Impact of enhanced recovery pathway in 408 gallbladder cancer resections

BackgroundGallbladder cancer (GBC) is the sixth most common gastrointestinal malignancy with poor prognosis. Enhanced Recovery Pathway (ERP) is associated with improved outcomes following abdominal surgical procedures. Currently, there is no study evaluating ERP in patients undergoing GBC surgery. The objective was to assess compliance with ERP elements and evaluate its impact on postoperative outcomes.MethodsProspective study conducted from February 2014–2019, including elective GBC surgery. Team was educated prior to ERP implementation. Compliance with the protocol, functional gastrointestinal (GI) recovery, mobilisation, and postoperative outcomes were recorded. Impact of degree of compliance (more or less than 80%) with ERP and postoperative outcomes was evaluated.ResultsIn 408 patients, compliance with ERP was 84.6% (53.8–100%). Compliance >80% with ERP elements was observed in 245 patients (60%). Patients with >80% compliance had lower rate of minor (18.8% vs. 27%, p = 0.050) and significantly less major (0.8% vs. 6.1%, p = 0.002) and postoperative stay (5.84 ± 4.86 vs. 7.55 ± 6.6 days, p < 0.001) and earlier functional GI recovery. Intraoperative blood loss more than 600 ml, lower compliance (<80%) with ERP and preoperative albumin independently predicted postoperative complications.ConclusionThis study demonstrates safety and efficacy of enhanced recovery pathway in gallbladder cancer. Higher compliance with the pathway was associated with significantly improved postoperative outcomes following gallbladder cancer surgery.     

Low serum albumin levels and in-hospital outcomes in patients with ST segment elevation myocardial infarction

Background and aimsLow serum albumin (SA) is associated with an increased risk of long-term adverse events (AEs) among patients with chronic coronary syndromes. Its prognostic role in patients with ST-elevation myocardial infarction (STEMI) is less clear. To investigate the association between low SA and in-hospital AEs in STEMI patients.Methods and resultsMulticenter retrospective cohort study of 220 STEMI patients undergoing primary percutaneous coronary intervention within 12 h from the onset of symptoms. Hypoalbuminemia was defined by serum SA <35 g/L. SA. In-hospital AEs were defined as cardiogenic shock, resuscitated cardiac arrest and death. Median SA was 38 (IQR 35.4–41.0) g/L and 37 (16.8%) patients showed hypoalbuminemia (<35 g/L) on admission. Patients with hypoalbuminemia were older, more frequently women and diabetics, prior CAD and HF. Furthermore, they showed lower hemoglobin levels and impaired renal function. At multivariable logistic regression analysis, diabetes (odds ratio [OR]:4.59, 95% confidence interval [CI] 1.71–12.28, p = 0.002) and haemoglobin (OR:0.52, 95%CI 0.37–0.72, p < 0.001) were associated with low SA. In a subgroup of 132 patients, SA inversely correlated with D-Dimer (rS −0.308, p < 0.001). Globally, twenty-eight (14.6%) AEs were recorded. Hypoalbuminemia (OR:3.43, 95%CI 1.30–9.07, p = 0.013), high-sensitive (HS)-Troponin peak above median (OR:5.41, 95%CI 1.99–14.7, p = 0.001), C-reactive protein (CRP) peak above median (OR:6.03, 95%CI 2.02–18.00, p = 0.001), and in-hospital infection (OR:3.61, 95%CI 1.21–10.80, p = 0.022) were associated with AEs.ConclusionLow SA levels are associated with worse in-hospital AEs in STEMI patients, irrespective of HS-troponin and CRP plasma levels. Our findings suggest that low SA may contribute to the pro-thrombotic phenotype of these patients.     

The impact of preoperative anemia on pancreatic resection outcomes

BackgroundPreoperative 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.MethodsRetrospective 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.ResultsIn 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.ConclusionPreoperative anemia is an independent risk factor for increased complication severity and blood transfusion in patients undergoing major pancreatic resection.     

