Distal Pancreatectomy Patients Research Articles

The evaluation of postoperative exocrine pancreatic insufficiency in patients with benign and low-malignant pancreatic tumor: A multicenter, prospective, observational study

Objectives: We assess the incidence of exocrine pancreatic insufficiency (EPI) at different time points after pancreatic surgery and explore pancreatic enzyme replacement therapy's (PERT) efficacy. Background: EPI is characterized by inadequate pancreatic enzymes, resulting in maldigestion and abdominal symptoms. EPI is a common postoperative complication of pancreatic surgery, yet often overlooked by surgeons. There is no clear answer to when EPI occurs after pancreatic surgery nor the duration of PERT after partial pancreatectomy. Methods: Benign or borderline pancreatic tumor patients undergoing surgeries were recruited between December 2020 and November 2021 from 10 medical centers in China. The EPI Questionnaire (EPI-Q) was performed at discharge, and 3-, 6-, 9-, and 12-month follow-ups to evaluate the occurrence of EPI. Statistical analyses were performed to identify the occurrence of EPI and explore PERT's efficacy. Results: Of the 146 patients, 105 (71.9%) were female, and the median age was 49 (range 16-78 yrs). Symptoms of EPI patients were most pronounced within 3 months post-surgery (15.7%), while most patients recovered after 1 year (96.9%). There was a negative correlation between symptom score and time since surgery. Lack of PERT in the 3-month post-surgery was associated with higher symptom scores in pancreatoduodenectomy (PD) patients, while not in distal pancreatectomy (DP) patients. Conclusions: Generally, the high-occurrence period for postoperative EPI is within 3 months after resection in patients with benign or borderline pancreatic tumors, and most will gradually recuperate with time. PERT can improve symptoms in PD patients, while reduced PERT duration may be considered for DP patients.

Incisional hernia after major pancreatic resection: long term risk assessment from two distinct sources – A large multi-institutional network and a single high-volume center

BackgroundPost-operative incisional hernia (IH) is a common complication following abdominal surgery. Data regarding IH after major pancreatic surgery are limited. We aim to evaluate the long-term risk of IH following major pancreatic resection. MethodsA dual-approach study: a large multi-institutional research network (RN) was investigated for IH incidence and risk factors in propensity-score matched survivors after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), was complemented by a patient-reported questionnaire. ResultsRN analysis identified 22,113 patients that underwent pancreatic surgery. 11.0% of PD patients and 8.6% of DP patients developed IH (P < 0.0001). IH rates were higher with open surgery compared with minimally invasive approaches in PD (OR = 1.56, P = 0.03) and DP (OR = 1.94, P = 0.003). BMI>35 was found to correlate with increased IH rates for PD and DP (OR = 1.87, and OR = 1.86, respectively, P < 0.0001 each), as did postoperative intraabdominal infections (P < 0.0001). Patient-based survey of 104 patients, revealed that 16 patients (15%) reported post-operative IH during the follow-up period. BMI≥30, SSI and intra-abdominal abscesses were associated with increased IH risk (P < 0.05). ConclusionImproved survival after pancreatic resection has led to an increased prevalence of long-term surgical sequela. In this study, we demonstrate significant rates of IH among long-term survivors and assess potential risk factors.

Significance of Specimen Extraction Site in Minimizing Hernia Risk After Distal Pancreatectomy.

Incisional hernia (IH) results in significant morbidity to patients and financial burden to healthcare systems. We aimed to determine the incidence of IH in distal pancreatectomy (DP) patients, stratified by specimen extraction sites. Imaging in DP patients in our institution from 2016 to 2021 were reviewed by radiologists blinded to the operative approach. Specimen extraction sites were stratified as upper midline/umbilical (UM) versus Pfannenstiel. IH was defined as fascial defect on postoperative imaging. Patients without preoperative and postoperative imaging were excluded. Of the 219 patients who met our selection criteria, the median age was 64 years, 54% were female, and 64% were White. The majority were minimally invasive (MIS) procedures (n=131, 60%), of which 52% (n=64) had a UM incision for specimen extraction, including 45 hand-assist and 19 purely laparoscopic procedures. MIS with Pfannenstiel incisions for specimen extraction was 48% (n=58), including 44 robotic and 14 purely laparoscopic procedures. Mean follow-up time was 16.3 months (standard deviation [SD] 20.8). Follow-up for MIS procedures with UM incisions was 16.6 months (SD 21.8) versus 15.5 months (SD 18.6) in the Pfannenstiel group (p=0.30). MIS procedures with UM incisions for specimen extraction had a 17.8 times increase in odds of developing an IH compared with MIS procedures with Pfannenstiel extraction sites (p=0.01). The overall odds of developing an IH increased by 4% for every month of follow-up (odds ratio 1.04; p<0.001). A Pfannenstiel incision should be performed for specimen extraction in cases with purely laparoscopic or robotic distal pancreatectomy, when feasible.

