Background
Solid pseudopapillary tumors (SPPTs) are low malignant potential entities found mainly in young females.
1
,
2
Pancreatectomy without tumor rupture is the treatment of choice, and the ...laparoscopic approach is indicated.
3
,
4
Limited pancreatectomy is possible due to the low risk of malignancy (< 10%) based on the low risk of lymph node invasion or true vascular invasion.
1
,
2
Centrally located large SPPTs can be treated by extended central pancreatectomy with or without vascular resection to avoid pancreatoduodenectomy or distal pancreatectomy.
Methods
A 24-year-old woman was admitted with abdominal pain. A 6-cm SPPT was discovered at the neck–body junction in close contact with the anterior aspect of the mesentericoportal vein (MPV) and the splenic vessels, with signs of segmental portal hypertension. To avoid an extended pancreatectomy for this young patient, an extended central pancreatectomy was performed, with resection of the splenic vessels, and the MPV was freed from the tumor under clamping for 10 min, with no need for vascular reconstruction. The duration of the surgery was 260 min, with 200 ml of blood loss and no transfusion.
Results
The woman’s postoperative course was uneventful, with a hospital stay of 16 days. Histology confirmed the diagnosis of a 6-cm SPPT tumor (R0 and N0). The patient was asymptomatic 1 year later, with no tumor recurrence and no pancreatic insufficiency. Between 2011 and 2018 the authors performed 72 laparoscopic central pancreatectomies, with SPPT performed for 13 patients (18%). Laparoscopic central pancreatectomy was extended (
n
= 5) or standard (
n
= 8) with no conversion, no recurrence, and no pancreatic insufficiency.
Conclusion
An SPPT tumor is a good indication for the laparoscopic approach because this entity is found in young patients with a low risk of malignancy. Large centrally located tumors can be treated by extended central pancreatectomy to avoid a large pancreatectomy with greater early and long-term disadvantages.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract Background Early biliary complications (EBC) following pancreaticoduodenectomy (PD) are poorly known. This study aimed to assess incidence, predictive factors, and treatment of EBC including ...bilio-enteric stricture, transient jaundice, biliary leak, and cholangitis. Method From 2007 to 2011, 352 patients underwent PD. Statistical analysis including logistic regression was performed to determine EBC predictive factors. Results 49 patients (14%) developed 51 EBC, including 7(2%) bilio-enteric strictures, 15(4%) transient jaundices, 9(3%) biliary leaks, and 20(6%) cholangitis with no mortality and a 18% reoperation rate. In multivariate analysis, male gender, benign disease, malignancy with preoperative chemoradiation, and common bile duct (CBD) diameter ≤5 mm were predictive of EBC. Of the 7 strictures, all were associated with CBD ≤5 mm and 5(71%) required reoperation. Transient jaundice resolved spontaneously in all 15 cases. Among 8 patients with serum bilirubin level >50 μmol/L (3 mg/dL) at POD3, 7(88%) developed bilio-enteric stricture. Biliary leak resolved spontaneously in 5(56%); otherwise, it required reoperation. Cholangitis recurred after antibiotics discontinuation in 5(25%). Conclusions EBC following PD do not increase mortality. EBC are more frequent in case of male gender, benign disease, malignancy with preoperative chemoradiation, and CBD ≤5 mm. Transient jaundice or cholangitis have a favorable outcome, whereas bilio-enteric stricture or biliary leak can require reintervention.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Out of the context of haematological patients, Candida sp. is rarely retrieved from pyogenic liver abscesses (PLA).
Our objective was to assess the risk factors for occurrence, and clinical, ...microbiological characteristics, management and outcome of Candida pyogenic liver abscesses (C-PLA).
We retrospectively analysed C-PLA cases and compared them to pyogenic liver abscesses exclusively due to bacteria (B-PLA) included in our monocentric database on liver abscesses. Unfavourable course was defined as the occurrence of a primary treatment failure (PTF), recurrence after an initial cure, or death within 3 months after diagnosis.
Between 2010 and 2018, 15 C-PLA and 292 B-PLA were included. All C-PLA had a biliary origin and were polymicrobial. All patients with C-PLA had at least one comorbidity at risk for Candida infection and 7 (53.3%) presented with sepsis requiring an admission in intensive care unit. Median duration of antifungal treatment was 42 days 24-55. In multivariate analysis, compared with B-PLA, a medical history of malignancy (OR 4.16; 95%CI 1.15-18.72) or liver abscess (OR 7.39; 95%CI 2.10-26.62), and sepsis with severity criteria (OR 3.52; 95%CI 1.07-11.90) were independently associated with the occurrence of C-PLA. In multivariate analysis, C-PLA was associated with a higher risk of recurrence (HR 3.08; 95%CI 1.38-11.22).
Candida liver abscesses in non-neutropenic is a rare and severe disease. The high rate of recurrence should lead to discuss a more intensive treatment.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
A standardized laparoscopic right hepatectomy (LRH) approach named the “caudal approach” was recently reported. Yet, the value of this approach compared with state-of-the-art open right ...hepatectomy (ORH) remains unknown. The purpose of this study was therefore to compare the short-term outcomes of LRH using the caudal approach and ORH with anterior approach and liver hanging maneuver.
Methods
One-hundred eleven consecutive patients who underwent LRH with caudal approach were prospectively collected; 346 patients who underwent ORH with anterior approach and liver hanging maneuver were enrolled as a control group. Propensity score matching (PSM) of patients in a ratio of 1: 1 was conducted and the perioperative outcomes were compared.