Cholangitis following biliary-enteric anastomosis: A systematic review and meta-analysis

BackgroundCholangitis is a serious biliary complication following biliary-enteric anastomosis (BEA). However, the rate of cholangitis in the postoperative period and its associated risk factors are inconclusive. The objective of this systematic review and meta-analysis was to assess the onset and risk factors of cholangitis after biliary-enteric reconstruction in literature.MethodsMEDLINE, EMBASE, and Cochrane databases were searched systematically to identify studies reporting about cholangitis following biliary-enteric anastomosis. Meta-analyses were performed for risk factors using random effects model with odds ratio (OR) and 95% confidence interval (95 %CI) as effect measures. Study quality was assessed by the MINORS (methodological index for non-randomized studies) criteria.Results28 studies involving 6904 patients were included in the study. The pooled rate for postoperative cholangitis (POC) was 10% (95 %CI: 8 %–13%) with studies reporting about an early- and late-onset of cholangitis. Male sex (OR 2.08; 95 %CI: 1.33–3.24; P = 0.001), postoperative hepatolithiasis (OR 137.19; 95 %CI: 29.00–648.97; P < 0.001) and postoperative anastomotic stricture (OR 178.29; 95 %CI: 68.64–463.11; P < 0.001) were associated with a higher risk of a late-onset of POC with a pooled rate of 8% (95 %CI: 6 %–11%) after a median time interval of 12 months. The quality of the included studies was low to moderate.ConclusionCholangitis is a frequent complication after BEA. Consensus definition and prospective trials are required to assess optimal therapeutic strategies. We proposed a standardized definition and grading of POC to enable comparisons between future studies.     

Defining the risk of liver failure after minor hepatectomy: a NSQIP analysis of 7029 patients

BackgroundPost-hepatectomy liver failure (PHLF) remains a significant complication after hepatic resection. This study aims to determine the rate of PHLF in patients undergoing resection of 3 or fewer segments and analyze the association of PHLF with perioperative characteristics and postoperative complications.MethodsThe American College of Surgeons hepatectomy-targeted National Surgical Quality Improvement Program database was queried for patients undergoing left hemi-hepatectomy or partial resection from 2014 to 2018. The primary outcome was PHLF, defined by ISGLS. Multivariable logistic regression models assessed the association between PHLF, preoperative and operative variables and postoperative complications.ResultsAmong 7029 patients, 187 (2.7%) experienced PHLF, with clinically significant (grade B/C) PHLF in 1.4%. PHLF was associated with older age, male gender, higher ASA classification, ascites, and elevated SGOT. Preoperative ascites (OR 4.94, 95%CI: 2.45–9.94, p < 0.001) had the strongest association with PHLF. There was no association between PHLF and concurrent colorectal resection, neoadjuvant therapy, or concurrent ablation. Surgical site infection (OR 3.64, 95%CI: 2.40–5.54, p < 0.001), sepsis (OR 3.78, 95%CI: 2.16–6.61, p < 0.001), postoperative invasive procedure (OR 6.92, 95%CI: 4.91–9.76, p < 0.001), and bile leak (OR 4.65, 95%CI: 3.04–7.12, p < 0.001) were associated with PHLF.ConclusionPHLF after minor hepatectomy is rare and associated with signs of preoperative liver dysfunction. The association with infectious complications suggests a multifactorial etiology and provides targets for quality improvement.     