Unnecessary Pancreatic Resection for Non-cancerous Lesions Masquerading as Pancreatic and Peri-ampullary Cancers: An Inevitable Circumstance

Background: Pancreatic and peri-ampullary cancers are deadly and require surgery. Some non-cancerous conditions, especially those that do not require surgery, have imaging findings similar to pancreatic and peri-ampullary carcinoma. The proportion of non-cancerous lesions that undergo pancreatic resection for suspected pancreatic or peri-ampullary cancer is scarce in eastern countries, especially when bile duct tumors are common. This study examined the proportion of non-cancerous lesions removed during pancreatic resection for suspected pancreatic or peri-ampullary cancer. Materials and Methods: The retrospective study included January 2013–December 2017. We investigated the medical and pathological data of 148 pancreatic resection patients at Srinagarind Hospital, Khon Kaen University. Results: Nine patients (6.1%) had postoperative pathology diagnoses that did not require surgery. The discordant group was significantly larger among distal pancreatectomy or enucleation patients (15%, 4/27) than pancreaticoduodenectomy patients (4.1%, 5/121). The concordant and discordant groups had similar clinical features for pancreaticoduodenectomy, except for gender (p=0.031). There were no clinical differences between concordant and discordant patients after distal pancreatectomy or enucleation. Conclusion: Pancreatic excision for non-cancerous conditions may be inevitable. Western and Eastern countries have different non-cancerous disorders that mimic pancreatic or peri-ampullary cancer. Western countries had more pancreatic conditions, especially inflammatory ones, but Eastern countries had more ampullary and bile duct conditions in pancreaticoduodenectomy patients and benign cystic lesions in distal pancreatectomy patients.

Clinical application of laparoscopic spleen-preserving distal pancreatectomy in patients with situs inversus totalis.

Clinical application of laparoscopic spleen-preserving distal pancreatectomy in patients with situs inversus totalis.

A novel clinical model for risk prediction and stratification of new-onset diabetes mellitus after distal pancreatectomy.

The incidence of new-onset diabetes mellitus (NODM) after distal pancreatectomy (DP) remains high. Few studies have focused on NODM in patients with pancreatic benign or low-grade malignant lesions (PBLML). This study aimed to develop and validate an effective clinical model for risk prediction and stratification of NODM after DP in patients with PBLML. A follow-up survey was conducted to investigate NODM in patients without preoperative DM who underwent DP. Four hundred and forty-eight patients from Peking Union Medical College Hospital (PUMCH) and 178 from Guangdong Provincial People's Hospital (GDPH) met the inclusion criteria. They constituted the training cohort and the validation cohort, respectively. Univariate and multivariate Cox regression, as well as least absolute shrinkage and selection operator (LASSO) analyses, were used to identify the independent risk factors. The nomogram was constructed and verified. Concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curves, and decision curve analysis (DCA) were applied to assess its predictive performance and clinical utility. Accordingly, the optimal cut-off point was determined by maximally selected rank statistics method, and the cumulative risk curves for the high- and low-risk populations were plotted to evaluate the discrimination ability of the nomogram. The median follow-up duration was 42.8 months in the PUMCH cohort and 42.9 months in the GDPH cohort. The postoperative cumulative 5-year incidences of DM were 29.1% and 22.1%, respectively. Age, body mass index (BMI), length of pancreatic resection, intraoperative blood loss, and concomitant splenectomy were significant risk factors. The nomogram demonstrated significant predictive utility for post-pancreatectomy DM. The C-indexes of the nomogram were 0.739 and 0.719 in the training and validation cohorts, respectively. ROC curves demonstrated the predictive accuracy of the nomogram, and the calibration curves revealed that prediction results were in general agreement with the actual results. The considerable clinical applicability of the nomogram was certified by DCA. The optimal cut-off point for risk prediction value was 2.88, and the cumulative risk curves of each cohort showed significant differences between the high- and low-risk groups. The nomogram could predict and identify the NODM risk population, and provide guidance to physicians in monitoring and controlling blood glucose levels in PBLML patients after DP.

