International Study Group Research Articles

Prevalence of sarcopenia and mortality rate in older adults with hip fracture.

Several international study groups adopted appendicular skeletal muscle mass (ASM) index adjusted by (1) height squared, (2) weight, and (3) body mass index (BMI) in the diagnosis of sarcopenia. However, different prevalence rates of sarcopenia by each index and clinical implications were not well known. The purpose of this study was to compare the differences in (1) the percentage of sarcopenia in hip fracture patients and (2) the relative mortality rate according to the sarcopenia criteria of three ASM indices. Between January 2009 and December 2020, 1003 older adult hip fracture patients at a tertiary institution were eligible and retrospectively reviewed for this study. Based on the ASM measured on dual-energy X-ray absorptiometry, three indices were calculated, and sarcopenia was diagnosed. The proportion of sarcopenia was evaluated according to each index. One, two, and five-year mortality rates were compared between each sarcopenia group and a normal musculature group, based on ASM criteria. The proportion of sarcopenia patients differed according to three ASM indices. The proportion of sarcopenic patients by ASM/height2 index was higher than those of the other two indices in both male and female hip fracture patients. In male patients, 61% were sarcopenic by ASM/height2 index, 37% by ASM/weight index, and 44% by ASM/BMI index. In female patients, 26%, 11%, and 14% were sarcopenic, respectively. Among the three indices, only ASM/height2 had significant correlations with all 1-, 2-, and 5-year mortality rates. The prevalence of sarcopenia in hip fracture patients differed substantially according to ASM indices. Sarcopenic hip fracture patients had a higher mortality rate than those with normal musculature. The 1-year, 2-year, and 5-year mortality rates were discriminated by ASM/height2 criteria in both men and women. Future prospective studies in a larger cohort are warranted.

Clinical significance of postpancreatectomy acute pancreatitis defined by the International Study Group for Pancreatic Surgery.

The International Study Group for Pancreatic Surgery (ISGPS) developed a structured definition of postpancreatectomy acute pancreatitis (PPAP) in 2021. This study aimed to evaluate the clinical significance of PPAP as defined by the ISGPS criteria. We evaluated the medical records and postoperative computed tomography (CT) findings of 247 patients who underwent pancreaticoduodenectomy. Postoperative hyperamylasemia (POH) was defined as an elevation in serum amylase levels over the upper baseline limit (≥133 U/L) on postoperative days 1 and 3. PPAP was defined as acute pancreatitis satisfying the following three requirements: POH, clinically relevant deterioration, and radiologic features consistent with acute pancreatitis. Postoperative hyperamylasemia and PPAP were prevalent in 9.7% (24/247) and 3.6% (9/247) of the patients, respectively. PPAP grade B occurred in eight patients, seven of whom experienced Clavien-Dindo grade IIIA complications, including postoperative pancreatic fistula (POPF) and extended periods of postoperative hospitalization. PPAP grade C occurred in one patient, who died from the exacerbation of underlying interstitial pneumonia following the POPF occurrence. Acute pancreatitis determined by CT was observed in 15.3% (38/247) of the patients who underwent pancreaticoduodenectomy and was strongly associated with severe morbidity (P < .0001) and longer postoperative hospitalization (P < .0001). POH preceded acute pancreatitis on CT in only 23.7% (9/38) of those cases, resulting in a low incidence rate of PPAP. Post-pancreatectomy acute pancreatitis is a major postoperative complication of pancreatic resection; however, based on the current ISGPS criteria, its prevalence is low. Defining PPAP promotes universal evaluation and understanding of this new concept.

Application of Transurethral Prostate Resection Instrumentation for Treating Low Rectal Anastomotic Leakage: A Pilot Study.

PurposeTo determine an accurate method of inspecting low anastomotic leakages and application of transurethral prostate resection instrumentation for treating low rectal anastomotic leakage.Patients and MethodsClinical data of eight patients treated for anastomotic leakage after rectal cancer surgery at Zhangye People’s Hospital (affiliated to Hexi University), from August 2019 to November 2021, were retrospectively analyzed. Transanal prostate resection instrumentation was used to assess the leakage and surrounding conditions. Using prostate resection instrumentation, the presacral and perirectal residual cavities were washed and removed, and indwelling suprapubic presacral, transanal presacral, and rectal drainage tubes were placed. Continuous presacral saline irrigation and drainage and open negative-pressure suction in the rectal cavity were performed until the patients’ fistula healed.ResultsOf the eight patients with anastomotic leakages, one had grade B and seven had grade C International Study Group of Rectal Cancer anastomotic leakage classifications following Dixon operation. Transanal prostate resection instrumentation showed that the leakage of the one patient with grade B was less than a third of the circumference of the anastomosis. Among the seven patients with grade C, one leakage was less than a third of the anastomotic circumference. One patient had complete separation of the anastomosis and one distal colon necrosis, which necessitated immediate descending colostomy. Conservative treatment was successful in six patients; the conservative overall cure rate was 75%, and the median healing time was 43 (21–68) days.ConclusionTransanal examination of rectal anastomotic leakage using prostate resection instrumentation is comprehensive, easy to perform, provides clear visualization, accurately guides catheter placement, and can be combined with continuous open negative-pressure drainage, which is a safe, convenient, and effective method for treating low rectal leakage.

