Simultaneous pancreatectomy and liver transplantation: a single-institution experience

Background:

There is wide debate among transplant centres regarding the indications for liver transplantation (LT) in malignancy. We report a single-centre experience with simultaneous LT and total pancreatectomy or pancreaticoduodenectomy.

Methods:

We performed a retrospective review of a prospectively established database of patients who underwent simultaneous LT and total pancreatectomy or pancreaticoduodenectomy. We analysed demographics, indications, approach and outcomes.

Results:

Between 1991 and 2006, 11 patients (four male; median age 51 years) underwent simultaneous LT and total pancreatectomy (n = 4) or pancreaticoduodenectomy (n = 7). Indications included metastatic neuroendocrine tumour (n = 5), hepatocellular carcinoma (n = 2), metastatic periampullary adenocarcinoma (n = 1), periampullary adenocarcinoma with end-stage liver disease (ESLD) (n = 2) and intraductal papillary mucinous neoplasm with ESLD (n = 1). The three patients with ESLD had non-alcoholic steatohepatitis, primary sclerosing cholangitis or cryptogenic cirrhosis. Median postoperative length of stay was 31 days (21–110 days). Overall median survival was 101 months (95% confidence interval 70.6–131.4). One-year survival was 91%, 2-year 90%, 5-year 67% and 10-year 33%. Postoperative complications included: re-operation (n = 4); anastamotic leak (n = 2); abdominal abscess (n = 3), and organ rejection (n = 1).

Conclusions:

We report a series of pancreatectomy or pancreaticoduodenectomy and simultaneous LT in patients with extensive malignancy or impending liver failure that prevented pancreatectomy. This series provides evidence that combined pancreatic resection and LT can be a strategy in both radical resections and cases with ESLD that would otherwise preclude operative intervention.     

Survival impact of distal pancreatectomy with en bloc celiac axis resection combined with neoadjuvant chemotherapy for borderline resectable or locally advanced pancreatic body carcinoma

BackgroundThe survival benefit associated with distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for patients with borderline resectable or locally advanced pancreatic body carcinoma is controversial. The aim of this study was to evaluate the impact of DP-CAR following neoadjuvant chemotherapy on survival in patients with borderline resectable or locally advanced pancreatic body carcinoma.MethodsMedical records of patients with pancreatic ductal adenocarcinoma who underwent distal pancreatectomy (DP, n = 102) and DP-CAR following neoadjuvant chemotherapy (n = 32) between 2008 and 2019 were analyzed retrospectively. Short- and long-term outcomes were compared between the two groups.ResultsAll patients who underwent DP-CAR had tumor contact with the celiac axis. Of these, 30 patients underwent preoperative embolization of the common hepatic artery. The pretreatment tumor size of patients who underwent DP-CAR was larger (P < 0.001), and rates of blood transfusion (P = 0.003) and postoperative complications (P = 0.016) were higher in patients who underwent DP-CAR compared with patients who underwent DP. The 5-year survival rate of patients who underwent DP and DP-CAR were 50.6% and 41.1%, respectively (median survival time, 65.9 vs 37.0 months). For all 134 patients, pretreatment serum CA19-9 levels (P < 0.001), adjuvant chemotherapy (P < 0.001), and lymph node status (P = 0.035) were independent prognostic factors of overall survival by multivariate analysis.ConclusionsDP-CAR following neoadjuvant chemotherapy for patients with borderline resectable or locally advanced pancreatic body carcinoma may bring the same survival impact as DP, despite increased morbidity.     

The role of older age and obesity in minimally invasive and open pancreatic surgery: A systematic review and meta-analysis