Results
After PSM, two well-balanced groups of 72 patients each were analyzed and compared. The conversion rate in the LRH group was 18.1%. Perioperative blood loss and transfusion rates were significantly lower in the LRH group as compared to the ORH group (median, 200 ml vs. 500 ml,
p
< 0.001 and 9.9% vs. 26.8%,
p
= 0.009, respectively), while operation time was significantly longer (median, 348 min vs. 290 min,
p
< 0.001). Overall (26.4% vs. 48.6%,
p
= 0.006) and symptomatic pulmonary (6.9% vs. 19.4%,
p
= 0.027) complication rates were significantly lower in the LRH group. Hospital stay was significantly shorter in the LRH group (median, 8 days vs. 9 days,
p
= 0.013).
Conclusions
LRH using the caudal approach is associated with improved short-term outcomes compared to state-of-the-art ORH in patients qualifying for both approaches, and can be proposed as standard practice.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The predictive risk factors of clinically relevant pancreatic fistula (CR-PF) following distal pancreatectomy (DP) remain to be identified.
Methods
This is a retrospective cohort analysis ...of a single-institution database of patients undergoing DP, taking into account usual demographic, operative, and pathologic variables and visceral fat area (VFA), total muscle area (TMA), and surface muscle index (SMI) measured on preoperative CT scan. The primary end point was CR-PF. All variables associated with a
p
value < 0.05 on univariate analysis were included in a logistic regression model for multivariate analysis.
Results
From 2012 to 2016, 208 patients operated by 4 pancreatic surgeons underwent DP including 32 (15%) who developed CR-PF. Risk factors of CR-PF on univariate analysis were: BMI ≥ 25 kg/m
2
(
p
= 0.050), VFA ≥ 92 cm
2
(
p
= 0.006), laparotomy (
p
= 0.023), main pancreatic duct dilatation (
p
= 0.035), open passive drainage (versus closed suction drainage) (
p
= 0.001), and blood loss ≥ 225 ml (
p
= 0.001). Sarcopenia did not influence the risk of CR-PF (
p
= 0.076). On multivariate analysis, VFA ≥ 92 cm
2
(OR 3.14; IC 95% (1.18–8.31),
p
= 0.022), blood loss ≥ 225 ml (OR: 2.72; IC 95% (1.06–6.96),
p
= 0.037), and open passive drainage (OR 3.72; IC 95% (1.40–9.87)
p
= 0.008) were three independent predictive factors of CR-PF. A CR-PF risk score was developed, predicting a 0% risk of CR-PF when no risk factors were present and a 39% risk when the 3 risk factors were present.
Conclusions
Visceral obesity, blood loss ≥ 225 ml and open passive drainage significantly increase the risk of CR-PF following DP.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Several studies have suggested a survival benefit of neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) in the pancreatic head. Data concerning NAT for PDAC located in ...pancreatic body or tail are lacking.
Methods
Post hoc analysis of an international multicenter retrospective cohort of distal pancreatectomy for PDAC in 34 centers from 11 countries (2007–2015). Patients who underwent resection after NAT were matched (1:1 ratio), using propensity scores based on baseline characteristics, to patients who underwent upfront resection. Median overall survival was compared using the stratified log-rank test.
Results
Among 1236 patients, 136 (11.0%) received NAT, most frequently FOLFIRINOX (25.7%). In total, 94 patients receiving NAT were matched to 94 patients undergoing upfront resection. NAT was associated with less postoperative major morbidity (Clavien–Dindo ≥ 3a, 10.6% vs. 23.4%,
P
= 0.020) and pancreatic fistula grade B/C (9.6% vs. 21.3%,
P
= 0.026). NAT did not improve overall survival 27 (95% CI 14–39) versus 31 months (95% CI 19–42),
P
= 0.277, as compared with upfront resection. In a sensitivity analysis of 251 patients with radiographic tumor involvement of splenic vessels, NAT (
n
= 37, 14.7%) was associated with prolonged overall survival 36 (95% CI 18–53) versus 20 months (95% CI 15–24),
P
= 0.049, as compared with upfront resection.
Conclusion
In this international multicenter cohort study, NAT for resected PDAC in pancreatic body or tail was associated with less morbidity and pancreatic fistula but similar overall survival in comparison with upfront resection. Prospective studies should confirm a survival benefit of NAT in patients with PDAC and splenic vessel involvement.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Postoperative pancreatic fistula (POPF) is the most serious complication following pancreaticoduodenectomy (PD). Identifying patients at high or low risk of developing POPF is important in ...perioperative management. This study aimed to determine a predictive risk score for POPF following PD, and compare it to preexisting scores.
Methods
All patients who underwent open PD from 2012 to 2017 in two high-volume centers were included. The training dataset was used for the development of the POPF predictive risk score (using the 2016 ISGPS definition), while the testing dataset was used for external validation. The proposed score was compared to the fistula risk score (FRS), the NSQIP-modified FRS (mFRS), and the alternative FRS (aFRS).
Results
Overall, 448 and 213 patients were included in the training and testing datasets, respectively. A probabilistic predictive risk score was developed using four independent POPF risk factors (increasing age, no preoperative radiation therapy, soft pancreatic stump, and decreasing main pancreatic duct diameter). The discriminative capacities of the new score, FRS, mFRS, and aFRS were similar (AUC ranging from 0.73 to 0.79 in the training cohort and from 0.73 to 0.76 in the testing cohort). However, the new score identified more specifically patients at low risk of POPF compared with other scores, in both cohorts, with a 6% false-negative rate.
Conclusions
Preoperative radiation therapy is an independent protective factor of POPF following PD. It should be included in the risk score of POPF to identify more precisely patients at low risk for this complication.
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EMUNI, FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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