Para-aortic lymph node involvement should not be a contraindication to resection of pancreatic ductal adenocarcinoma.

BACKGROUNDPara-aortic lymph nodes (PALN) are found in the aortocaval groove and they are staged as metastatic disease if involved by pancreatic ductal adenocarcinoma (PDAC). The data in the literature is conflicting with some studies having associated PALN involvement with poor prognosis, while others not sharing the same results. PALN resection is not included in the standard lymphadenectomy during pancreatic resections as per the International Study Group for Pancreatic Surgery and there is no consensus on the management of these cases.AIMTo investigate the prognostic significance of PALN metastases on the oncological outcomes after resection for PDAC. METHODSThis is a retrospective cohort study of data retrieved from a prospectively maintained database on consecutive patients undergoing pancreatectomies for PDAC where PALN was sampled between 2011 and 2020. Statistical comparison of the data between PALN+ and PALN- subgroups, survival analysis with the Kaplan-Meier method and risk analysis with univariable and multivariable time to event Cox regression analysis were performed, specifically assessing oncological outcomes such as median overall survival (OS) and disease-free survival (DFS). RESULTS81 cases had PALN sampling and 17 (21%) were positive. Pathological N stage was significantly different between PALN+ and PALN- patients (P = 0.005), while no difference was observed in any of the other characteristics. Preoperative imaging diagnosed PALN positivity in one case. OS and DFS were comparable between PALN+ and PALN- patients with lymph node positive disease (OS: 13.2 mo vs 18.8 mo, P = 0.161; DFS: 13 mo vs 16.4 mo, P = 0.179). No difference in OS or DFS was identified between PALN positive and negative patients when they received chemotherapy either in the neoadjuvant or in the adjuvant setting (OS: 23.4 mo vs 20.6 mo, P = 0.192; DFS: 23.9 mo vs 20.5 mo, P = 0.718). On the contrary, when patients did not receive chemotherapy, PALN disease had substantially shorter OS (5.5 mo vs 14.2 mo; P = 0.015) and DFS (4.4 mo vs 9.8 mo; P < 0.001). PALN involvement was not identified as an independent predictor for OS after multivariable analysis, while it was for DFS doubling the risk of recurrence.CONCLUSIONPALN involvement does not affect OS when patients complete the indicated treatment pathway for PDAC, surgery and chemotherapy, and should not be considered as a contraindication to resection.

Modified binding pancreaticogastrostomy vs modified Blumgart pancreaticojejunostomy after laparoscopic pancreaticoduodenectomy for pancreatic or periampullary tumors.

BACKGROUNDLaparoscopic pancreaticoenteric anastomosis is one of the technically challenging steps of minimally invasive pancreaticoduodenectomy (PD), especially during the learning curve. Despite multiple randomized controlled trials and meta-analyses, the type of pancreatico-enteric anastomosis as a risk factor for post-pancreatectomy complications is debatable. Also, the ideal technique of pancreatic reconstruction during the learning curve of laparoscopic PD has not been well studied.AIMTo compare the short-term outcomes of modified binding pancreaticogastrostomy (PG) and Blumgart pancreaticojejunostomy (PJ) during learning curve of laparoscopic PD.METHODSThe first 25 patients with resectable pancreatic or periampullary tumors who underwent laparoscopic PD with modified binding PG or modified Blumgart PJ between January 2015 and May 2020 were retrospectively analyzed to compare perioperative outcomes during the same learning curve. A single layer of the full-thickness purse-string suture was placed around the posterior gastrotomy in the modified binding PG. In the modified Blumgart technique, only a single transpancreatic horizontal mattress suture was placed on either side of the pancreatic duct (total two sutures) to secure the pancreatic parenchyma to the jejunum. Also, on the ventral surface, the knot is tied on the jejunal wall without going through the pancreatic parenchyma. Post pancreatectomy complications are graded as per the International Study Group for Pancreatic Surgery criteria.RESULTSDuring the study period, modified binding PG was performed in 27 patients and modified Blumgart PJ in 29 patients. The demographic and clinical parameters of the first 25 patients included in both groups were comparable. Lower end cholangiocarcinoma and ampullary adenocarcinoma were the primary indications for laparoscopic PD in both groups (32/50, 64%). The median operative time for pancreatic reconstruction was significantly lower in the binding PG group (42 vs 58 min, P = 0.01). The clinically relevant (Grade B/C) postoperative pancreatic fistula (POPF) was significantly more in the modified PJ group (28% vs 4%, P = 0.04). In contrast, intraluminal postpancreatectomy hemorrhage (PPH) was more in the binding PG group (32% vs 4%, P = 0.02). There was no significant difference in the incidence of delayed gastric emptying between the two groups.CONCLUSIONDuring the learning curve of laparoscopic PD, modified binding PG reduces POPF but is associated with increased intraluminal PPH compared to PJ using the modified Blumgart technique.

