Intraoperative Ultrasound with Contrast Medium in Resective Pancreatic Surgery: A Pilot Study

Background  

The introduction of contrast-enhanced ultrasound has been a major innovation in liver and pancreatic imaging. Previous studies have validated its intraoperative use during liver surgery, while there is a lack of data regarding its use during pancreatic surgery. The purpose of the present study was to prospectively evaluate the possible role of contrast-enhanced intraoperative ultrasound (CEIOUS) during resective pancreatic surgery for primary lesion characterization and intraoperative staging.     

Anatomy-Specific Pancreatic Stump Management to Reduce the Risk of Pancreatic Fistula After Pancreatic Head Resection

Background  

The anatomical status of the pancreatic remnant after a pancreatic head resection varies greatly among patients. The aim of the present study was to improve management of the pancreatic remnant for reducing pancreatic fistula after pancreatic head resection.     

Inverted Meckel’s Diverticulum with Ectopic Pancreatic Tissue as a Source of Severe Gastrointestinal Bleeding

Introduction  

Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract. Authors present a 67-year-old woman treated for iron deficiency anemia for the past 5 years. Suddenly, her disease was presented with painless severe gastrointestinal bleeding (fresh melena). Inverted Meckel’s diverticulum with ectopic pancreatic tissue as a source of severe gastrointestinal bleeding was diagnosed by intraoperative enteroscopy.     

After Distal Pancreatectomy Pancreatic Leakage from the Stump of the Pancreas May Be Due to Drain Failure or Pancreatic Ductal Back Pressure

Hypothesis  

The method to lower postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) involves controlling risk factors for leakage from the pancreatic stump.     

Effect of TachoSil Patch in Prevention of Postoperative Pancreatic Fistula

Background  

Postoperative pancreatic fistula (POPF) is a severe complication after pancreatic resections. The aim was to assess if application of TachoSil? patch could reduce incidence of postoperative fistulas after laparoscopic distal pancreatic resections.     

Enucleation of Pancreatic Cystadenomas

Background  

Optimal surgical treatment of pancreatic cystadenomas is controversial due to the rarity of the tumors and paucity of studies regarding long-term outcomes. This is especially true for large pancreatic cystadenomas. The objective of this study was to determine the safety and effectiveness of treating pancreatic cystadenomas by enucleation.     

Correlation between Preoperative Imaging and Intraoperative Risk Assessment in the Prediction of Postoperative Pancreatic Fistula Following Pancreatoduodenectomy

Background

Prediction of postoperative pancreatic fistula (POPF) can be carried out with the intraoperative assessment of pancreatic consistency (PC) and via pancreatic duct width (iPDW). Preoperative computed tomography (CT) calculated pancreatic remnant volume (PRV) and duct width (rPDW) have also been shown to offer useful information about the risk of POPF.

Objective

The objective of this study was to determine the predictive value of the preoperative radiological features as compared with the intraoperative risk estimation for the subsequent development of POPF.

Method

All patients undergoing pancreatoduodenectomy between September 2007 and March 2012 at the Karolinska University Hospital Stockholm were included. PRV and rPDW were determined on preoperative CT and in parallel, intraoperative PC and iPDW of the remnant pancreas were independently assessed.

Results

A total of 296 consecutive pancreatoduodenectomies were included. POPF occurred in 45 patients (15.2 %). Of those with a preoperatively calculated PRV < 23.0 cm³, 2.8 % developed POPF compared with 25.7 % of those with a corresponding volume > 46.0 cm³. In patients with an rPDW > 7.0 mm, 4.1 % had a POPF as compared with 38.7 % for those with rPDW < 2.0 mm. The POPF risk estimates based on PRV and rPDW and the intraoperative risk assessments were found to be identical (p < 0.001). In the receiver operating characteristic analysis, area under the curve was 0.80 (95 % confidence interval [CI] 0.72–0.87) and 0.80 (95 % CI 0.72–0.88) for the CT-based and intraoperative risk prediction models, respectively.

Conclusions

Preoperative CT-based and intraoperative gland risk assessments offer comparable predictive information on the risk of POPF after pancreatoduodenectomy. These results imply that accurate POPF risk estimation can be carried out in the preoperative setting to opt for improved patient selection into relevant research protocols and the availability of surgical expertise and techniques.     