Background/objectivesThe aim of this study was to assess the impact of older age (≥70 years) and obesity (BMI ≥30) on surgical outcomes of minimally invasive pancreatic resections (MIPR). Subsequently, open pancreatic resections or MIPR were compared for elderly and/or obese patients.MethodsA systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on MIPR (IG-MIPR). Study quality assessment was according to The Scottish Intercollegiate Guidelines Network (SIGN). A meta-analysis was performed to assess the impact of MIPR or open pancreatic resections in elderly patients.ResultsAfter screening 682 studies, 13 observational studies with 4629 patients were included. Elderly patients undergoing laparoscopic distal pancreatectomy (LDP) had less blood loss (117 mL, p < 0.001) and a shorter hospital stay (3.5 days p < 0.001) than elderly patients undergoing open distal pancreatectomy (ODP). Postoperative pancreatic fistula (POPF) B/C, major complication and reoperation rate were not significantly different in elderly patients undergoing either laparoscopic or open pancreatoduodenectomy (OPD). One study compared robot PD with OPD in obese patients, indicating that patients with robotic surgery had less blood loss (mean 250 ml vs 500 ml, p = 0.001), shorter operative time (mean 381 min vs 428 min, p = 0.003), and lower rate of POPF B/C (13% vs 28%, p = 0.039).ConclusionThe current available limited evidence does not suggest that MIPR is contraindicated in elderly or obese patients. Additionally, outcomes in MIPR are equal or more beneficial compared to the open approach when applied in these patient groups.     

Prevalence of pancreatic exocrine insufficiency after pancreatic surgery measured by 13C mixed triglyceride breath test: A prospective cohort study

BackgroundPatients undergoing pancreatic surgery are at risk of pancreatic exocrine insufficiency (PEI) and needing pancreatic enzyme replacement therapy (PERT).MethodsThis study included 254 patients undergoing pancreatic surgery for oncologic indications. A¹³C mixed triglyceride breath test was performed immediately preoperative and postoperative. This test analyzes the pancreatic remnant lipase activity measuring ¹³CO₂ in breath samples after a test meal with 1.3-distearyl-(¹³C-Carboxyl)octanol-glycerol. Cumulative percent dose recovery after 6 h of less than 23% confirms PEI. In addition, PEI was compared between pathology subgroups.ResultsIn 197 patients undergoing pancreaticoduodenectomy, cPDR-6h decreased significantly from a median of 32.84% before to 15.80% after surgery (p < 0.0001). This decrease in exocrine function was significant in all pathology subgroups except in pancreatic neuroendocrine tumors. Exocrine function decreased most in pancreatic ductal adenocarcinoma (PDAC). In addition, the percentage of patients needing PERT because of PEI increased from 25.9% to 68.0% postoperative (p < 0.001). Overall, patients with an MPD diameter of more than 3 mm had a higher risk of developing postoperative PEI: 62.7% compared to 37.3% (p = 0.009), OR = 3.11.In contrast, the majority of the 57 patients undergoing a distal pancreatectomy did not experience any significant change in exocrine function.ConclusionsThe vast majority of patients undergoing pancreaticoduodenectomy for oncologic indications experience a significant drop in exocrine function, are at high risk of developing pancreatic exocrine insufficiency and consequently need to be treated with pancreatic enzyme replacement therapy. Therefore, systematic screening for pancreatic exocrine insufficiency is needed after pancreaticoduodenectomy.     

Isolated pulmonary recurrence after resection of pancreatic cancer: the effect of patient factors and treatment modalities on survival

BackgroundThe literature suggests favorable survival for patients with isolated pulmonary recurrence after resection of pancreatic ductal adenocarcinoma (PDAC) as compared to other recurrence patterns. Within this cohort, it remains unclear what factors are associated with improved survival.MethodsPatients who developed pulmonary recurrence after pancreatectomy were selected from a prospective database. Predictors for post-recurrence survival (PRS) were analyzed using a multivariable Cox regression model.ResultsNinety-six patients were included. Median recurrence-free survival (RFS), PRS and overall survival (OS) were 16.3, 18.8 and 39.6 months, respectively. Further systemic treatment and/or metastasectomy (n = 64, 67%) was associated with significantly improved PRS and OS when compared to best supportive care (n = 35, 22%) (26.3 vs. 5.3 and 48.1 vs. 18.4, respectively; both P < 0.001). Patients who were able to undergo metastasectomy (n = 19) achieved a PRS and OS of 35.0 and 68.9 months, respectively. More than 5 pulmonary lesions, symptoms and CA 19-9 ≥100 U/mL at time of recurrence were predictive of decreased PRS. A recurrence-free interval of >16 months and treatment for recurrence were independently associated with improved PRS.ConclusionsIsolated pulmonary recurrence occurs in 13% of patients with recurrent PDAC and is associated with a median OS of 40 months. Aggressive treatment in highly selected patients was correlated with improved survival.     