ASO Author Reflections: Preoperative Endoscopic Minor Papilla Sphincterotomy May Effectively Prevent Pancreatic Fistula After Distal Pancreatectomy in Patients with Pancreas Divisum.

ASO Author Reflections: Preoperative Endoscopic Minor Papilla Sphincterotomy May Effectively Prevent Pancreatic Fistula After Distal Pancreatectomy in Patients with Pancreas Divisum.

Robot-Assisted Versus Laparoscopic Distal Pancreatectomy in Patients with Resectable Pancreatic Cancer: An International, Retrospective, Cohort Study

BackgroundRobot-assisted distal pancreatectomy (RDP) is increasingly used as an alternative to laparoscopic distal pancreatectomy (LDP) in patients with resectable pancreatic cancer but comparative multicenter studies confirming the safety and efficacy of RDP are lacking.MethodsAn international, multicenter, retrospective, cohort study, including consecutive patients undergoing RDP and LDP for resectable pancreatic cancer in 33 experienced centers from 11 countries (2010–2019). The primary outcome was R0-resection. Secondary outcomes included lymph node yield, major complications, conversion rate, and overall survival.ResultsIn total, 542 patients after minimally invasive distal pancreatectomy were included: 103 RDP (19%) and 439 LDP (81%). The R0-resection rate was comparable (75.7% RDP vs. 69.3% LDP, p = 0.404). RDP was associated with longer operative time (290 vs. 240 min, p < 0.001), more vascular resections (7.6% vs. 2.7%, p = 0.030), lower conversion rate (4.9% vs. 17.3%, p = 0.001), more major complications (26.2% vs. 16.3%, p = 0.019), improved lymph node yield (18 vs. 16, p = 0.021), and longer hospital stay (10 vs. 8 days, p = 0.001). The 90-day mortality (1.9% vs. 0.7%, p = 0.268) and overall survival (median 28 vs. 31 months, p = 0.599) did not differ significantly between RDP and LDP, respectively.ConclusionsIn selected patients with resectable pancreatic cancer, RDP and LDP provide a comparable R0-resection rate and overall survival in experienced centers. Although the lymph node yield and conversion rate appeared favorable after RDP, LDP was associated with shorter operating time, less major complications, and shorter hospital stay. The specific benefits associated with each approach should be confirmed by multicenter, randomized trials.

Interrupting thromboembolic prophylaxis on thrombotic complications following distal pancreatectomy

Background: Venothromboembolic (VTE) prophylaxis is indicated for surgical patients with pancreatic cancer as there is a significant risk of developing a deep vein thrombosis (DVT) post-operatively. The data for when to initiate VTE prophylaxis after pancreatic surgery is inconclusive and support for preoperative chemoprophylaxis is limited since the risk of hemorrhage often exceeds that of thrombosis making it difficult to standardize a regimen. At this institution, distal pancreatectomies routinely receive subcutaneous heparin 5000 units every 8 hours or subcutaneous enoxaparin 40 mg once daily pre-operatively and/ or post-operatively. The purpose of this study was to determine the cause and impact of missed dosing peri-operatively in distal pancreatectomy patients.

Chronic Glucocorticoid Use is a Potential Risk Factor for Delayed Pancreatic Fistula after Laparoscopic Distal Pancreatectomy: A Retrospective Analysis.

Pancreatic fistula is a potentially morbid complication after distal pancreatectomy. Chronic glucocorticoid use is one of the risk factors for pancreatic fistula in pancreaticoduodenectomy, though it has not been reported in distal pancreatectomy. We explored whether chronic glucocorticoid use can be a risk factor for pancreatic fistula in distal pancreatectomy. We reviewed 408 consecutive patients who underwent elective distal pancreatectomy from 2011 to 2021. We evaluated two kinds of pancreatic fistula (postoperative pancreatic fistula and delayed pancreatic fistula). We defined delayed pancreatic fistula as a patient who was re-admitted for pancreatic fistula after the first discharge from the hospital. Preoperative characteristics and postoperative outcomes were analyzed. Two hundred sixty-seven patients underwent open distal pancreatectomy, while 141 patients had laparoscopic distal pancreatectomy. A comparison of patient with and without chronic glucocorticoid use showed that only patients with chronic glucocorticoid use developed delayed pancreatic fistula (0% vs. 16.7%; p < 0.001). In addition, delayed pancreatic fistula occurred in only laparoscopic distal pancreatectomy patients with chronic glucocorticoid use (0% vs. 25.0%; p < 0.001). Although sample size is small, it is reasonable to presume that chronic glucocorticoid use is a potential risk factor for delayed pancreatic fistula in laparoscopic distal pancreatectomy.