POS1345 BEYOND PULMONARY ARTERY ANEURYSM; PULMONARY INVOLVEMENT IN BEHCET’S SYNDROME

BackgroundPulmonary involvement (PI) other than pulmonary artery aneurysm (PAA) in Behcet’s syndrome (BS) is still an area of investigation.ObjectivesHerein, we aimed to retrospectively evaluate all types of pulmonary involvement associated with Behcet’s syndrome (BS).MethodsAmong 800 BS patients according to International Study Group for Behcet’s Disease (ISG) criterias, 28 patients were selected based on their radiologic examination consistent with BS-related PI. Demographic features, other clinical manifestations of BS, treatment modalities and types of PI were analyzed.ResultsThe overall prevalence of PI was estimated 3,5% among all BS patients. PI was more common in males (82.1% vs 17.9%). Mean age for BS diagnosis and onset of PI were as following; 32 ± 10,9 and 37 ± 11,4 years. Deep vein thrombosis (DVT) was the most common accompanying vascular involvement (53,6%). PAA, pulmonary vasculitis (PV), and pulmonary thromboembolism (PTE) were seen in 7 (25%), 13 (46,3%), and 18 (64,4%) of patients, respectively. In 5 patients, intracardiac thrombosis was present simultaneously in the right ventricle. Cyclophosphamide (CYC) was the most common preferred agent (78%) followed by azathioprine (AZA) as first line. Warfarin used in 18 patients (Table 1) Mortality was seen in 3 patients during follow up (1 due to PAA bleeding, others with unknown causes).Table 1.Characteristics of pulmonary involvement in BS patientsMale/Female, (n), (%)23/5 (82,1%/17,9%)Age of diagnosis, years (Mean± SD)32 ± 10,9Age of pulmonary involvement, years (Mean ± SD)37 ± 11,4Oral ulcer, (n), (%)28 (100%)Genital ulcer, (n), (%)20 (71,4%)Osteofollicular lesion,(n), (%)20 (71,4%)Erythema nodosum, (n), (%)13 (46,4%)Uveitis, (n), (%)8 (28,6%)DVT, (n), (%)15 (53,6%)Cardiac involvement, (n), (%)5 (17,8%)Pulmonary involvement, (n)-PAA, (n), (%)287 (25%)-PV, (n), (%)13 (46,4%)-PTE, (n), (%)18 (64,3%)Immunosuppression (first line agents)26/28-Steroid, (n), (%)26/28-CYC, (n), (%)22/26 (84,6%)-AZA, (n), (%)4/26 (15%)Anticoagulation (warfarin), (n), (%)18PAA; pulmonary artery aneurysm, PTE; pulmonary thromboembolism, PV; pulmonary vasculitis, CYC; cyclophosphamide, AZA; azathioprine, DVT; deep vein thrombosisConclusionDespite the importance of PAA in BS patients, capillaritis and thromboembolism other than PAA may occur commonly in BS as well. Onset at young age, male gender and previous DVT seem to be significant risk factors for the development of PI.

Is the ISGPS definition of pancreatic fistula applicable after gastrectomy?