Multivisceral Resections in Pancreatic Cancer: Identification of Risk Factors

Background

There is an assumption that multivisceral resections (MVRs) in patients with a pancreatic malignancy are associated with higher morbidity. The oncologic benefit, however, remains controversial.

Methods

The aim was to identify risk factors for complications in cases of MVR in patients with pancreatic cancer. Of 1099 patients who underwent major pancreatic resection at our institution between January 1992 and October 2008, a total of 55 were treated with an MVR involving resection of one or more additional organs. This group was compared with 154 patients who had palliative bypass surgery and 303 patients who underwent standard pancreatic head resection.

Results

Multivisceral resection patients had an overall higher incidence of major surgical complications (p?2?days were identified as predictors of survival in the univariate Cox regression analysis; in the multivariate analysis, only the T status was confirmed. Median survival after MVR was 16?months, after palliative bypass 6?months, and after standard resection 18?months (p?Conclusions Multivisceral resections are technically feasible procedures with increased survival when compared to palliative bypass procedures. The incidence of postoperative complications was increased with kidney resection and when intraoperative transfusion was required.     

Laparoscopic Drainage of Pancreatic Pseudocysts: a Methodological Approach

Background  

This paper describes our tailored and methodological approach to laparoscopic drainage of pancreatic pseudocysts (PPs) based on an anatomical classification.     

Intraoperative Pancreatic Cancer Detection using Tumor-Specific Multimodality Molecular Imaging

Background

Operative management of pancreatic ductal adenocarcinoma (PDAC) is complicated by several key decisions during the procedure. Identification of metastatic disease at the outset and, when none is found, complete (R0) resection of primary tumor are key to optimizing clinical outcomes. The use of tumor-targeted molecular imaging, based on photoacoustic and fluorescence optical imaging, can provide crucial information to the surgeon. The first-in-human use of multimodality molecular imaging for intraoperative detection of pancreatic cancer is reported using cetuximab-IRDye800, a near-infrared fluorescent agent that binds to epidermal growth factor receptor.

Methods

A dose-escalation study was performed to assess safety and feasibility of targeting and identifying PDAC in a tumor-specific manner using cetuximab-IRDye800 in patients undergoing surgical resection for pancreatic cancer. Patients received a loading dose of 100 mg of unlabeled cetuximab before infusion of cetuximab-IRDye800 (50 mg or 100 mg). Multi-instrument fluorescence imaging was performed throughout the surgery in addition to fluorescence and photoacoustic imaging ex vivo.

Results

Seven patients with resectable pancreatic masses suspected to be PDAC were enrolled in this study. Fluorescence imaging successfully identified tumor with a significantly higher mean fluorescence intensity in the tumor (0.09?±?0.06) versus surrounding normal pancreatic tissue (0.02?±?0.01), and pancreatitis (0.04?±?0.01; p?<?0.001), with a sensitivity of 96.1% and specificity of 67.0%. The mean photoacoustic signal in the tumor site was 3.7-fold higher than surrounding tissue.

Conclusions

The safety and feasibilty of intraoperative, tumor-specific detection of PDAC using cetuximab-IRDye800 with multimodal molecular imaging of the primary tumor and metastases was demonstrated.

     

CC Chemokine Receptor 9 Enhances Proliferation in Pancreatic Intraepithelial Neoplasia and Pancreatic Cancer Cells

Introduction  

Chemokine receptors may regulate the progression and metastasis of invasive malignancies. There are little data, however, regarding their role in premalignant lesions. Our objective was to determine the role of CC chemokine receptor 9 (CCR9) in pancreatic intraepithelial neoplasia (PanIN).     

Potential Contribution of Preoperative Neoadjuvant Concurrent Chemoradiation Therapy on Margin-Negative Resection in Borderline Resectable Pancreatic Cancer

Background  

Margin-negative pancreatectomy provides only chance to cure pancreatic cancer. However, borderline resectable pancreatic cancer (BRPCa) has the risk of incomplete palliative resection.     

