Background
Enhanced recovery after surgery (ERAS
®
) pathways have reduced morbidity and length of hospital stay (LOS) in orthopedics, bariatric, and colorectal surgery. New perioperative care ...protocols have been tested in patients undergoing pancreaticoduodenectomy (PD), with controversial results on morbidity. Incomplete data about ERAS items compliance have been reported. The aim of this study was to assess compliance with an ERAS protocol and its impact on short-term outcome in patients undergoing PD.
Methods
A comprehensive ERAS protocol was applied in 115 consecutive patients undergoing PD. Each ERAS patient was matched with one patient who received standard perioperative care. Match criteria were age, gender, malignant/benign disease, and PD-specific prognostic score.
Results
No adverse effect related to ERAS items occurred. Compliance with postoperative items ranged between 38 and 66 %. The ERAS group had an earlier recovery of mobilization (
p
< 0.001), oral feeding (
p
< 0.001), gut motility (
p
< 0.001), and an earlier suspension of intravenous fluids (
p
= 0.041). No difference between ERAS and control group was found in mortality, overall morbidity, and major complication rates. Subgroup analysis showed that 43/60 (71 %) patients with early postoperative low compliance with the ERAS pathway had complications. The ERAS pathway significantly shortened LOS in uneventful patients or those with minor complications (11.2 vs. 13.7 days,
p
= 0.001).
Conclusion
The ERAS pathway was feasible and safe, yielding an earlier postoperative recovery. An ERAS protocol should be implemented in patients undergoing PD; however, patients with early postoperative low compliance should be carefully managed.
To develop and validate a simple prognostic score to predict major postoperative complications after pancreaticoduodenectomy (PD).
PD still carries a high rate of severe postoperative complications. ...No specific score is currently available to stratify the patient's risk of major morbidity.
Between 2002 and 2010, preoperative, intraoperative, and outcome data from 700 consecutive patients undergoing PD in our institution were prospectively collected in an electronic database. Major complications were defined as levels III to V of Clavien-Dindo classification. On the basis of a multivariate regression model, the score was developed using a random two-thirds of the population (n = 469) and was validated on the remaining 231 patients.
Major complication rate was 16.7% (117/700). Significant predictors included in the scoring system were: pancreas texture, pancreatic duct diameter, operative blood loss, and ASA score. The mean risk of developing major postoperative complications was 7% in patients with score 0 to 3, 13% in patients with score 4 to 7, 23% in patients with score 8 to 11, and 36% in patients with score 12 to 15. In the validation population, the predicted risk of major complications was 15.2% versus a 16.9% observed risk (C-statistic index = 0.743).
This new score may accurately predict a patient's postoperative outcome. Early identification of high-risk patients could help the surgeon to adopt intraoperative and postoperative strategies tailored on individual basis.
Pancreatic surgery is being offered to an increasing number of patients every year. Although postoperative outcomes have significantly improved in the last decades, even in high-volume centers ...patients still experience significant postoperative morbidity and full recovery after surgery takes longer than we think. In recent years, enhanced recovery pathways incorporating a large number of evidence-based perioperative interventions have proved to be beneficial i n t e r m s o f i m p rove d p o s t o p e ra t i ve o u t c o m e s, and accelerated patient recovery in the context of gastrointestinal, genitourinary and orthopedic surgery. The role of these pathways for pancreatic surgery is still unclear as high-quality randomized controlled trials are lacking. To date, non-randomized studies have shown that care pathways for pancreaticoduodenectomy and distal pancreatectomy are safe with no difference in postoperative morbidity, leading to early discharge and no increase in hospital readmissions. Hospital costs are reduced due to better organization of care and resource utilization. However, further research is needed to clarify the effect of enhanced recovery pathways on patient recovery and post-discharge outcomes following pancreatic resection. Future studies should be prospective and follow recent recommendations for the design and reporting of enhanced recovery pathways.
Background
The prognostic role of resection margins in pancreatic ductal adenocarcinoma (PDAC) is debated. This study aimed to investigate the impact that global and individual resection margin ...status after pancreatic head resection for PDAC has on disease-free survival (DFS) and disease-specific survival (DSS).
Methods
Surgical specimens of pancreaticoduodenectomy/total pancreatectomy performed for PDAC were examined with a standardized protocol. Surgical margin status (biliary, pancreatic neck, duodenal, anterior and posterior pancreatic, superior mesenteric vein groove and superior mesenteric artery margins) was classified as the presence of malignant cells (1) directly at the inked surface (
R
1 direct), (2) within less than 1 mm (
R
1 ≤ 1 mm), or (3) with a distance greater than 1 mm (
R
0). Patients with a positive neck margin at the final histology were excluded from the study.