Pancreatic fistula is one of the most common and potentially fatal surgical complications after radical gastrectomy. The purpose of this study was to assess the validity of extrapolating the definition of pancreatic fistula by the International Study Group on Pancreatic Surgery to include situations surrounding gastric cancer surgery. The clinicopathological data of 443 patients who underwent elective gastrectomy with suprapancreatic lymph node dissection (D1+, D2, or D2+ dissection) without pancreatic resection were reviewed. The relationship between postoperative pancreas-related complications (PPRC) and laboratory data, including drain fluid amylase levels on postoperative day 1 (dAmy1) and day 3 (dAmy3), were investigated. Twenty-four patients (5.4%) developed PPRC of ≥ grade II according to Clavien-Dindo classification. Among them, 15 patients had dAmy3 levels ≥ 375IU/L, while all 24 patients had dAmy1 levels ≥ 375IU/L. None of the patients with dAmy1 levels < 375IU/L developed PPRC. The area under the curve of dAmy1 and dAmy3, calculated by drawing receiver operating characteristic curves, were 0.896 and 0.791, respectively. Univariate and multivariate analyses demonstrated that both dAmy1 and dAmy3 were significant predictors of PPRC; however, dAmy1 (p < 0.001) was more strongly correlated with PPRC than dAmy3 (p = 0.049). DAmy1 is more sensitive than dAmy3 as an indicator of pancreatic fistula after gastric cancer surgery.

Interobserver Agreement for CT and MRI Findings of Chronic Pancreatitis in Children: A Multicenter Ancillary Study Under the INSPPIRE Consortium.

BACKGROUND. Imaging findings represent key criteria for diagnosing chronic pancreatitis in children. Understanding radiologists' agreement for imaging findings is critical to standardizing and optimizing diagnostic criteria. OBJECTIVE. The purpose of this study is to evaluate the interobserver agreement among experienced pediatric radiologists for subjective, quantitative, and semiquantitative imaging findings of chronic pancreatitis in children. METHODS. In this retrospective study, CT or MRI examinations performed in children with chronic pancreatitis were submitted by six sites participating in the INSPPIRE (International Study Group of Pediatric Pancreatitis: In Search for a Cure) Consortium. One pediatric radiologist from each of the six sites reviewed examinations; three of the radiologists independently reviewed all CT examinations, and the other three radiologists independently reviewed all MRI examinations. Reviewers recorded 13 categoric imaging findings of chronic pancreatitis and measured pancreas thickness and pancreatic duct diameter. Agreement was assessed using kappa coefficients for the categoric variables and intraclass correlation coefficients (ICCs) for the continuous variables. RESULTS. A total of 76 CT and 80 MRI examinations performed in 110 children (65 girls and 45 boys; mean age, 11.3 ± 4.6 [SD] years) were reviewed. For CT, kappa coefficients for categoric findings ranged from -0.01 to 0.81, with relatively high kappa coefficients noted for parenchymal calcifications (κ = 0.81), main pancreatic duct dilatation (κ = 0.63), and atrophy (κ = 0.52). ICCs for parenchymal thickness measurements ranged from 0.57 in the pancreas head to 0.80 in the body and tail. The ICC for duct diameter was 0.85. For MRI, kappa coefficients for categoric findings ranged from -0.01 to 0.74, with relatively high kappa coefficients noted for main duct irregularity (κ = 0.74), side branch dilatation (κ = 0.70), number of dilated side branches (κ = 0.65), and main duct dilatation (κ = 0.64); kappa coefficient for atrophy was 0.52. ICCs for parenchymal thickness measurements ranged from 0.53 for the neck and body individually to 0.68 in the tail. ICC for duct diameter was 0.77. CONCLUSION. Interobserver agreement was fair to moderate for most CT and MRI findings of chronic pancreatitis in children. CLINICAL IMPACT. This study highlights challenges for the imaging diagnosis of pediatric chronic pancreatitis. Standardized and/or objective criteria are needed given the importance of imaging in diagnosis.

Pancreatic Fistula and Biochemical Leak after Splenectomy: Incidence and Risk Factors—A Retrospective Single-Center Analysis

PurposePostoperative pancreatic fistula (POPF) is a complication discussed in the context of pancreatic surgery, but may also result from splenectomy; a relationship that has not been investigated extensively yet.MethodsThis retrospective single-center study aimed to analyze incidence of and risk factors for POPF after splenectomy. Patient characteristics included demographic data, surgical procedure, and intra- and postoperative complications. POPF was defined according to the International Study Group on Pancreatic Surgery as POPF of grade B and C or biochemical leak (BL).ResultsOver ten years, 247 patients were identified, of whom 163 underwent primary (spleen-associated pathologies) and 84 secondary (extrasplenic oncological or technical reasons) splenectomy. Thirty-six patients (14.6%) developed POPF of grade B/C or BL, of which 13 occurred after primary (7.9%) and 23 after secondary splenectomy (27.3%). Of these, 25 (69.4%) were BL, 7 (19.4%) POPF of grade B and 4 (11.1%) POPF of grade C. BL were treated conservatively while three patients with POPF of grade B required interventional procedures and 4 with POPF of grade C required surgery. POPF and BL was noted significantly more often after secondary splenectomy and longer procedures. Multivariate analysis confirmed secondary splenectomy and use of energy-based devices as independent risk factors for development of POPF/BL after splenectomy.ConclusionWith an incidence of 4.5%, POPF is a relevant complication after splenectomy. The main risk factor identified was secondary splenectomy. Although POPF and BL can usually be treated conservatively, it should be emphasized when obtaining patients’ informed consent and treated at centers with experience in pancreatic surgery.