Division of the pancreas at the neck reduces postoperative pancreatic fistula in laparoscopic distal pancreatectomy: Comparison of pancreatic division at the body

Backgroundobjectives: During laparoscopic distal pancreatectomy (LDP), the optimal site for pancreatic division with consideration of postoperative pancreatic fistula (POPF) is unclear. We evaluate which site of pancreatic division, neck or body, has better outcomes after LDP.MethodsThis was a retrospective, observational study. LDP was performed in 102 consecutive patients between December 2009 and May 2020. After excluding 14 patients with pancreatic division at tail, 88 patients (pancreatic division at neck n = 46, at body n = 42) were included in this study. Short- and long-term outcomes after LDP were compared between pancreatic division at neck and body.ResultsThe pancreatic transection site was thicker at body than at neck (17.5 vs. 11.9 mm, P < 0.001), although there were no significant differences of pancreatic texture and pancreatic duct size. The Grade B/C POPF rate was significantly higher when the pancreas was divided at body than when divided at neck (21.4 vs. 6.5%, P = 0.042). We found no significant differences between pancreatic division at neck and body in residual pancreatic volume (34.0 vs. 34.8 ml, P = 0.855), incidence of new-onset or worsening diabetes mellitus more than six months after LDP (P = 0.218), or body weight change (six-month: P = 0.116, one-year: P = 0.108, two-year: P = 0.195, tree-year: P = 0.131, four-year: P = 0.608, five-year: P = 0.408).ConclusionThis study suggests that the pancreatic division at neck might reduce the Grade B/C POPF incidence after LDP, compared to division at body. A potential reason is that the pancreas at body is thicker than that at neck. However, further large-scale studies are necessary to confirm our results.     

Optimal duration of the early and late recurrence of pancreatic cancer after pancreatectomy based on the difference in the prognosis

BackgroundThe term “early recurrence” of pancreatic cancer has not been well-defined in most previous studies.MethodsThe clinical records of 86 patients who underwent macroscopic curative pancreatectomy for pancreatic cancer between 2000 and 2009 were retrospectively examined. We divided 55 patients who experienced disease recurrence into two groups, the early and late recurrence groups, using the minimum p value approach. The relationships between the interval prior to recurrence and clinical outcomes were investigated.ResultsThe cumulative 5-year overall survival rates for all 86 patients were 30.2%. For 55 patients who experienced disease recurrence, the optimal cut-off value for differentiating early (n = 37) and late (n = 18) recurrence based on the overall survival was 12 months (p = 0.0000045). The Cox proportional hazard analysis identified carbohydrate antigen 19-9 > 100 U/ml (p = 0.017) and surgical margin (p = 0.007) as the independent prognostic factors associated with overall survival. Positive surgical margin (p = 0.037) and severe venous invasion (p = 0.005) were identified as independent factors associated with early recurrence.ConclusionTwelve months after pancreatectomy is the optimal cut-off value for defining early versus late recurrence based on the overall survival. Early recurrence was related to the status of the surgical margin and venous invasion.     

The role of coeliac axis resection in resected ductal adenocarcinoma of the distal pancreas: A result of tumour topography or a prognostic factor?

BackgroundWhether coeliac axis resection (CAR) results from tumour topography or a prognostic factor for distal pancreatic ductal adenocarcinoma (PDAC) remains unclear. We aimed to compare the clinicopathological data between distal pancreatectomy with en bloc CAR (DP-CAR) and distal pancreatectomy plus splenectomy (DP-S) and analyse the prognostic factors.MethodsWe retrospectively analysed clinicopathological data from 102 patients who underwent distal pancreatectomy for PDAC and the factors affecting disease-free survival (DFS) and overall survival (OS). Of these patients, 45 and 57 underwent DP-CAR and DP-S, respectively.ResultsDP-CAR was associated with more operative challenges than DP-S: more portomesenteric vein resections (48.9% vs. 14.0%), longer operations (320 vs. 242 min), and greater estimated blood loss (EBL) (600 vs. 200 ml). DP-CAR had larger tumours (5 vs. 4 cm), more perineural invasion (91.1% vs. 73.7%), and more microscopically positive surgical margins (20% vs. 3.5%), compared to DP-S. The major complication was clinically relevant postoperative pancreatic fistula (20.6%). The median DFS was 15.8 months and the median OS was 20.1 months. CAR was not associated with DFS or OS. EBL>700 ml, lymphovascular invasion (LVI), and adjuvant chemotherapy independently affected DFS and OS.ConclusionDP-CAR was associated with larger tumours and more surgical challenges but not with poorer DFS and OS than DP-S. CAR was more likely to result from tumour topography rather than from an adverse prognostic factor for resected distal PDAC. EBL>700 ml, LVI, and adjuvant chemotherapy were independent factors affecting the survival of patients with distal PDAC who underwent surgical resection.     