Association of indirect measurement of cell function by bioimpedance analysis with complications in oncologic hepatic surgery

BackgroundBioelectric impedance vector analysis (BIVA) is a reliable tool to assess body composition. The aim was to study the association of BIVA-derived phase angle (PA) and standardized PA (SPA) values and the occurrence of surgery-related morbidity.MethodsPatients undergoing hepatectomy for cancer in two Italian centers were prospectively enrolled. BIVA was performed the morning of surgery. Patients were then stratified for the occurrence or not of postoperative morbidity.ResultsOut of 190 enrolled patients, 76 (40%) experienced postoperative complications. Patients with morbidity had a significant lower PA, SPA, body cell mass, and skeletal muscle mass, and higher extracellular water and fat mass. At the multivariate analysis, presence of cirrhosis (OR 7.145, 95% CI:2.712–18.822, p < 0.001), the Charlson comorbidity index (OR 1.236, 95% CI: 1.009–1.515, p = 0.041), the duration of surgery (OR 1.004, 95% CI:1.001–1.008, p = 0.018), blood loss (OR 1.002. 95% CI: 1.001–1.004, p = 0.004), dehydration (OR 10.182, 95% CI: 1.244–83.314, p = 0.030) and SPA < ?1.65 (OR 3.954, 95% CI: 1.699–9.202, p = 0.001) were significantly and independently associated with the risk of complications.ConclusionIntroducing BIVA before hepatic resections may add valuable and independent information on the risk of morbidity.     

The impact of intra- and postoperative fluid balance in pancreatic surgery - A retrospective cohort study

Background/objectivesThe aim of this study was to evaluate the impact of perioperative fluid administration in pancreatic surgery.MethodsPatients who underwent pancreatic resections were identified from our institution's prospectively maintained database. Fluid balances were recorded intraoperatively and at 24hr postoperatively. Patients were stratified into tertiles of fluid administration (low, medium, high). Adjusted multivariable analysis was performed and outcome measures were postoperative complications.ResultsA total of 211 patients were included from 2012 to 2017. Complication rates were POPF(B/C) 19.4%, DGE(B/C) 14.7%, PPH(C) 10.0% and CDC ≥ IIIb 26.1%. In multivariable analysis, high perioperative fluid balance was an independent risk factor associated with POPF (OR = 10.5, 95%CI 2.7–40.7, p = .001), CDC (OR = 2.5, 95%CI 1.2–5.3, p < .002), DGE (OR = 2.3, 95%CI 1.0–5.2, p = .017), PPH (OR = 6.7 95%CI 2.2–20.0, p = .038) and reoperation (OR = 3.1, 95%CI 1.6–6.2, p = .006). In multivariable analysis with intraoperative and postoperative fluid balances as separate predictors, intraoperative (OR = 2,5, 95%CI 1.2–5.5, p = .04) and postoperative fluid balance (OR = 2.5, 95%CI 1.2–5.5, p = .02) were predictors of POPF. Postoperative fluid balance was the only predictor for mortality (OR = 4.5, 95%CI 1.0–18.9, p = .041) and predictor for CDC (OR = 2.0, 95%CI 1.0–4.0, p = .043) and OHS days (OR = 6.9, 95%CI 0.03–13.7, p = .038).ConclusionsHigh postoperative fluid balance in particular is associated with postoperative morbidity. Maintaining a fluid-restrictive strategy postoperatively should be recommended for patients undergoing pancreatic surgery.     

Postoperative biliary anastomotic strictures after pancreaticoduodenectomy

BackgroundBiliary anastomotic stricture (BAS) is an uncommon complication of pancreaticoduodenectomy (PD). As PDs are performed more frequently, BAS may become a more common pathologic entity requiring clinical engagement. The aim of this study was to report the incidence of BAS in the modern era of pancreatic surgery and identify risk factors associated with it.MethodsPatients undergoing PD at the Johns Hopkins Hospital between 2007 and 2016 were identified using an institutional registry and clinicopathological features were analyzed to identify risk factors associated with BAS.ResultsOf 2125 patients identified, 103 (4.9%) developed BAS. Factors independently associated with BAS included laparoscopic approach (HR:2.83,95%CI:1.35–5.92, p = 0.006), postoperative pancreatic fistula (HR:2.45,95%CI:1.56–4.16,p < 0.001), postoperative bile leak (BL) (HR:5.26,95%CI:2.45–11.28,p < 0.001), and administration of adjuvant radiation therapy (HR:6.01,95%CI:3.19–11.34,p < 0.001). Malignant pathology was associated with lower rates of BAS (HR:0.52,95%CI:0.30–0.92, p = 0.025). BL was associated with higher rates of early-BAS (HR:16.49,95%CI:3.28–82.94, p = 0.001) while use of Vicryl suture for biliary enteric anastomosis was associated with lower rates of early-BAS (HR:0.20,95%CI:0.05–0.93, p = 0.041).ConclusionApproximately 5% of patients undergoing PD experience BAS. Multiple factors are associated with the development and timing of BAS.     