MO028: Kidney biopsy in females with Fabry disease is an important tool to establish the indication for Fabry-specific therapy

Abstract BACKGROUND AND AIMS Fabry disease (FD) is a rare lysosomal storage disease causing progressive kidney, nervous system and heart disorders. Specific therapy may stop or mitigate disease progression, but is very expensive and results depend significantly on early initiation of treatment. Thus, clear criteria for treatment options are necessary. Kidney biopsy in FD has important diagnostic, prognostic and therapeutically implications. Some countries already decided to include as a criterion for reimbursement of FD-specific therapy in presence of renal biopsy evidence related to FD. National criteria for starting FD specific therapy according to renal involvement include eGFR &amp;lt;80 mL/min/1.73 m2 and/or proteinuria &amp;gt;300 mg/day. METHOD The aim of our retrospective study is to evaluate clinical and histological aspects of renal involvement in untreated female patients diagnosed with FD by genetic test between 2015 and 2021 in our center. Biological renal manifestations using serum creatinine, albumin creatinine ratio and proteinuria. Also, presence of neurological involvement was assessed by clinical exam, electroneurographic exam and brain magnetic resonance, and heart manifestations were assessed by echocardiography, electrocardiogram (ECG), ECG Holter and cardiac magnetic resonance. Kidney biopsy specimens were analyzed by light and electron microscopy. Specific renal FD lesions, as well as general lesions of progression, were evaluated according to the International Study Group of Fabry Nephropathy Score Sheet. RESULTS From a total of 25 female patients, we enrolled 11 female patients in which kidney biopsy was performed. The mean age at diagnosis was 47.7 ± 12 years (range 30–65 years), although mean age of symptoms onset was 36.1 years. The mean eGFR was 72.7 ± 19.8 mL/min/1.72 m2 while mean proteinuria was 0.72 ± 1.3 mg/day. Average Mainz score was 16.6 ± 11.5. Heart involvement was found in five patients (45.5%), and neurological manifestations were present in five patients. Co-morbidities were as follows: arterial hypertension in six patients, diabetes mellitus in one patient and obesity in two patients. All kidney biopsies showed lysosomal accumulation in the podocytes, in the parietal cells of the Bowman capsule and in the tubules, while vascular inclusions were found in nine cases. Also, we observed segmental glomerular sclerosis in four cases and global glomerular sclerosis in three cases, interstitial fibrosis in six cases, tubular atrophy in five cases, arteriosclerosis in four cases and arteriolar hyalinosis in five cases. Considering national criteria for initiation of FD therapy, five patients (54.6%) fulfilled the renal criteria, three patients (27.3%) presented criteria for other organs involvement, while three patients (mean age 37.7 years) did not fulfill any criteria. We emphasize that, even in our six patients without renal criteria for FD therapy, kidney biopsy showed FD-specific lesions (lysosomal accumulation) in all cases, associated with segmental glomerular sclerosis in one case, interstitial fibrosis in four cases, tubular atrophy in three cases, arteriosclerosis in one case and arteriolar hyalinosis in three cases. Thus, in our three patients without clinical, biological and imaging criteria for FD therapy, evidence of specific FD lesions in kidney biopsy supported our recommendation to initiate FD treatment. CONCLUSION The data from our small cohort of females with Fabry disease underline the importance of kidney biopsy for detection of early kidney involvement and provide additional support to the consideration of early initiation of FD-specific therapy, potentially improving long-term outcome. Thus, proof of specific FD renal lesions as revealed by kidney biopsy could become a distinct criterion for initiation of FD therapy, in the absence of other criteria according to current guidelines. Future studies are necessary in order to specify the role of renal histology in the establishment of the proper timing to start the FD treatment, especially in young patients.