Long-term survival after multimodality treatment for resectable pancreatic cancer

Summary Background. The prognosis of pancreatic adenocarcinoma after radical pancreatectomy is poor, especially in advanced-stage disease. Study Aim. To determine the survival rates and evaluate the effectiveness of multimodality treatment for advanced pancreatic cancer. Methods. From November 1983 to January 1993, 30 patients with pancreatic adenocarcinoma including 9 with carcinoma of the body and tail were treated by a multimodal approach consisting of extended pancreatectomy, intraoperative radiotherapy (IORT), and hepatic artery or portal vein infusion of mitomycin C (MMC) followed by systemic bolus injection. All surviving patients were followed for more than 8 yr and survival rates were calculated by the Kaplan-Meier method. Results. There were no operative or hospital deaths. Eight patients survived for more than 5 yr, 3 of whom survived more than 10 yr. The 5-yr survival rate for 27 patients excluding 3 with metastasis to the liver, peritoneum, or lung was 31%, with a median survival of 31.1 mo. Among them, the 1-, 3-, and 5-yr survival rates for 19 patients with regional nodal metastasis were 95, 50, and 28%, respectively, with a median survival of 36.0 mo. Conclusion. The multimodality treatment combined with IORT and MMC chemotherapy appeared to have a benefit for prognosis of advanced pancreatic adenocarcinoma.     

Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery

BackgroundThe refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery.MethodsThe institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used.ResultsPerioperative outcomes of 32 Jehovah’s Witnesses patients were included. Median age was 67 years (range, 31–77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100–1000) and 470 min (range, 290–595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7–15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1–14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8–54) with no patient requiring transfusion or re-operation and no 90-day mortality.ConclusionsA multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.     

Long‐term survival after resection for non‐pancreatic periampullary cancer followed by adjuvant intra‐arterial chemotherapy and concomitant radiotherapy

BackgroundThere is no consensus regarding the optimal adjuvant treatment after resection of non‐pancreatic periampullary adenocarcinoma (NPPC; distal common bile duct, ampulla, duodenum).ObjectivesThe present study was conducted to evaluate the impacts on longterm survival and recurrence of adjuvant intra‐arterial chemotherapy (IAC) and concomitant radiotherapy (RT) in patients submitted to resection for NPPC or pancreatic ductal adenocarcinoma (PDAC) in a randomized controlled trial.MethodsA total of 120 patients with PDAC (n = 62) or NPPC (n = 58) were prestratified at a ratio of 1:1 for tumour origin and randomized. Half of these patients were treated with adjuvant IAC/RT and the other half were treated with surgery alone. Follow‐up was completed for all patients up to 5 years after resection or until death.ResultsThere was no survival benefit in either the whole group (primary endpoint) or the PDAC group after IAC/RT. In the NPPC group, longterm survival was observed in 10 patients in the IAC/RT group and five patients in the control group: median survival was 37 months and 28 months, respectively. The occurrence of liver metastases was reduced by IAC/RT from 57% to 29% (P = 0.038). Cox regression analysis revealed a substantial effect of IAC/RT on survival (hazard ratio: 0.44, 95% confidence interval 0.23–0.83; P = 0.011).ConclusionsThis longterm analysis shows that median and longterm survival were improved after IAC/RT in patients with NPPC, probably because of the effective and sustained reduction of liver metastases. The present results illustrate that NPPC requires an adjuvant approach distinct from that in pancreatic cancer and indicate that further investigation of this issue is warranted.     

Impact of spleen preservation on the incidence of postoperative pancreatic fistula after distal pancreatectomy: Is less more?