Factors predicting ablation site recurrence following percutaneous microwave ablation of colorectal hepatic metastases

BackgroundMicrowave ablation (MWA) is a recognised treatment option for liver metastases. The size of the tumour is a well-established factor that influences the success of MWA. However, the effect of “heat sink” on the success of MWA for hepatic metastases is unclear. The aim of this study was to determine whether heat sink effect is a factor that contributes to ablation site recurrence (ASR).MethodsA prospectively maintained database of patients who underwent percutaneous MWA for treatment of colorectal liver metastases was analysed. Imaging and demographic characteristics were compared between metastases that recurred following ablation and those that did not. Proximity to a large hepatic vein was defined as <10 mm.Results126 ablations in 87 patients met the inclusion criteria and were studied over a median follow-up period of 28 (12–75) months. ASR was detected in 43 ablations (34%) and was associated with clinical risk score (CRS) ≥2 (OR 2.2 95% CI 1.3–3.3, p = 0.029), metastasis size (OR 0.953 95% CI (0.929–0.978), p < 0.001) and proximity to a large hepatic vein (OR 7.5 95%CI 2.4–22.8, p < 0.001). Proximity to a large hepatic vein was not associated with reduced overall survival (OS) but was associated with liver-specific recurrence (HR 4.7 95%CI 1.7–12.5, p = 0.004).ConclusionsIn addition to tumour size proximity to large hepatic venous structures is an independent predictor of ASR and liver-specific recurrence following MWA. However, this was not associated with overall survival.     

Obesity affects outcomes of pancreatoduodenectomy

BackgroundObesity is a major global health problem, and it has reached epidemic proportions worldwide. Therefore, surgeons will confront an increasingly larger proportion of obese candidates for pancreatoduodenectomy (PD) in the future. Several small retrospective studies have been conducted to evaluate the role of Body Mass Index (BMI) in postoperative surgical complications after PD, with conflicting results. The aim of this study was to use a large multi-institutional database to clarify the impact of different levels of obesity after PD.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent PD from 2014 to 2016. Patients were categorized in the following six BMI groups: <18.5 (Underweight), 18.5–24.9 (Normal Weight), 25–29.9 (Overweight), 30–34.9 (Class I obesity), 35–39.9 (Class II Obesity) and >40 (Class III Obesity). The primary outcomes of interest were 30-day mortality and morbidity after PD among the six BMI groups.ResultsThe final population consists of 10,316 patients. Class III is associated with higher risk of 30-day mortality (OR 2.56, 95% CI 1.25–5.25, p = 0.011), major complications (OR 2.23, 95% CI 1.54–3.22, p < 0.001), clinically relevant postoperative pancreatic fistula (OR 2.48, 95% CI 1.89–3.24, p < 0.001), surgical site infections (OR 2.06, 95% CI 1.61–2.65, p < 0.001) and wound dehiscence (OR 3.47, 95% CI 1.7–7.1, p < 0.001) in multivariable analysis.ConclusionsIn conclusion, our study shows that obesity is significantly associated with higher risk of postoperative complications in patients undergoing PD and patients with BMI≥40 have increased risk of mortality after PD.     