Therapeutic lymphography for persistent chyle leak after pancreatic surgery

Chyle leak is a common complication following pancreatic surgery. After failure of conservative treatment, lymphography is one of the last therapeutic options. The objective of this study was to evaluate whether lymphography represents an effective treatment for severe chyle leak (International study Group on Pancreatic Surgery, grade C) after pancreatic surgery. Patients with grade C chyle leak after pancreatic surgery who received transpedal or transnodal therapeutic lymphography between 2010 and 2020 were identified from a prospectively maintained database. Clinical success of the lymphography was evaluated according to percent decrease of drainage output after lymphography (>50% decrease=partial success; >85% decrease=complete success). Of the 48 patients undergoing lymphography, 23 had a clinically successful lymphography: 14 (29%) showed partial and 9 (19%) complete success. In 25 cases (52%) lymphography did not lead to a significant reduction of chyle leak. Successful lymphography was associated with earlier drain removal and hospital discharge [complete clinical success: 7.1 days (±4.1); partial clinical success: 12 days (±9.1), clinical failure: 19 days (±19) after lymphography; p=0.006]. No serious adverse events were observed. Therapeutic lymphography is a feasible, safe, and effective option for treating grade C chyle leak after pancreatic surgery.

Delayed gastric emptying following distal pancreatectomy: incidence and predisposing factors.

Delayed gastric emptying (DGE) following elective distal pancreatectomy (DP) is poorly known. This study aimed to report incidence of DGE following DP, to identify its predisposing factors, and to assess its impact on hospital stay. Patients who had elective DP without additional organ or vascular resection (2012-2017) in two academic hospitals were included. Factors predisposing to DGE, defined according to the International Study Group of Pancreatic Surgery, were identified by multivariate analysis. A systematic review was performed to evaluate DGE incidence following elective DP. 311 elective DPs were performed. Three perioperative mortalities (1.0%) were unrelated to DGE. DGE occurred in 31 (10.0%) patients (grade A=21, grade B=7, grade C=3) with a median hospital stay of 16 (13-22) days versus 10 (7-14) without DGE (p<0.001). In multivariate analysis, predisposing factors of DGE were age>75 years (OR=4.32 [1.53-12.19]; p=0.006), open approach (OR=2.97 [1.1-8]; p=0.031) and POPF grade B-C (OR=2.54 [1.05-6.1]; p=0.038). The systematic review identified 7 series including 876 patients with an overall 8.1% DGE incidence. DGE complicates around 10% of elective DP. Laparoscopic approach and prevention of POPF should be encouraged to reduce DGE incidence.

Protocol of a prospective study investigating the association of PAncreatic parenchymal RISk factors with postoperative pancreatic fistula after partial pancreaticoduodenectomy (PARIS trial)

IntroductionPartial pancreatoduodenectomy (PD) is the treatment of choice for many malignant and benign diseases of the pancreatic head. Postoperative complication rates of up to 40% are regularly reported. One of...

Epidemiology and clinical domains of Behçet's disease in the Cantabria region, Northern Spain.

The prevalence of Behçet's disease (BD) has a considerable geographical and temporal variability. Data regarding epidemiology in Spain are limited. Our study aimed to assess the epidemiology and clinical domains of BD in a population-based cohort from Northern Spain and to compare the results with other geographical areas of other countries. We conducted a cross-sectional study of a well-defined population in Northern Spain. Cases of suspected BD between January 1980 and December 2018 were identified. The diagnosis of BD was established according to the International Study Group (ISG) for Behçet's Disease. The incidence of BD between 1999 and 2018 was estimated by sex, age, and year of diagnosis. Of 120 patients with probable BD, 59 patients met ISG criteria and were finally included in the study, with a male/female ratio of 0.97; mean age 49.7±14.7 years. Incidence during the period of study was 0.492 per 100,000 people, observing an increase from January 1999 to December 2018. Prevalence was 10.14 per 100,000 inhabitants in 2018. Clinical manifestations were relapsing aphthous stomatitis (100%), genital ulcers (78%), skin involvement (84.7%), joint involvement (64.4%), uveitis (55.9%), central nervous system (16.9%), vascular (10.2%), and gastrointestinal manifestations (6.8%). The prevalence of BD in Cantabria is higher than in other Southern European countries. This difference may reflect a combination of geographic, genetic, or methodological variations, as well as the free accessibility to the Spanish Public Health System for the entire population. Clinical phenotypes observed are similar to those described in other world regions.

A Novel Nomogram for Predicting Postoperative Liver Failure After Major Hepatectomy for Hepatocellular Carcinoma.