Surveillance of Pancreatic Cancer Patients after Surgical Resection

Background  

There are no clear recommendations to guide posttreatment surveillance in patients with pancreatic cancer. Our goal was to describe the posttreatment surveillance patterns in patients undergoing curative-intent resection for pancreatic cancer.     

Presence of Pancreatic Intraepithelial Neoplasia in the Pancreatic Transection Margin does not Influence Outcome in Patients with R0 Resected Pancreatic Cancer

Background

Margin status is one of the strongest prognosticators after resection of pancreatic ductal adenocarcinoma (PDAC). The clinical significance of pancreatic intraepithelial neoplasia (PanIN) at a surgical margin has not been established.

Methods

A total of 208 patients who underwent R0 resection for PDAC between 2004 and 2008 were selected. Intraoperative frozen section slides containing the final pancreatic parenchymal transection margin were evaluated for presence or absence, number, and grade of PanINs. Data were compared to clinicopathologic factors, including patient survival.

Results

PanIN lesions were present in margins in 107 of 208 patients (51.4%). Median number of PanINs per pancreatic resection margin was 1 (range, 1–11). A total of 72 patients had PanIN-1 (34.6%), 44 had PanIN-2 (21.1%), and 16 had PanIN-3 (7.2%) at their margin. Overall median survival was 17.9 (95% confidence interval, 14–21.9) months. Neither the presence nor absence of PanIN nor histological grade had any significant correlation with important clinicopathologic characteristics. There were no significant survival differences between patients with or without PanIN lesions at the resection margin or among patients with PanIN-3 (carcinoma in situ) versus lower PanIN grades. However, patients with R1 resection had a significantly worse outcome compared with patients without invasive cancer at a margin irrespective of the presence of PanIN (P = 0.02).

Conclusions

The presence of PanINs at a resection margin does not affect survival in patients who undergo R0 resection for PDAC. These results have significant clinical implications for surgeons, because no additional resection seems to be indicated when intraoperative frozen sections reveal even high-grade PanIN lesions.     

Preoperative Diabetes Mellitus and Long-Term Survival After Resection of Pancreatic Adenocarcinoma

Purpose  

To assess clinicopathologic features and postresection survival of diabetes mellitus (DM)-associated pancreatic ductal adenocarcinoma (PDAC).     

Intra-abdominal Fat Predicts Survival in Pancreatic Cancer

Background  

Body mass index (BMI) has proven unreliable in predicting survival following pancreaticoduodenectomy for cancer. While measures of intra-abdominal fat correlate with medical and postoperative complications of obesity, the impact of intra-abdominal fat on pancreatic cancer survival is uncertain. We hypothesized that the quantity of intra-abdominal fat would predict survival following resection of pancreatic cancer.     

A Focal Mass-Forming Autoimmune Pancreatitis Mimicking Pancreatic Cancer with Obstruction of the Main Pancreatic Duct

Introduction and background  

Autoimmune pancreatitis (AIP) is a rare disease that closely mimics pancreatic cancer (PC) in its presentation. It is very important for clinicians to distinguish one from the other because their treatment and prognosis are vastly different. Typical radiological imaging findings, in particular observation of diffusely or segmentally narrowed main pancreatic duct (MPD) with an irregular wall by endoscopic retrograde cholangiopancreatography (ERCP), are essential for making the diagnosis of AIP. On the other hand, MPD obstruction is one of the most frequent features on ERCP.     

Contemporary Management of Nonfunctioning Pancreatic Neuroendocrine Tumors

Background  

This article reviews the current literature and recommendations pertaining to the management of nonfunctioning pancreatic neuroendocrine tumors.     

Pancreas-Protocol Imaging at a High-Volume Center Leads to Improved Preoperative Staging of Pancreatic Ductal Adenocarcinoma

Background  

High-quality preoperative cross-sectional imaging is vital to accurately stage patients with pancreatic ductal adenocarcinoma (PDAC). We hypothesized that imaging performed at a high-volume pancreatic cancer center with pancreatic imaging protocols more accurately stages patients compared with pre-referral imaging.     

Dual-Phase Computed Tomography for Assessment of Pancreatic Fibrosis and Anastomotic Failure Risk Following Pancreatoduodenectomy

Introduction  

Delayed or decreased computed tomography (CT) enhancement characteristics in pancreatic fibrosis have been described.