Fourteen years of pancreatic surgery for malignancy among ACS-NSQIP centers: Trends in major morbidity and mortality

BackgroundThe American College of Surgeons National Surgical Quality Improvement Program was established to help participating hospitals track and report surgical complications with the goal of improving surgical care. We sought to determine whether this has led to improvements in surgical outcomes for pancreatic malignancies. MethodsPatients with pancreatic malignancies who underwent surgical resection were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2006–2019). Thirty-day postoperative major morbidity and mortality were analyzed by year. Major morbidity included organ and deep surgical site infection, venous thromboembolism, cardiac event, pneumonia, acute renal failure, sepsis, and respiratory failure. ResultsOf the 28,888 patients identified, 51% were male, the median age was 68, 74.3% underwent a pancreaticoduodenectomy, and 25.7% underwent a distal pancreatectomy. Among patients who underwent a pancreaticoduodenectomy, there was a significant increase in major morbidity (annual percent change 0.77, P = .012) driven by increases in organ space surgical site infection (annual percent change 3.52, P < .001) and venous thromboembolism (annual percent change 4.72, P = .005). However, there was a decrease in postoperative mortality (annual percent change -4.58, P = .001). For distal pancreatectomy patients, there was no change in rates of overall major morbidity (annual percent change -1.35, P = .08) or mortality (annual percent change -3.21, P = .25). ConclusionAlthough major morbidity and mortality have not significantly changed for distal pancreatectomy patients, mortality has steadily decreased for patients undergoing pancreaticoduodenectomy, despite an increase in major morbidity. Whether this trend reflects a change in patient selection, an increase in detection of postoperative morbidities and/or an improvement in mitigation of these morbidities warrants further study.

Central or distal pancreatectomy in patients with pancreatic tumors: assessment of short‑term outcomes

Objective: to compare short-term and long-term postoperative complications between patients who have undergone central pancreatectomy (CP) and distal pancreatectomy (DP).Materials and methods. This retrospective study included patients who had CP for benign pancreatic tumors and tumors of low malignant potential (cases) and patients who had DP for similar reasons (controls). The controls were randomly selected and matched cases for tumor size, presence of diabetes mellitus (Dm), and ASA physical status. we evaluated the incidence of grade ≥III complications (Clavien–Dindo classification), clinically significant pancreatic fistulas, Dm, and impaired exocrine pancreatic function in the late postoperative period.Results. There were 25 cases and 25 controls. Both groups were matched for the main clinical characteristics. Surgeries were significantly longer in the CP groups compared to the DP group (230 min vs 180 min, р &lt; 0.0001). There was no difference in the overall incidence of postoperative complications (9 (36 %) vs 14 (56 %), р = 0.26); there was a trend towards a higher incidence of postoperative complications in the CP group. Two patients after CP (8 %) required repeated surgeries. none of the study participants died. Clinically significant (B and C) pancreatic fistulas were registered in 8 (32 %) and 11 (44 %) patients, respectively (p = 0.56). Two patients in the DP group (8 %) developed impairments of exocrine pancreatic function that required pharmacotherapy. none of the patients developed Dm postoperatively.Conclusion. Despite the fact that CP and DP outcomes were comparable in terms of the main parameters evaluated, severe post-CP complications indicate that there is a need for careful selection of patients for such interventions and further accumulation of experience. Our findings can be used in the subsequent analysis of the experience of different clinics.