BackgroundPost-hepatectomy liver failure (PHLF) is the most common cause of mortality after major hepatectomy in hepatocellular carcinoma (HCC) patients. We aim to develop a nomogram to preoperatively predict grade B/C PHLF defined by the International Study Group on Liver Surgery Grading (ISGLS) in HCC patients undergoing major hepatectomy.Study DesignThe consecutive HCC patients who underwent major hepatectomy at the Eastern Hepatobiliary Surgery Hospital between 2008 and 2013 served as a training cohort to develop a preoperative nomogram, and patients from 2 other hospitals comprised an external validation cohort. Least absolute shrinkage and selection operator (LASSO) logistic regression was applied to identify preoperative predictors of grade B/C PHLF. Multivariable logistic regression was utilized to establish a nomogram model. Internal and external validations were used to verify the performance of the nomogram. The accuracy of the nomogram was also compared with the conventional scoring models, including MELD and ALBI score.ResultsA total of 880 patients who underwent major hepatectomy (668 in the training cohort and 192 in the validation cohort) were enrolled in this study. The independent risk factors of grade B/C PHLF were age, gender, prothrombin time, total bilirubin, and CSPH, which were incorporated into the nomogram. Good prediction discrimination was achieved in the training (AUROC: 0.73) and validation (AUROC: 0.72) cohorts. The calibration curve also showed good agreement in both training and validation cohorts. The nomogram has a better performance than MELD and ALBI score models.ConclusionThe proposed nomogram showed more accurate ability to individually predict grade B/C PHLF after major hepatectomy in HCC patients than MELD and ALBI scores.

Prognostic value of examined lymph node count in patients with lymph node negative pancreatic head carcinoma: A single-center experience

Background/Aim: One of the important prognostic factors for pancreatic cancer is the count of examined lymph nodes (ELN). The ratio of metastatic to ELNs reflects survival and is required for accurate staging. The survival effect of the count of ELNs in patients with an absence of metastatic lymph nodes is unclear. However, the single-center survival outcomes related to higher ELN count based on only lymph node negative-patients are limited to a few studies with controversial results. We aimed to present the single-center experience in survival outcomes based on ELN count in patients with lymph node-negative pancreatic head cancer after pancreaticoduodenectomy. Methods: The data of 129 patients who underwent pancreaticoduodenectomy for pancreatic cancer from October 2011-December 2021 were analyzed. Among them, those who had metastatic lymph nodes, those who died from non-PC causes, died in the first 90 days postoperatively, or had missing follow-up data were excluded. Finally, 37 patients with negative lymph nodes who satisfied our criteria were included. The cut-off value for the examined lymph node count was 15, according to the minimum LN count recommended by the International Study Group of Pancreatic Surgery and the European Society for Medical Oncology for accurate staging. Thus, node-negative patients were divided into ELN

Postoperative acute pancreatitis after pancreatic resection in patients with pancreatic ductal adenocarcinoma.

Postoperative pancreatic fistula (POPF) is one of the major critical complications after pancreatic resection. Recently, postoperative acute pancreatitis (POAP), a new concept for a pancreatic-specific complication following pancreatic resection, has been advocated, and its association with POPF has been reported. The present study examined the clinical features of POAP and identified the associations of POAP with POPF and other postoperative morbidities in pancreatic ductal adenocarcinoma (PDAC) patients undergoing pancreatic resection. A total of 312 consecutive patients who underwent pancreatic resection for PDAC at our institution from 2013 to 2019 were enrolled in this study. POAP was defined as an elevated serum amylase level above the upper limit normal on postoperative day (POD) 0 or 1, based on Connor's definition. The severity of POPF was assessed by the International Study Group on Pancreatic Surgery definition. A total of 184 patients (58.9%) had POAP. POAP occurred in 58.5% of subtotal stomach-preserving pancreatoduodenectomy patients and 60% of distal pancreatectomy combined with splenectomy patients. The presence of POAP was significantly associated with the development of clinically relevant POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection. A multivariate analysis showed that the presence of POAP and elevated C-reactive protein levels on POD 3 were independent predictors of clinically relevant POPF after subtotal stomach-preserving pancreatoduodenectomy. POAP is associated with the development of POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection and is an independent risk factor for clinically relevant POPF after pancreatoduodenectomy. POAP represents an important indicator for planning treatment strategies to prevent serious complications, including POPF.

Health-Related Quality of Life in Pediatric Acute Recurrent or Chronic Pancreatitis: Association With Biopsychosocial Risk Factors.