Results
Of the 362 patients included in the study, 179 patients (49.4 %) had an
R
0 resection, 123 patients (34 %) had an
R
1 ≤ 1 mm resection, and 60 patients (16.6 %) had an
R
1 direct resection. The independent predictors of DFS were
R
1 direct resection (hazard ratio HR, 1.49),
R
1 ≤ 1 mm resection (HR, 1.38), involvement of one margin (HR, 1.36), and involvement of two margins or more (HR, 1.55). When surgical margins were analyzed separately, only
R
1 ≤ 1 mm superior mesenteric vein margin (HR, 1.58) and
R
1 direct posterior margin (HR, 1.69) were independently associated with DFS.
Conclusions
Positive
R
status is an independent predictor of DFS (
R
1 direct and
R
1 ≤ 1 mm definitions) and of DSS (
R
1 direct). The presence of multiple positive margins is a risk factor for cancer recurrence and poor survival. Different surgical margins could have different prognostic roles.
Autologous islet cell transplantation is a procedure performed to prevent or reduce the severity of diabetes after pancreatic resection. Autologous islet cell transplantation is being used almost ...exclusively in patients undergoing pancreatectomy because of painful, chronic pancreatitis, or multiple recurrent episodes of pancreatitis that is not controlled by standard medical and surgical treatments. Here, we discuss the possibility of extending the clinical indications for this treatment on the basis of our experience in patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, including patients undergoing completion pancreatectomy because of anastomosis leakage after pancreaticoduodenectomy and those with pancreatic anastomosis deemed at high risk for failure.
Background
Pancreatic neuroendocrine neoplasms (PanNEN) are ideal entities for minimally invasive surgery. The advantage of the laparoscopic approach in terms of complications, length of stay (LOS) ...and cosmetic results has been previously demonstrated. However, scarce data are available on long-term oncological outcomes. Aim of this study was to compare short-term postoperative outcomes, pathological findings and long-term oncological results of minimally invasive distal pancreatectomy (MIDP) and open distal pancreatectomy (ODP) for PanNEN.
Methods
Patients who underwent ODP or MIDP for nonfunctioning PanNEN (NF-PanNEN) were retrospectively analyzed. Inverse probability of treatment weighting using propensity score was performed to compare the outcomes of MIDP and ODP.
Results
Overall, 124 patients were included in the study: 84 underwent OPD, whereas 40 were submitted to MIDP. The rate of high-grade postoperative complications was significantly lower in the MIDP group (
p
= 0.005, grade of complication with highest estimated probability 0 vs 2) and the postoperative LOS was significantly shorter after MIDP (
p
< 0.001, estimated days 8 versus 10). The number of examined lymph nodes (ELN) in the ODP group was significantly higher (
p
= 0.0036, estimated number of ELN 13 vs 10). Similar disease-free survival and overall survival were reported for the two groups (
p
= 0.234 and
p
= 0.666, respectively).
Conclusions
Although MIDP for PanNEN seems to be associated with a lower number of ELN, long-term survival is not influenced by the type of surgical approach. MIDP is advantageous in terms of postoperative complications and LOS, but prospective studies are needed to confirm the overall oncological quality of resection in this group of neoplasms.
Background
A recent RCT showed similar postoperative outcomes and a reduced time to functional recovery in patients undergoing minimally invasive distal pancreatectomy (DP) compared to open approach. ...However, it reported very-high post-discharge readmission rates, calling for further investigation. The aim of our study was to evaluate the extent to which minimally invasive surgery impacts on postoperative readmissions following DP.
Methods
Clinical data for patients undergoing DP between 2011 and 2018 were reviewed. Primary outcome was hospital readmission at 90 days after surgery. Secondary outcomes included post-discharge emergency department (ED) visits and time to functional recovery. Regression analyses were performed to evaluate the impact of the laparoscopic approach and other perioperative factors.
Results
Overall, 376 consecutive patients underwent DP during the study period. Laparoscopy was successfully performed in 219 (58%) patients. Overall, 62 patients (16.5%) returned to the ED after discharge, 41 (18.7%) of laparoscopically operated patients, and 21 (13.4%) of those undergoing open surgery (
p
= 0.162). Forty-six (12.2%) of them required readmission, 31 (14.2%) after laparoscopic, and 15 (9.6%) after open procedures (
p
= 0.179). At multivariate regression, a low preoperative physical status (OR 2.3, 95% CI 1.2–4.7;
p
= 0.017), occurrence of pancreatic fistula (OR 6.8, 95% CI 2.9–15.9;
p
< 0.001), and post-pancreatectomy hemorrhage (OR 3.9, 95% CI 1.2–13.1;
p
= 0.025) were significantly associated with 90-day readmission, while laparoscopy had no impact. Median time to reach functional recovery was 5 (IQR 4–6) days. At multivariate analysis, laparoscopy reduced time to functional recovery by 13% (95% CI − 19 to − 6%;
p
< 0.001), time to adequate oral intake by 19% (95% CI − 27 to − 10%;
p
< 0.001), and time to adequate pain control by 12% (95% CI − 18 to − 5%;
p
< 0.001).