Surgery for Intraductal Papillary Mucinous Neoplasms of the Pancreas: Preoperative Factors Tipping the Scale of Decision-Making

BackgroundDecision-making in intraductal papillary mucinous neoplasms (IPMNs) of the pancreas depends on scaling the risk of malignancy with the surgical burden of a pancreatectomy. This study aimed to develop a preoperative, disease-specific tool to predict surgical morbidity for IPMNs.MethodsBased on preoperative variables of resected IPMNs at two high-volume institutions, classification tree analysis was applied to derive a predictive model identifying the risk factors for major morbidity (Clavien–Dindo ≥3) and postoperative pancreatic insufficiency.ResultsAmong 524 patients, 289 (55.2%) underwent pancreaticoduodenectomy (PD), 144 (27.5%) underwent distal pancreatectomy (DP), and 91 (17.4%) underwent total pancreatectomy (TP) for main-duct (18.7%), branch-duct (12.6%), or mixed-type (68.7%) IPMN. For 98 (18.7%) of the patients, major morbidity developed. The classification tree distinguished different probabilities of major complications based on the type of surgery (area under the surve [AUC] 0.70; 95% confidence interval [CI], 0.63–0.77). Among the DP patients, the presence of preoperative diabetes identified two risk classes with respective probabilities of 5% and 25% for the development of major morbidity, whereas among the PD/TP patients, three different classes with respective probabilities of 15%, 20%, and 36% were identified according to age and body mass index (BMI). Overall, history of diabetes, age, and cyst size segregated three different risk classes for new-onset/worsening diabetes.ConclusionsIn presumed IPMNs, the disease-specific risk of major morbidity and pancreatic insufficiency can be determined in the preoperative setting and used to personalize the possible surgical indication. Age and overweight status in case of PD/TP and diabetes in case of DP tip the scale toward less aggressive clinical management in the absence of features suggestive for malignancy.

Early biochemical predictors of clinically relevant pancreatic fistula after distal pancreatectomy: a role for serum amylase and C-reactive protein.

Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP. Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien-Dindo grade ≥ 3) were performed. At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p < 0.001), followed by serum amylase on POD 1 (0.651, p < 0.001), serum CRP on POD3 (0.644, p < 0.001), and CRP change between POD 2 and POD 3 (0.644, p < 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36-3.86; p = 0.002), DFA ≥ 1500 U/Lon POD2 (OR 4.63, 95% CI 2.72-7.89; p < 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01-2.93; p = 0.046), and CRP increase by at least 25mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11-3.21; p = 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714-0.816, p < 0.001). Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management.

The short-term and long-term outcomes of distal pancreatectomy in patients with ductal adenocarcinoma

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Оценить непосредственные и отдаленные результаты дистальной панкреатэктомии у пациентов с протоковой аденокарциномой хвоста и тела поджелудочной железы. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> В ретроспективное, проспективное, нерандомизированное, моноцентровое исследование было включено 47 пациентов с гистологически подтвержденной аденокарциномой тела и/или хвоста поджелудочной железы, которым было выполнено хирургическое лечение в отделении абдоминальной онкологии МНИОИ им. П.А. Герцена в период с 2010 по 2021 г. <h3>РЕЗУЛЬТАТЫ</h3> Медиана интраоперационной кровопотери составила 650 (250—1200) мл, длительность оперативного вмешательства — 220 (165—355) мин, частота послеоперационных осложнений и послеоперационной панкреатической фистулы составила 38 и 25% соответственно. Операция в объеме R0- и R1-резекции была выполнена в 19 (40,4%) и 28 (59,6%) случаях соответственно. Медиана наблюдения составила 21 (IQR 5—90) мес; медиана общей выживаемости — 24 мес (95% ДИ, 15—33 мес); 3- и 5-летняя кумулятивная выживаемость в нашем исследовании составила 37,9±7,2 и 15,6±5,4% соответственно. Медиана времени без прогрессирования опухолевого процесса была 18 мес (95% ДИ, 10—25 мес); 3- и 5-летнее время без прогрессирования процесса 28,4±6,7 и 13,1±5,0% соответственно. <h3>ВЫВОДЫ</h3> Размер опухоли и радикальность оперативного лечения являются основными факторами прогноза. Современная стратегия лечения пациентов с локализацией опухолевого процесса в дистальных отделах поджелудочной железы направлена на улучшение техники оперативного вмешательства, снижение частоты ранних послеоперационных осложнений и поиск оптимальных схем неоадъювантной и адъювантной химиотерапии.