Abdominal pain, emergency department visits, and hospitalizations impact lives of children with acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP). Data on health-related quality of life (HRQOL) in this population, however, remains limited. We aimed to evaluate HRQOL in children with ARP or CP; and test biopsychosocial risk factors associated with low HRQOL. Data were acquired from the INternational Study Group of Pediatric Pancreatitis: In search for a cuRE registry. Baseline demographic and clinical questionnaires, the Child Health Questionnaire (measures HRQOL) and Child Behavior Checklist (measures emotional and behavioral functioning) were completed at enrollment. The sample included 368 children (54.3% girls, mean age = 12.7years, standard deviation [SD] = 3.3); 65.2% had ARP and 34.8% with CP. Low physical HRQOL (M = 38.5, SD = 16.0) was demonstrated while psychosocial HRQOL (M = 49.5, SD = 10.2) was in the normative range. Multivariate regression analysis revealed that clinical levels of emotional and behavioral problems (B = -10.28, P < 0.001), episodic and constant abdominal pain (B = 04.66, P = 0.03; B = -13.25, P < 0.001) were associated with low physical HRQOL, after accounting for ARP/CP status, age, sex, exocrine, and endocrine disease (F [9, 271] = 8.34, P < 0.001). Borderline and clinical levels of emotional and behavioral problems (B = -10.18, P < 0.001; B = -15.98, P < 0.001), and constant pain (B = -4.46, P < 0.001) were associated with low psychosocial HRQOL (F [9, 271] = 17.18, P < 0.001). Findings highlight the importance of assessing HRQOL and treating pain and psychosocial problems in this vulnerable group of children.

Early derangement of INR predicts liver failure after liver resection for hepatocellular carcinoma

BackgroundSurgical resection, where appropriate, remains one of the best treatment options for hepatocellular carcinoma (HCC), however outcomes can be compromised by the development of liver failure. We reviewed our experience of liver resection for HCC patients to identify factors that may predict the development of post-hepatectomy liver failure (PHLF) and survival. MethodsA single centre retrospective cohort study. Data was collected between 1999 and 2017 from all patients undergoing HCC resection in a tertiary university hospital from electronic medical records. PHLF was defined as per the International Study Group for Liver Surgery criteria. Variables with p < 0.15 on univariate analysis were included in a multivariate binary logistic regression model. Kaplan–Meier analyses were used to determine correlations with overall survival (OS) and disease-free survival (DFS), and variables with p < 0.15 on univariate analysis selected for a step-down Cox proportional hazard regression model. ResultsOverall, 120 patients underwent liver resection within the study period, of which 22 (18%) developed PHLF. Patients with normal INR ≤1.20 at day 2 did not develop PHLF whereas patients with INR >1.60 were at significant risk. Resection of multiple tumours (odds ratio 21.63, p = 0.002) and deranged postoperative day 2 INR>1.6 (odds ratio 21.05, p < 0.0001) were identified as independent prognostic markers of PHLF. ConclusionThe use of INR measurement at day 2 predicts PHLF and may enable us to objectively identify and stratify patients who may be eligible for enhanced recovery programs from those who will merit close monitoring in high dependency areas.

A single-center analysis of 30- and 90-day post-pancreatectomy complications in patients undergoing neoadjuvant radiation with EBRT versus MRI-guided SBRT.

572 Background: Stereotactic MRI -guided adaptive radiation therapy (SMART) is being investigated for enhanced efficacy in locally advanced, borderline resectable and medically inoperable pancreatic cancer. Traditionally, conventionally fractioned chemoradiation (EBRT) has been used for operable patients. We sought to evaluate whether there would be differences in surgical complications and outcomes in the 30- and 90- day postoperative period in patients who received either neoadjuvant EBRT or SMART followed by definitive surgery. Methods: A retrospective single-center analysis of patients with either resectable, borderline resectable or locally advanced tumors of the pancreas or duodenum, treated with neoadjuvant radiation and surgical management between 2014 and 2021 was performed. Patient demographics and post-surgical complications were collected and stratified according to both treatment arms. The International Study Group of Pancreatic Surgery (ISGPS) classifications were used to define and grade postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and postpancreatectomy hemorrhage (PPH). A univariate analysis was done followed by a multivariate analysis. Results: Among the 65 patients (mean age 62.6 years, 46% female) who underwent definitive surgical intervention, 44 (67.7%) received EBRT, and 21 (32.3%) received SMART. Baseline characteristics including age, sex, race, ASA, and Charlson comorbidity index (CCI) scores were found to be similar. On univariate analysis, PPH was significantly higher in SMART (OR, 6.6; 95% CI, 1.2 to 37.3; p = 0.034). After adjusting for confounders on multivariate analysis, it appears there is a trend towards higher PPH in the SMART cohort ( p = 0.052). Conclusions: Neoadjuvant SMART followed by definitive surgery is not associated with worse outcomes in the 30- and 90- day postoperative period vs. neoadjuvant EBRT. Although there was a trend towards PPH on multivariate analysis, further discussion is warranted involving vascular resection, vascular stents and anticoagulation.[Table: see text]