Conclusion
Hospital readmissions and ED visits following DP were not influenced by the surgical approach. A low preoperative physical status, occurrence of postoperative pancreatic fistula and hemorrhage were significantly associated with post-discharge readmission within 90 days. Laparoscopy reduced time to functional recovery.
Background
Despite the close relationship between hospital volume and mortality after pancreaticoduodenectomy (PD), the role of surgeon volume still remains an open issue. Retrospective ...multi-institutional reviews considered only in-hospital mortality, whereas no data about major complications are available so far. The aim of this study is to assess the independent impact of surgeon volume on outcome after PD in a single high-volume institution.
Methods
Demographics and clinical and surgical variables were prospectively collected on 610 patients who underwent PD from August 2001 to August 2009. The cutoff value to categorize high- and low-volume surgeons (HVS and LVS, respectively) was 12 PD/year. The primary endpoint was operative mortality (death within 30-day post-discharge). Secondary endpoints were morbidity, pancreatic fistula (PF), and length of hospital stay (LOS).
Results
In the whole series, mortality was 4.1%, overall morbidity was 61.3%, and PF rate was 27.5%. Two HVS performed 358 PD (58.6%), while six LVS performed 252 PD (41.4%). Mortality was 3.9% for HVS and 4.3% for LVS (
p
= 0.84). The major complication rate was similar for HVS and LVS (14.5% vs. 16.2%). The PF rate was higher for LVS (32.4% vs. 24.1%,
p
= 0.03). The mean LOS was 15.5 days for HVS vs. 16.9 days for LVS (
p
= 0.11). At multivariate analysis, risk factors for PF occurrence were LVS, soft pancreatic stump, small duct diameter, and longer operative time.
Conclusion
Low-volume surgeons had a higher PF rate. However, this did not increase mortality and major morbidity rates probably because of the protective effect of high-volume hospital in improving patient rescue from life-threatening complications.
The aim of this study is to provide a comprehensive characterization of stemness in pancreatic ductal adenocarcinoma (PDAC) cell lines. Seventeen cell lines were evaluated for the expression of ...cancer stem cell (CSC) markers. The two putative pancreatic CSC phenotypes were expressed heterogeneously ranging from 0 to 99.35% (median 3.46) for ESA+CD24+CD44+ and 0 to 1.94% (median 0.13) for CXCR4+CD133+. Cell lines were classified according to ESA+CD24+CD44+ expression as: Low-Stemness (LS; <5%, n = 9, median 0.31%); Medium-Stemness (MS; 6−20%, n = 4, median 12.4%); and High-Stemness (HS; >20%, n = 4, median 95.8%) cell lines. Higher degree of stemness was associated with in vivo tumorigenicity but not with in vitro growth kinetics, clonogenicity, and chemo-resistance. A wide characterization (chemokine receptors, factors involved in pancreatic organogenesis, markers of epithelial−mesenchymal transition, and secretome) revealed that the degree of stemness was associated with KRT19 and NKX2.2 mRNA expression, with CD49a and CA19.9/Tie2 protein expression, and with the secretion of VEGF, IL-7, IL-12p70, IL-6, CCL3, IL-10, and CXCL9. The expression of stem cell markers was also evaluated on primary tumor cells from 55 PDAC patients who underwent pancreatectomy with radical intent, revealing that CXCR4+/CD133+ and CD24+ cells, but not ESA+CD24+CD44+, are independent predictors of mortality.
Background
Pancreas is a possible site of metastases from renal cell carcinoma (RCC). The aim of this study was to define the role of surgery in their treatment.
Methods
We retrospectively analyzed ...36 patients with pancreatic metastasis from RCC observed between January 1998 and February 2006. Patients were categorized into three risk groups according to the modified Memorial Sloan-Kettering prognostic factors model.
Results
Resective surgery was performed in 23 patients, as follows: 11 distal pancreatectomy, 5 enucleation, 4 pancreatoduodenectomy, 2 total pancreatectomy, and 1 middle pancreatectomy. No perioperative mortality was observed; the morbidity rate was 47.8%. All patients who underwent resection belonged to the favorable risk group. Surgical resection was excluded in 13 cases because of locally advanced disease (2 cases) or extrapancreatic disease (11 cases); 5 of these patients were at favorable, 7 at intermediate, and 1 at poor risk. In patients undergoing surgery, the 5-year actuarial survival rate was 88%, and median disease-free survival was 44 months. Patients who did not undergo surgery had a 5-year survival rate of 47%, with a median survival time of 27 months (
P
= .02).
Conclusions
Patients with pancreatic metastases from RCC belonging to a favorable risk group are candidates for resection, even in the presence of another metastatic site or multifocal pancreatic disease.
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