Visceral adipose tissue is a better predictor than BMI in the alternative Fistula Risk Score in patients undergoing pancreatoduodenectomy

BackgroundMuscle attenuation (MA) and visceral adipose tissue (VAT) have not yet been included in the currently used alternative Fistula Risk Score (a-FRS). The aim of this study was to examine the added value of these parameters as predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) in the a-FRS after pancreatoduodenectomy compared to Body Mass Index (BMI).MethodsA single center retrospective cohort study was performed in patients who underwent pancreatoduodenectomy between 2009 and 2018. The a-FRS model was reproduced, MA and VAT were both combined and separately added to the model instead of BMI using logistic regression analysis. Model discrimination was assessed by ROC-curves.ResultsIn total, 329 patients were included of which 55 (16.7%) developed CR-POPF. The a-FRS model showed an AUC of 0.74 (95%CI: 0.68–0.80). In this model, BMI was not significantly associated with CR-POPF (p = 0.16). The MA + VAT model showed an AUC of 0.81 (95%CI: 0.75–0.86). VAT was significantly associated with CR-POPF (per cm², OR: 1.01; 95%CI: 1.00–1.01; p < 0.001). The AUC of the MA + VAT model differed significantly from the AUC of the a-FRS model (p = 0.001).ConclusionVisceral adipose tissue is of added value in the a-FRS compared to BMI in predicting CR-POPF in patients undergoing pancreatoduodenectomy.     

Influence of perception of glucocorticoids on compliance of treatment in patients with rheumatoid arthritis and systemic lupus erythematosus

BackgroundGlucocorticoids (GCs) are alleged as hazardous medications among Egyptian patients and their relatives.Aim of the workTo highlight the beliefs held about GCs and the effect of these beliefs on adherence to GCs treatment.Patients and methodsThe study included 70 systemic lupus erythematosus (SLE) patients, 70 rheumatoid arthritis (RA) patients and 140 GC-naïve subjects as the control. The demographic and socioeconomic standards of the patients and control as well as the GCs use experience in patients were recorded. GCs perception was assessed by Beliefs about medication Questionnaire (BMQ). Adherence was assessed by Compliance Questionnaire of Rheumatology (CQR).ResultsGCs were significantly perceived as harmful and of low benefit by the control (p < 0.001, p < 0.001, respectively), a beneficial drug by SLE patients, while RA patients had significantly higher harm scores (p = 0.015 and p = 0.003 respectively). Most of SLE and RA patients were non-adherent (57.1% and 65.7%, respectively). Higher general-BMQ harm scores were significantly associated with a lower odd of adherence (OR: 0.25, 95%CI: 0.1–0.63). Reduced OR of necessity > concern was associated with higher socioeconomic standards and maximum oral GCs dose (OR:0.09 and 0.96, respectively). Increased OR of high necessity was significantly associated with number of currently used disease modifying anti-rheumatic drugs (DMARDs) (OR:5.54, p = 0.025). High OR of harm perception was significantly associated with higher socioeconomic standards (OR: 5.12, p = 0.016).ConclusionGCs are perceived as pillars in management by SLE and RA patients. Concerns about side effects and dependency are still troublesome. Improvement of patients’ GCs perception impacts level of adherence to treatment.     

Synchronous resection of colorectal cancer primary and liver metastases: an outcomes analysis

BackgroundConcurrent resection of the primary cancer and synchronous colorectal cancer liver metastases (CRCLM) was evaluated for differences in outcomes following stratification of both the liver and colorectal resection.MethodsConsecutive cases of synchronous resection of both the CRC primary and CRCLM were reviewed retrospectively at a single, high-volume institution over a 17-year period (2000–2017).Results273 patients underwent simultaneous resection of CRCLM. The distribution of the primary lesion was similar between the colon (52.4%) and rectum (47.6%), while 46.9% of patients had bilobar liver disease. Major liver/major colorectal resection (n = 24) were significantly more likely to experience colorectal specific morbidity (OR 3.98, 95% CI 1.56–10.15, p = 0.004), liver specific morbidity (OR 7.4, 95% CI 2.22–24.71, p = 0.001), total morbidity (OR 2.91, 95% CI 1.18–7.18, p = 0.020) and 90-day mortality (OR 5.50, 95% CI 1.27–23.81, p = 0.023). Failure to receive adjuvant chemotherapy secondary to postoperative morbidity was associated with significantly worsened survival (HR for death 5.91, 95% CI 1.59–22.01, p = 0.008).ConclusionsPostoperative morbidity precluding the administration of adjuvant chemotherapy is associated with an increase in mortality. Combining a major liver with major colorectal resection is associated with a significant increase in major morbidity and 90-day mortality, and should be avoided.     

