported surveillance system to determine the association between preoperative chemoradiation and adverse events, pancreatic fistulae, readmissions, and mortality.

Results

Among 209 consecutive patients who underwent pancreatectomy, 159 (76 %) experienced at least one adverse event within 90 postoperative days. Patients who received preoperative chemoradiation (n?=?137, 66 %) were more likely to have borderline resectable/locally advanced tumors, to have received induction chemotherapy, and to require vascular resection at pancreatectomy than those who did not receive chemoradiation (all P?<?0.05). Nonetheless, there were no significant differences in the rates of severe complications, readmission, or mortality between these groups (all P?>?0.05). Among patients who underwent pancreatoduodenectomy, the rate of pancreatic fistula was similar between those who received chemoradiation and those who did not (P?=?0.96). In contrast, those who received chemoradiation prior to distal pancreatectomy had a lower rate of pancreatic fistula (P?<?0.01).

Conclusion

Preoperative chemoradiation is not associated with an increase in 90-day morbidity or mortality, and it may reduce the rate of pancreatic fistula following distal pancreatectomy.

     

Neo-adjuvant Chemoradiation Therapy Using S-1 Followed by Surgical Resection in Patients with Pancreatic Cancer

Objective

The aim of this study was to compare short-term surgical results in pancreatic cancer patients who underwent surgical resection after neo-adjuvant chemoradiation therapy (NACRT) using S-1.

Methods

The study population comprised 77 patients with pancreatic cancer between 2006 and 2010. Out of 34 patients who underwent staging laparoscopy between 2008 and 2010, 31 patients without occult distant organ metastasis underwent chemoradiation and of whom 30 underwent pancreatectomy (NACRT group). Of the other 43 patients, 36 underwent surgical resection in 2006?C2008, followed by adjuvant therapy (adjuvant group). The primary endpoint was frequency of pathological curative resection (R0).

Results

The new regimen of NACRT was feasible and safe. Twenty-eight of 30 (93%) patients in the NACRT group had R0 resection, which was significantly higher than in the adjuvant group (21 of 36 patients, 58%, p?=?0.005). The number and extent of metastatic lymph nodes in the NACRT group (1 (0?C25), N0/1; 18 of 38) was significantly lower than in the adjuvant group (2 (0?C19), N0/1; 23 of 30), p?=?0.0363). The frequency of intractable ascites in the NACRT group (eight of 30) was significantly higher than in the adjuvant group (two of 36, p?=?0.035).

Conclusion

Neo-adjuvant chemoradiation therapy using S-1 followed by pancreatectomy can improve the rate of pathologically curative resection and reduces the number and extent of lymph node metastasis.     

Osteopontin Expression is Associated with Improved Survival in Patients with Pancreatic Adenocarcinoma

Background

Osteopontin (OPN) is a secreted protein of the extracellular matrix. It has been used as a marker for tumor aggressiveness and correlated with clinical outcomes in several solid tumors, such as liver, lung, and breast. We determined the OPN expression and its influence on survival in patients with resected pancreatic adenocarcinoma.

Methods

Tissue microarrays were constructed from 245 resected pancreatic adenocarcinomas. Immunohistochemical staining for OPN was undertaken and compared to normal pancreas (n?=?12). OPN expression was then correlated with patient demographics, tumor size, grade, node, and margin status. Survival curves were created by the Kaplan?CMeier method and compared by log rank analysis.

Results

In total, 181 (74?%) of pancreatic adenocarcinoma tissues expressed OPN compared to 7 (58?%) of normal controls (p?=?0.004). Expression was observed predominantly in the cytoplasm of the tumor cells. The median and 2?year overall survival was longer when OPN was expressed (17.1 vs. 11.6?months, and 38 vs. 24?%, respectively, p?=?0.04). Multivariate analysis showed OPN expression and T stage to be independent predictors of overall survival, while other histopathologic factors such as tumor grade, tumor size, and nodal status were not.

Conclusions

These results suggest that the presence of OPN expression in pancreatic adenocarcinoma may have a protective effect independent of tumor stage. This emphasizes the importance of the interaction between pancreatic cancer cells and their stromal elements.     