BackgroundPostoperative pancreatic fistula (POPF) remains a major complication after distal pancreatectomy (DP) with a significant impact on patients’ quality of life. There is limited evidence that preservation of the spleen reduces the risk of POPF. Therefore, we aimed to investigate the impact of splenectomy on perioperative outcome.MethodsData from patients who underwent DP for malignant and benign disease at our institution between 2004 and 2021 were reviewed. Patients were grouped according to spleen preservation (SP-DP) and splenectomy (DPS). Intraoperative parameters and postoperative outcomes were compared between groups. Univariable and multivariable analyses were used to investigate factors that influence the occurrence of clinically relevant (cr)POPF.ResultsA total of 199 patients were included, of whom 61 (30.7%) patients underwent SP-DP. Patients who underwent SP-DP had a significantly lower rate of crPOPF (p = 0.022), shorter hospital stay (p = 0.003), and less readmissions (p = 0.012). On multivariate analysis, obesity (OR 2.88, p = 0.021), benign lesions (OR 2.35, p = 0.018), postoperative acute pancreatitis (OR 2.53, p = 0.028), and splenectomy (OR 2.83, p = 0.011) were independent risk factors associated with the onset of crPOPF.DiscussionPreservation of the spleen reduces the risk of crPOPF in patients undergoing distal pancreatectomy for benign and malignant disease.     

Rapid postoperative reduction in prognostic nutrition index is associated with the development of pancreatic fistula following distal pancreatectomy

BackgroundsDespite recent advances in surgical techniques and devices for pancreatic remnant closure, postoperative pancreatic fistula (POPF) still remains one of the common complications after distal pancreatectomy (DP). Identification of risk factors for POPF may lead to the development of new strategies to prevent this ominous complication.MethodsWe retrospectively reviewed data on 44 patients undergoing DP with the use of a stapler to identify risk factors for POPF. Study variables included preoperative prognostic nutritional index (PNI) and reduction rate of PNI on postoperative day (POD) 7.ResultsPOPF occurred in 23 patients (52%), of which 13 (56%) were grade B or C. Univariate analyses comparing patients with POPF and those without POPF showed significant differences in body mass index (P = 0.0102), pancreatic thickness (P = 0.0134), white blood cell count on POD7 (P = 0.0432), C-reactive protein level on POD7 (P = 0.0123), and PNI reduction rate (P = 0.0471). A multivariate analysis revealed pancreatic thickness (P = 0.0121) and PNI reduction rate (P = 0.0165) to be significant factors for POPF. Furthermore, the PNI reduction rate was significantly higher in patients with clinically relevant (grade B/C) POPF than in those with no or grade A POPF (P = 0.0257). In most patients, the massive postoperative PNI reduction preceded the diagnosis of clinically relevant POPF.ConclusionsThese findings suggest that rapid postoperative reduction in PNI is associated with the development of POPF.     

Tailored adjuvant gemcitabine versus 5-fluorouracil/folinic acid based on hENT1 immunohistochemical staining in resected pancreatic ductal adenocarcinoma: A biomarker stratified prospective trial

BackgroundThe study aimed to evaluate the clinical outcomes of tailored adjuvant chemotherapy according to human equilibrative nucleoside transporter 1 (hENT1) expression in resected pancreatic ductal adenocarcinoma (PDA).MethodsPatients who underwent pancreatectomy for PDA were enrolled prospectively. According to intra-tumoral hENT1 expression, the high hENT1 (≥50%) group received gemcitabine and the low hENT1 (<50%) group received 5-fluorouracil plus folinic acid (5-FU/FA). The propensity score-matched control consisted of patients who received hENT1-independent adjuvant chemotherapy. The primary outcome was recurrence free survival (RFS) and the secondary outcomes were overall survival (OS) and toxicities.ResultsBetween May 2015 and June 2017, we enrolled 44 patients with resected PDA. During a median follow-up period of 28.5 months, the intention-to-treat population showed much longer median RFS [22.9 (95% CI, 11.3–34.5) vs. 10.9 (95% CI, 6.9–14.9) months, P = 0.043] and median OS [36.2 (95% CI, 26.5–45.9) vs. 22.1 (95% CI, 17.7–26.6) months, P = 0.001] compared to the controls. Among 5 patients in the low hENT1 group who discontinued treatment, 2 patients receiving 5-FU/FA discontinued treatment due to drug toxicities (febrile neutropenia and toxic epidermal necrolysis).ConclusionTailored adjuvant chemotherapy based on hENT1 staining provides excellent clinical outcomes among patients with resected PDA.Clinical trial registrationclinicaltrials.gov identifier: NCT02486497.     