Systematic review and meta-analysis of fluid therapy protocols in acute pancreatitis: type,rate and route

BackgroundAdequate fluid resuscitation is paramount in the management of acute pancreatitis (AP). The aim of this study is to assess benefits and harms of fluid therapy protocols in patients with AP.MethodsMEDLINE, Embase, Science Citation Index and clinical trial registries were searched for randomised clinical trials published before May 2020, assessing types of fluids, routes and rates of administration.ResultsA total 15 trials (1073 participants) were included. Age ranged from 38 to 73 years; follow-up period ranged from 0.5 to 6 months. Ringer lactate (RL) showed a reduced number of severe adverse events (SAE) when compared to normal saline (NS) (OR 0.48; 95%CI 0.29–0.81, p = 0.006); additionally, NS showed reduced SAE (RR 0.38; 95%IC 0.27–0.54, p < 0.001) and organ failure (RR 0.30; 95%CI 0.21–0.44, p < 0.001) in comparison with hydroxyethyl starch (HES).High fluid rate fluid infusion showed increased mortality (OR 2.88; 95%CI 1.41–5.88, p = 0.004), increased number of SAE (RR 1.42; 95%CI 1.04–1.93, p = 0.030) and higher incidence of sepsis (RR 2.80; 95%CI 1.51–5.19, p = 0.001) compared to moderate fluid rate infusion.ConclusionsIn patients with AP, RL should be preferred over NS and HES should not be recommended. Based on low-certainty evidence, moderate-rate fluid infusion should be preferred over high-rate infusion.     

The quality of pain management in pancreatic cancer: A prospective multi-center study

Background/objectivesPancreatic ductal adenocarcinoma (PDAC) is frequently associated with severe pain. Given the almost inevitably fatal nature of the disease, pain control is crucial. However, data on quality of pain management in PDAC is scarce.MethodsThis is a multi-center, prospective study to evaluate the quality of pain management in PDAC. Insufficient pain treatment (undertreatment) was prevalent if there was an incongruence between the patients level of pain and the potency of analgesic drug therapy. Determinants of pain and undertreatment were identified using multivariable logistic regression.Results139 patients with histologically confirmed PDAC were analyzed. The prevalence of pain was 63%, with approximately one third of the patients grading their pain as moderate to severe. Palliative stage (OR: 3.37, 95%CI: 1.23–9.21, p = 0.018) and localization of the primary tumor in the body or tail (OR: 2.57, 95%CI: 1.05–6.31, p = 0.039) were independent determinants of pain. Of those reporting pain, 60% were undertreated and in 89% pain interfered with activities and emotions. Age ≥ 70 years (OR: 3.20, 95%CI: 1.09–9.41, p = 0.035) was an independent predictor of undertreatment. Patients with longer-known PDAC ( ≥ 30 days) showed improved pain management compared to new cases (OR: 0.19, 95%CI: 0.05–0.81, p = 0.025). Treatment by gastroenterologists (OR: 0.22, 95%CI: 0.05–0.89, p = 0.034) was associated with less undertreatment.ConclusionsThe results show a high proportion of PDAC patients with pain, pain interference and undertreatment, whose characteristics could help to identify patients at risk in the future. Several changes in the management of cancer-related pain are necessary to overcome barriers to optimal treatment.     