Laparoscopic appendectomy as a teaching procedure: experiences with 1197 patients in a community hospital

Purpose

Since laparoscopic procedures have become more common, resident surgeons have to learn complex laparoscopic skills at an early stage of their career. The aim of this study was to compare the short-term clinical outcome parameters of laparoscopic appendectomy (LA) performed by resident surgeons (RS) or attending surgeons (AS).

Methods

A total of 1197 LA and 57 open appendectomies were performed in a Swiss community hospital between 1999 and 2009. RS performed 684 operations. Parameters including the duration of the operation and hospital stay, intraoperative complications, surgical reinterventions, and a 30-day morbidity and mortality were observed.

Results

The mean age of the patients was 35.6?±?18.17?years. The duration of the operation was longer (61.34?±?25.73?min [RS] vs. 53.65?±?29.89 [AS]?min; p?=?0.0001), but the hospital stay was shorter, in patients treated by RS (3.92?±?2.61?days [RS] vs. 4.87?±?3.23 [AS]?days; p?=?0.0001). The rate of intraoperative complications was not significantly different between the two groups (1.02?% [RS] vs. 0.8?% [AS]; p?=?0.6). The need for surgical reintervention (0.6?% [RS] vs. 2.5?% [AS]; p?=?0.005) and the 30-day morbidity were higher in patients treated by AS (3.7?% [AS] vs. 1.8?% [RS]; p?=?0.04). There was no postoperative mortality.

Conclusions

Under appropriate supervision, surgical residents are able to perform LA with results comparable to those of experienced surgeons.     

Right Hepatectomy in Patients over 70 Years of Age: An Analysis of Liver Function and Outcome

Background

As a consequence of the increase in life expectancy, hepatobiliary surgeons have to deal with an emerging aged population. We aimed to analyze the liver function and outcome after right hepatectomy (RH) in patients over 70?years of age.

Methods

From January 2006 to December 2009, we prospectively collected data of 207 consecutive elective hepatectomies. In patients who had RH, cardiac risk was assessed by a dedicated preoperative workup. Liver failure (LF) was defined by the “fifty–fifty” criteria at postoperative day 5 (POD) and morbidity by the Clavien–Dindo classification. Liver function tests (LFTs) and short-term outcome were retrospectively analyzed in patients over (elderly group, EG) and younger (young group, YG) than 70?years of age.

Results

Eighty-seven consecutive RH were performed during the study period. Indication for surgery included 90?% malignancy in 47?% of patients requiring preoperative chemotherapy. ASA grade?>?2 (44 vs. 16?%, p?=?0.027), ischemic heart disease (17 vs. 5?%, p?=?0.076), and preoperative cardiac failure (26 vs. 2?%, p?n?=?23) than in the YG (n?=?64). Both groups were similar regarding rates of normal liver parenchyma, chemotherapy and intraoperative parameters. The overall morbidity rates were comparable, but the serious complication (grades III–V) rate was relatively higher in the EG (39 vs. 25?%, p?=?0.199), particularly in patients with diabetes mellitus (100 vs. 29?%, p?=?0.04) and those who had additional nonhepatic surgery (67 vs. 35?%, p?=?0.110) and transfusions (44 vs. 30?%, p?=?0.523). The 90-day mortality rate was similar (9?% in the EG vs. 3?% in the YG, p?=?0.28) and was related to heart failure in the EG. LFTs showed a similar trend from POD 1 to 8, and patients ≥70?years of age had no liver failure.

Conclusions

Age ≥70?years alone is not a contraindication to RH. However, major morbidity is particularly higher in the elderly with diabetes. This high-risk group should be closely monitored in the postoperative course. Liver function is not altered in the elderly patient after RH.     

Laparoscopic and open surgical treatment of left-sided pancreatic lesions: clinical outcomes and cost-effectiveness analysis

Background

Previous studies comparing open distal pancreatectomy (ODP) and laparoscopic distal pancreatectomy (LDP) have found advantages related to minimal-access surgery. Few studies have compared direct and associated costs after LDP versus ODP. The purpose of the current study was to compare perioperative outcomes of patients undergoing LDP and ODP and to assess whether LDP was a cost-effective procedure compared with the traditional ODP.