Radical antegrade modular pancreatosplenectomy (RAMPS): does adrenalectomy alter outcomes?

BackgroundRadical antegrade modular pancreatosplenectomy (RAMPS) has oncologic superiority compared to a standard distal pancreatectomy (DP). For tumors invading into the adrenal gland, a posterior RAMPS takes the left adrenal gland en bloc with the pancreas specimen. The aim of this analysis is to determine whether addition of adrenalectomy alters the outcomes of DP.MethodsThe American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Procedure-Targeted Pancreatectomy database was accessed from 2014 to 2019. Patients with pancreatic ductal adenocarcinoma (PDAC) undergoing posterior RAMPS were compared to patients having a standard DP. 30-day outcomes were analyzed using multivariable regression.Results3467 PDAC patients underwent DP; 159 (4.6%) also had an adrenalectomy. Posterior RAMPS patients had higher T stage (T3-4 77% vs. 58%, p < 0.01). On multivariable analysis, posterior RAMPS patients had worse perioperative outcomes including more transfusions (OR 2.78, p < 0.01), serious morbidity (OR 1.45, p = 0.04), prolonged hospital stay (OR 1.36, p < 0.05), and less optimal pancreatic surgery (OR 0.61, p < 0.01).ConclusionRadical antegrade modular pancreatosplenectomy with adrenalectomy (posterior RAMPS) is associated with worse perioperative outcomes compared to a standard distal pancreatectomy. Improved oncologic outcomes must be weighed against higher perioperative morbidity when selecting patients for this more extensive surgical resection.     

Clinical and pathologic prognostic factors for curative resection for pancreatic cancer

Background. Pancreatic cancer is the fifth leading cause of cancer-related deaths in the world. Operative resection is the only therapeutic option with curative potential for this disease. Objective. The aim of the present study was to correlate clinical and pathologic parameters with survival in patients submitted to pancreatic resection for pancreatic adenocarcinoma. Methods. Surgical resection with curative intent (R0 and R1 resections) was performed in 65 pancreatic cancer patients between 1990 and 2006. The overall results of surgical treatment were retrospectively analyzed and compared with the clinicopathologic features of these patients. Results. Pylorus-preserving pancreatoduodenectomy was performed in 37 patients (56.9%), classic resection in 35.4%, distal pancreatectomy in 4.6% and total pancreatectomy in 3.6%. The inhospital mortality was 5% (three patients). Postoperative complications occurred in 28 patients (43%). Mean survival and five-year survival rate after curative resection were 27 months and 9.0%, respectively. Sex, TNM stage, tumor differentiation, neural invasion, tumor size and involvement of resection margin were significant prognostic factors on univariate analysis. Multivariate analysis showed tumor differentiation and neural invasion as prognostic factors. Conclusion. Patients with pancreatic cancer, even those with poor prognostic factors should be given the opportunity of surgical resection with curative intent.     

Second pancreatectomy for recurrent pancreatic ductal adenocarcinoma in the remnant pancreas: A pooled analysis

ObjectivesThe aim of this study was to examine the outcomes of second pancreatectomy for the treatment of recurrent pancreatic ductal adenocarcinoma (PDAC) in the remnant pancreas.MethodSearch of the PubMed database was undertaken to identify relevant English language studies. Pooled individually data were examined for clinical outcomes after second pancreatectomy for recurrent PDAC.ResultsA total of 19 articles involving 55 patients were eligible for inclusion. The median disease-free interval after initial resection was 33 (range 7–143) months. Of the 55 patients reported, 52 (94.5%) patients underwent completion total pancreatectomy in the second operation for recurrences, including 15 patients who developed recurrences more than 5 years after the initial operation. There was no perioperative death. The 1-, 3- and 5-year overall survival rate after the second pancreatectomy was 82.2%, 49.2% and 40.6% respectively.ConclusionSecond pancreatectomy for recurrent PDAC can be performed safely with long-term survival in selected patients.     