Risk factors for development of endocrine insufficiency in chronic pancreatitis

Endocrine insufficiency is a common and frequent complication of chronic pancreatitis. Identifying the role of pancreatic damage in the development of diabetes is important for early identification and appropriate management.MethodsAll consecutive CP patients between January 2019 and May 2020 were retrospectively studied. Relevant statistical tests were performed. A two sided p value < 0.05 was considered statistically significant.ResultsTotal 587 chronic pancreatitis patients were included of which 118 (20.1%) patients developed diabetes with duration of 12 (IQR 4–48) months. Older age (OR 1.079; 95% CI 1.045–1.113; p < 0.001), presence of pancreatic parenchymal (OR 2.284; 95% CI 1.036–5.038; p = 0.041) and ductal (OR 2.351; 95% CI 1.062–5.207; p = 0.035) calcifications, exocrine insufficiency (OR 6.287; 95% CI 2.258–17.504; p < 0.001), and pancreatic duct stricture (OR 3.358; 95% CI 1.138–9.912; p = 0.028) were independently associated with development of diabetes mellitus in chronic pancreatitis patients. On cox-regression analysis, smoking (HR 2.370; 95% CI 1.290–4.354; p = 0.005) and pancreatic ductal calcification (HR 2.033; 95% CI 1.286–3.212; p = 0.002) were independently associated with earlier onset of diabetes mellitus in patients with chronic pancreatitis.ConclusionPancreatic calcification, pancreatic duct stricture and pancreatic exocrine insufficiency are associated with development of diabetes mellitus in chronic pancreatitis indicating disease progression. Smoking is the modifiable risk factors associated with early onset of diabetes mellitus in CP patients.     

Morning chronotype is associated with higher adherence to the Mediterranean diet in a sample of Italian adults

Background and aimsA growing body of evidence has associated subjects with an evening chronotype with worse eating behaviours and poorer diet quality. However, only few studies have investigated the relationship between chronotype and Mediterranean diet (MD). The aim of this study was to better understand the chronotype influence on dietary habits and MD adherence in a large sample of Italian adults.Methods and resultsA total of 1247 participants (66.7% women) with a mean age of 36.1 ± 14.6 years were included in the analysis. Chronotype was classified as morning in 35.6% of subjects, intermediate in 56.7%, and evening in 7.1%. Regarding meal frequency, evening subjects showed a significantly (p < 0.05) greater tendency to skip breakfast (20.5%) than morning (6.9%) and intermediate (12%) subjects. Similarly, evening subjects were found to skip mid-morning snack more often than morning subjects (59.1% vs. 47.1%; p = 0.04), and lunch more often than intermediate subjects (8% vs. 2.8%; p = 0.01). In addition, all meals were eaten by evening subjects at a significantly delayed time, except for lunch. As to MD adherence a significant (p < 0.001) higher adherence in morning subjects (10.1 ± 2.2) compared to intermediate (9.5 ± 2.1) and evening (9.5 ± 2.2) subjects was observed. At a logistic regression analysis adjusted for possible confounding factors, morning subjects showed an increased probability (OR 1.54, 95%CI 1.19–1.99; p < 0.001) of being in the highest MD adherence tertile.ConclusionChronotype was associated with MD adherence. In particular, morning subjects showed higher MD adherence than intermediate and evening subjects.     

Preoperative heart disease and risk for postoperative complications after pancreatoduodenectomy