The Need for Pancreatic Enzyme Replacement Therapy (PERT) after Pancreatic Surgery is Determined by Tumor Location: A Prospective Cohort Study

Introduction: Patients undergoing oncologic pancreatic surgery are at risk for pancreatic exocrine insufficiency (PEI) and for needing PERT. There are few well-designed studies on the magnitude of this risk. Methods: In 198 patient undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) for oncologic indications, we performed an 13C-labeled mixed-triglyceride breath test, immediately preoperative and approximately 6 weeks postoperative. This test gives an idea of the pancreatic remnant lipase-activity analyzing the 13CO2 in breath after a test meal with 1.3-distearyl-(13C-Carboxyl)octanol-glycerol. Cumulative 13CO2 recovery after 6 hours is expressed as ‘MTG%’ and a level <23% confirms PEI and the need for PERT. Results: In 159 patients undergoing PD for a pancreatic head tumor, MTG% decreased significantly from 33.69% to 15.61% postoperative (p=0.002) (table 1). The percentage patients diagnosed with PEI and need for PERT increased from 23.0% to 68.3% postoperative (p<0.001). This decrease in exocrine function was significant in all pathology subgroups (figure 1), but most important in pancreatic adenocarcinoma. The postoperative percentage PEI in this subgroup increased to 78.1%. The decrease in function was less pronounced, but still significant, in pancreatic neuroendocrine tumor and ampullary tumor patients (p=0.002). In contrast, 39 patients undergoing a DP for a body-tail tumor did not experience any significant change in exocrine function. Conclusion: Patients with a pancreatic head tumor treated with PD experience a significant drop in exocrine function, are at high risk for developing PEI and consequently need for PERT. Therefore, systematic screening for PEI is mandatory after PD. Patients undergoing DP rarely need PERT.Tabled 1EP02D-185 Table 1: Evolution MTG% in pancreaticoduodenectomy and distal pancreatectomy patients measured by 13C-labeled mixed-triglyceride breath testPD n=159MTG% median preopMTG% median postopp=Median Δ MTG%MTG% range preopMTG% range postop% PEI preop% PEI postopp=pancreatic adenoca30.6111.48<0.001-16.25.44-53.340.02-34.7326.678.1<0.001ampullary tumor35.5525.73<0.001-13.016.87 -67.22.1 -34.3710.045.00.034PNET38.8927.080.022-7.0618.67 - 127.3117.4 -36.6710.030.0nsIPMN32.615.610.009-5.343.5-52.324.23 -44.1226.760.0nsdist cholangioca34.0222.50.021-7.482.96-43.916.37 - 34.889.154.50.046total group PD33.4915.61<0.0001-14.972.96-127.310.02-64.7323,068.3<0.001DP n=39MTG% median preopMTG% median postopp=Median Δ MTG%MTG% range preopMTG% range postop% PEI preop% PEI postopp=total group DP38.2838.09ns-1.9119.31-56.665.76-48.7310.257.7ns Open table in a new tab

A comparison of robotic versus laparoscopic distal pancreatectomy: Propensity score matching analysis.

The aim of this study was to assess the perioperative and pathologic outcomes of robotic distal pancreatectomy compared with a laparoscopic approach. A total of 121 robotic distal pancreatectomies and 992 laparoscopic distal pancreatectomies were retrospectively evaluated, comparing the demographic, perioperative and pathologic outcomes. After 1:2 propensity score matching (PSM) with 11 demographic variables, the factors were analysed again. Following PSM, 104 robotic distal pancreatectomy patients were compared with 208 laparoscopic distal pancreatectomy patients. The operation time and proportion of spleen preservation were not different between the groups. The rates of open conversion were lower, whereas the hospital costs were higher in the robotic group. Other perioperative outcomes and pathologic factors did not differ between the groups. Although robotic distal pancreatectomy is more expensive, this operation is feasible, with a higher probability of proceeding with the planned operation and with low open conversion rate.