Long-term outcomes of patients with multifocal intraductal papillary mucinous neoplasm following pancreatectomy

BackgroundThe decision to perform surgery is complicated by the presence of multifocal (MF) intraductal papillary mucinous neoplasms (IPMNs), which are characterized by two or more cysts located in different areas of the pancreas.ObjectivesWe aimed to establish a suitable treatment strategy and surgical indications in patients with MF-IPMNs.MethodsThis single-center retrospective study included patients with IPMNs who underwent pancreatic resection from 2006 to 2020. Patients with distant metastasis and patients with IPMNs of the main pancreatic duct were excluded from the analysis.ResultsAfter excluding 22 patients, 194 patients were included. One hundred thirteen patients (58.2%) had unifocal IPMNs, while 81 patients (41.8%) had MF-IPMNs. There were no significant differences in the 5-year disease-specific survival (DSS) rate (92.3% vs. 92.4%, p = 0.976) and the 5-year disease-free survival rate (88.6% vs. 86.5%, p = 0.461). The multivariate analysis identified high-risk stigmata, invasive carcinoma, and lymph node metastasis as independent predictors of DSS. The presence of cystic lesions in the pancreatic remnant was not a predictor of survival. Even in the MF-IPMN group, there were no significant differences in DSS when stratified by procedure (total pancreatectomy vs. segmental pancreatectomy, p = 0.268) or presence of cystic lesions in the pancreatic remnant (p = 0.476). The multivariate analysis identified lymph node metastasis as an independent predictor of DSS in the MF-IPMN group.ConclusionsIn patients with MF-IPMNs, each cyst should be evaluated individually for the presence of features associated with malignancy.     

Exocrine pancreatic insufficiency in distal pancreatectomy: incidence and risk factors

BackgroundExocrine pancreatic insufficiency (EPI) is a known consequence of pancreatic resection; however, its incidence following distal pancreatectomy is not well defined. The aim of this study was to describe the prevalence of EPI in patients undergoing distal pancreatectomy and moreover identify risk factors for developing de-novo EPI after distal pancreatectomy.MethodsA prospectively maintained institutional pancreatic resection database was interrogated to identify patients who underwent distal pancreatectomy from 2005 to 2015. Pre- and post-operative exocrine function, histopathology, demographics and volume of pancreas resected were analyzed.ResultsThe cohort consisted of 324 patients, 22 (6.8%) presented with EPI pre-operatively. 38 (12.6%) patients developed new onset EPI requiring pancreatic enzyme replacement therapy. There was no relationship between patient demographics or diabetes status and requirement for pancreatic enzyme replacement therapy, and no significant effect of resection volume on the need for pancreatic enzyme replacement therapy post-operatively (p ≥ 0.05). Having an underlying obstructive pancreatic pathology (p = 0.002) or a presenting history of acute pancreatitis (p < 0.001) significantly predicted development of de-novo EPI.ConclusionThese results indicate that pre-existing EPI at time of surgery is not uncommon. Patients presenting for distal pancreatectomy should be assessed pre-operatively for the need for pancreatic enzyme replacement therapy.     

Hepato-pancreatectomy: how morbid? Results from the national surgical quality improvement project

BackgroundSimultaneous resection of both the liver and the pancreas carries significant complexity. The objective of this study was to investigate peri-operative outcomes after a synchronous hepatectomy and pancreatectomy (SHP).MethodsThe American College of Surgeons National Surgical Quality Improvement Project database was queried to identify patients who underwent SHP. Resections were categorized as ‘< hemihepatectomy’, ‘≥ hemihepatectomy’ (hemihepatectomy and trisectionectomy), ‘PD’ (pancreaticoduodenectomy and total pancreatectomy) and ‘distal’ (distal pancreatectomy and enucleation).ResultsFrom 2005 to 2013, 480 patients underwent SHP. Patients were stratified based on the extent of resection: ‘< hemihepatectomy + distal (n = 224)’, ‘≥ hemihepatectomy + distal’ (n = 49), ‘< hemihepatectomy + PD’ (n = 83) and ‘≥ hemihepatectomy + PD’ (n = 24). Although the first three groups had a reasonable and comparable safety profile (morbidity 33–51% and mortality 0–6.6%), the ‘≥ hemihepatectomy + PD’ group was associated with an 87.5% morbidity (organ space infection 58.3%, re-intubation 12.5%, reoperation 25% and septic shock 25%), 8.3% 30-day mortality and 18.2% in-hospital mortality.ConclusionsA synchronous hemihepatectomy (or trisectionectomy) with PD remains a highly morbid combination and should be reserved for patients who have undergone extremely cautious selection.