BackgroundComorbidities increase the risk for postoperative complications after pancreatoduodenectomy. The importance of different categories of heart disease on postoperative outcomes has not been thoroughly studied.MethodsPatients aged ≥18 years undergoing pancreatoduodenectomy between 2008 and 2019 at Karolinska University Hospital, Sweden were included. Heart disease was defined as a preoperatively established diagnosis, and subcategorized into ischaemic, valvular, heart failure and atrial fibrillation. Postoperative outcome was analysed by multivariable regression.ResultsOut of 971 patients, 225 (23.3%) had heart disease. Heart disease was associated with an increased risk for complications; Clavien–Dindo score ≥ IIIa (Odds Ratio [OR] 1.53, 95% confidence interval [CI] 1.07–2.18; p = 0.019), intensive care unit admissions (OR 3.20, 95% CI 1.81–5.66; p < 0.001) and longer hospitalizations (median 14 vs. 11 days; p < 0.001). Although heart disease was not associated with 90-day mortality, it conferred a shorter median overall survival (22 vs. 32 months; p < 0.001). Atrial fibrillation and heart failure were each associated with increased risk for postoperative complications, whereas ischaemic and valvular heart disease were not.ConclusionAtrial fibrillation and heart failure were independently associated with increased risk for postoperative complications. Despite no association with early postoperative mortality, heart disease negatively affected long-term survival.     

Impact of enhanced recovery after surgery protocol on pancreaticoduodenectomy: a meta-analysis of non-randomized and randomized controlled trials

BackgroundEnhanced recovery after surgery (ERAS) has been widely applied in many surgical specialties. However, with respect to the impact of ERAS on pancreaticoduodenectomy (PD), there still exist some controversies.MethodsLiterature search was performed in PubMed, Web of Science and the Cochrane Library from January, 1990 to July, 2019. A meta-analysis was performed using fixed-effects or random-effects models.ResultsTwenty-two studies containing 4147 patients were identified. The entire pooled data showed that ERAS significantly reduced overall and minor morbidity (RR: 0.80, 95% CI: 0.72–0.88, p < 0.001; RR: 0.78, 95% CI: 0.69–0.88, p < 0.001, respectively), but didn't affect major morbidity (RR: 0.97, 95% CI: 0.84–1.13, p = 0.72). ERAS markedly reduced the incidences of delayed gastric emptying (DGE) (RR: 0.69, 95% CI: 0.55–0.88, p = 0.002), incisional infection (RR: 0.75, 95% CI: 0.60–0.94, p = 0.01) and intra-abdominal infection (RR: 0.79, 95% CI: 0.63–1.00, p = 0.05), but didn't influence clinically-relevant postoperative pancreatic fistula (CR-POPF) (RR: 0.86, 95% CI: 0.73–1.01, p = 0.07). Shorter length of stay (LOS) (WMD: −5.07, 95% CI: −6.71 to −3.43, p < 0.001) was noted in ERAS group, without increasing 30-day readmission (RR: 1.03, 95% CI: 0.86–1.24, p = 0.71) and mortality (RR: 0.70, 95% CI: 0.41–1.21, p = 0.20).ConclusionERAS significantly reduced overall and minor morbidity, incidences of DGE, incisional and intra-abdominal infections, and shortened LOS in PD, without increasing 30-day readmission and mortality. However, more large-scale randomized controlled trials are still needed to confirm the findings.     

Failure to rescue in patients with distal pancreatectomy: a nationwide analysis of 10,632 patients

BackgroundFTR appears as a major cause of postoperative mortality (POM). Hospital volume has an impact on FTR in pancreatic surgery but no study has investigated this relationship more specifically in DP.MethodsWe analysed patients with DP between 2009 and 2018 through a nationwide database. FTR definition was mortality among patients who experiment major complications. The cutoff between high and low volume centers was 20 pancreatectomies per year.ResultsSome 10,632 patients underwent DP, 5048 (47.5%) were operated in 602 (95.4%) low volume centers and 5584 (52.5%) in 29 (4.6%) high volume centers. Overall FTR occurred in 11.2% of patients and was significantly reduced in high volume centers compared to low volume centers (10.2% vs 12.5%, p = 0.047). In multivariate analysis, surgery in a high volume center was a protective factor for POM (OR = 0.570, CI95% [0.505–0.643], p < 0.001) and also for FTR (OR = 0.550, CI95% [0.486–0.630], p < 0.001).ConclusionHospital volume has a positive impact on FTR in DP. Patients with higher risk of FTR are men, with high modified Charlson comorbidity index, malignant conditions and open procedures.