Methods

A retrospective analysis of a prospectively maintained database of 52 distal pancreatic resections that were performed during a 10-year period was performed.

Results

Patients included in the analysis were 16 in the LDP group and 29 in the ODP. Tumors operated laparoscopically were smaller than those removed at open operation, but the length of pancreatic resection was similar. The mean operating time for LDP was longer than ODP (204?±?31 vs. 160?±?35; P?P?P?=?0.373) and pancreatic fistula (18 vs. 20%; P?=?0.6) rates were similar after LDP and ODP, as was 30-day mortality (0 vs. 2%; P?=?0.565). LDP had a shorter mean length of hospital stay than ODP (6.4 (2.3) vs. 8.8 (1.7) days; P?<?0.0001). Operative cost for LDP was higher than ODP (€2889 vs. €1989; P?<?0.0001). The entire cost of the associated hospital stay was higher in the ODP group (€8955 vs. €6714; P?P?=?0.204).

Conclusions

Laparoscopic distal pancreatectomy for left-sided lesions can be performed safely and effectively in selected patients, with reduced hospital stay and operative blood loss. Major complications, including pancreatic leak, were not reduced, whereas total cost was comparable between LDP and ODP. A selective use of LDP seems to be an effective and cost-efficient alternative to ODP.     

Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database

Background

Postpancreatectomy hemorrhage (PPH) is a dreaded complication in pancreatic surgery. Today, there is a definition and grading of PPH without therapeutic consensus. We reviewed our prospective database to identify predictors and assess therapeutic strategy.

Method

We included all patients who underwent pancreatectomy between 2005 and 2010. Data were collected prospectively. We used the International Study Group Of Pancreatic Surgery (ISGPS) definition for PPH to include patients in the PPH group.

Results

Forty-six of 285 patients showed a PPH (16.1 %). The ISGPS classification was graded A?=?3, B?=?26, and C?=?17. The average time to the onset of PPH was 7 days. CT-scan identified the origin of PPH in 43.5 % of the cases. PPH was responsible for a longer duration of hospital stay (p?=?0.004), a higher hospital mortality (21.7 vs 2.5 %, p?<?0.0001) and a lower survival (40 vs 70 % (p?=?0.05) at 36 months). The first-intention treatment of PPH was conservative in 32 % and interventional in 68 %: endoscopy (6.4 %), transcatheter arterial embolization (TAE, 30.4 %), and surgical (30.4 %). In multivariate analysis, predictors of PPH were: pancreatic fistula (24 vs 8 % p?=?0.028), pancreatoduodenectomy (70 vs 43 % p?=?0.029), age (61.6 vs 58.8 %, p?=?0.03), and nutritional risk index (NRI) (p?=?0.048).

Conclusion

In our series, risk factors for PPH were age, pancreatic fistula, pancreatoduodenectomy, and NRI. Its occurrence is associated with significantly higher hospital mortality and a lower survival rate. Our first-line treatment was radiological TAE. Surgical treatment is offered in case of failure of interventional radiology or in case of uncontrolled hemodynamic.     

Nodal Counts and Lymph Node Ratio Impact Survival After Distal Pancreatectomy for Pancreatic Adenocarcinoma

Background

The number of lymph nodes required for accurate staging after distal pancreatectomy for pancreatic adenocarcinoma is unknown.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 1,473 patients who underwent distal pancreatectomy for pancreatic adenocarcinoma from 1998 to 2010. We evaluated the influence of the total number of lymph nodes examined (NNE) and the lymph node ratio (LNR-positive nodes/total nodes examined) on survival.

Results

The median NNE was 8. No nodes were examined in 232 (16 %) of the patients, and 843 (57 %) had <10 NNE. Of the patients who had at least one node examined, 612 (49 %) were node positive. In the node-negative subset, the median and 5-year overall survival for patients with ≤10 NNE was significantly worse than patients with >10 NNE (16 vs. 20 months and 13 vs. 19 %, respectively, p?0.1 (17 vs. 6 %, p?=?0.002).

Discussion

Patients with pancreatic cancer undergoing distal pancreatectomy should ideally have at least 11 lymph nodes examined to avoid understaging. For node-positive patients, LNR may be a better prognostic indicator than the total number of positive nodes.