Should we be reluctant to perform pancreatectomy in patients with chronic liver disease? A single center 10-year experience

Purpose Many studies have shown extra-hepatic surgery in patients with chronic liver disease (CLD) with or without portal hypertension can result in complications. The aim of this study was to analyze the results of major pancreatectomy in patients with CLD including cirrhosis and to evaluate their efficacy and safety. Methods We retrospectively reviewed 319 patients undergoing open pancreatoduodenectomy (PD) or distal pancreatectomy (DP) in our center. Those who received PD and DP in patients without CLD were classified into groups A and D, and those with CLD into groups B and C, respectively. Group B and C were subdivided into groups 1 and 2 according to the presence of portal hypertension. Results Forty-three patients (13.5%) had CLD. Of the 221 patients who received PD, 25 had CLD. Of the 98 patients who received DP, 18 (Group C) had CLD. In the PD group, patients with portal hypertension (group B1) had longer operative time. However, the transfusion rate and complication rate were not significantly different from other groups. There was no mortality in patients with CLD without portal hypertension (group B2) and the complication and mortality rate was comparable to patients with normal liver function (group A). In the DP group, the transfusion rate, complication rate and mortality rate were significantly higher in patients with portal hypertension (group C1). Conclusions Acceptable outcomes were obtainable following pancreatic surgery in cirrhotic, non-portal hypertensive patients with surgical outcomes equivalent to non-cirrhotic patients.

Comparison of oncologic outcome between open versus laparoscopic distal pancreatectomy in patients with pancreatic ductal adenocarcinoma: Analysis with 1,202 patients in national database

Although the lack of high-level evidence, laparoscopic distal pancreatectomy (LDP) in pancreatic ductal adenocarcinoma (PDAC) is being performed by many surgeons due to the development of surgical techniques. The purpose of this study was to investigate the long-term oncologic outcomes of LDP in PDAC through propensity score matching (PSM) analysis with large-scale national database. Patients who received DP for PDAC registered in the official database of KAHBPS (KOTUS-BP) were enrolled. For long-term oncologic outcome analysis, 5-year overall survival rate (5YOSR) and 5-year disease-free survival rate (5YDFSR) were compared to open DP (ODP). From May 2001 to December 2016, 1,202 patients with detailed operative information and sufficient pathological data in 16 hospitals were selected. There were 846 ODP cases (70.4%) and 356 LDP cases (29.6%). In the ODP group, more aggressive surgery was performed, the pathologic stage was higher, R0 rate was higher (81.2% vs. 77.0%, p < 0.001) and there was a greater number of retrieved lymph nodes (15.3 vs. 13.5, p = 0.002) than the LDP group. PSM was performed with 8 variables including age, sex, operation period, combined organ resection, major vessel resection, R status, T stage, and N stage. After matching, the 5YOSR of ODP and LDP were 37.3% and 41.4% (p = 0.150), and 5YDFSR was 23.4% and 27.2% (p = 0.332), respectively. Prognostic factors for 5YOSR were R status, T stage, N stage, differentiation, and lymphovascular invasion. LDP was performed in a selected group, and within this group, it had comparable long-term oncologic outcome to ODP in patients with PDAC.

Importance of Intestinal Environment and Cellular Plasticity of Islets in the Development of Postpancreatectomy Diabetes.

To elucidate the pathogenesis of postpancreatectomy diabetes mellitus (PPDM). Forty-eight patients without diabetes undergoing either pancreatoduodenectomy (PD) (n = 20) or distal pancreatectomy (DP) (n = 28) were included. A 75-g oral glucose tolerance test was performed every 6 months. Microbiome composition and short-chain fatty acids (SCFAs) in feces were examined before and 6 months after surgery. The association of histological characteristics of the resected pancreas with PPDM was examined. During follow-up (median 3.19 years), 2 of 20 PD patients and 16 of 28 DP patients developed PPDM. Proteobacteria relative abundance, plasma glucagon-like peptide 1 (GLP-1), and fecal butyrate levels increased only after PD. Postsurgical butyrate levels were correlated with postsurgical GLP-1 levels. With no significant difference in the volume of the resected pancreas between the surgical procedures, both β-cell and α-cell areas in the resected pancreas were significantly higher in DP patients than in PD patients. In DP patients, the progressors to diabetes showed preexisting insulin resistance compared with nonprogressors, and both increased α- and β-cell areas were predictors of PPDM. Furthermore, in DP patients, α-cell and β-cell areas were associated with ALDH1A3 expression in islets. We postulate that a greater removal of β-cells contributes to the development of PPDM after DP. Islet expansion along with preexisting insulin resistance is associated with high cellular plasticity, which may predict the development of PPDM after DP. In contrast, PD is associated with alterations of gut microbiome and increases in SCFA production and GLP-1 secretion, possibly protecting against PPDM development.