Outcomes Of Pancreatic Surgery Research Articles

Perioperative textbook outcomes of minimally invasive pancreatoduodenectomy: a multicenter retrospective cohort analysis in a Korean minimally invasive pancreatic surgery registry.

The aim of this study is to investigate the perioperative composite textbook outcomes of pancreatic surgery after minimally invasive pancreatoduodenectomy (MIPD). The cohort study was conducted across 10 institutions and included 1552 patients who underwent MIPD registered with the Korean Study Group on Minimally Invasive Pancreatic Surgery between May 2007 and April 2020. We analyzed perioperative textbook outcomes of pancreatic surgery after MIPD. Subgroup analyses were performed to assess outcomes based on the hospital volume of MIPD. Among all patients, 21.8% underwent robotic pancreatoduodenectomy. High-volume centers (performing >20 MIPD/year) performed 88.1% of the procedures. The incidence of clinically relevant postoperative pancreatic fistula was 11.5%. Severe complications (Clavien-Dindo grade ≥IIIa) occurred in 15.1% of the cases. The 90-day mortality rate was 0.8%. The mean hospital stay was 13.7 days. Textbook outcomes of pancreatic surgery success were achieved in 60.4% of patients, with higher rates observed in high-volume centers than in low-volume centers (62.2% vs. 44.7%, P<0.001). High-volume centers exhibited significantly lower conversion rates (5.4% vs. 12.5%, P=0.001), lower 90-day mortality (0.5% vs. 2.7%, P=0.001), and lower 90-day readmission rates (4.5% vs. 9.6%, P=0.006) than those low-volume centers. MIPD could be performed safely with permissible perioperative outcomes, including textbook outcomes of pancreatic surgery, particularly in experienced centers. The findings of this study provided valuable insights for guiding surgical treatment decisions in periampullary disease.

Impact of Preoperative Diabetes Mellitus on Postoperative Outcomes in Elective Pancreatic Surgery and Its Implications for Prehabilitation Practice.

Patients with pancreatic disease(s) have a high risk of developing diabetes mellitus (DM). Diabetes mellitus is associated with adverse postoperative outcomes. This study aimed to investigate the prevalence and effects of DM on postoperative outcomes in pancreatic surgery. Subgroup analysis of a prospective cohort study conducted at an academic hospital. Patients undergoing pancreatoduodenectomy between January 2019 and November 2022 were included and screened for DM preoperatively using glycated hemoglobin (HbA1c). New-onset DM was diagnosed based on HbA1c ≥ 6.5% (48 mmol/mol). Postoperative outcomes were compared between patients with and without DM. From 117 patients, 29 (24.8%) were given a diagnosis of DM, and of those, 5 (17.2%) were diagnosed with new-onset DM, and 15 (51.8%) displayed poorly controlled preoperative DM (HbA 1c ≥ 7% [53 mmol/mol]). The incidence of surgical site infections (48.3% vs 27.3% in the non-DM group; P = 0.04) was higher for patients with DM. This association remained significant after adjusting for confounders (odds ratio, 2.60 [95% confidence interval, 1.03-6.66]; P = 0.04). One-quarter of the patients scheduled for pancreatoduodenectomy had DM; over half of them had poor glycemic control. The association between DM status and surgical site infections revealed in this study emphasizes the importance of adequate preoperative glycemic control.

Oncologic outcomes of pancreatic surgery: a Spanish centre and its specialized surgical team

Oncologic outcomes of pancreatic surgery: a Spanish centre and its specialized surgical team

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries.

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide. This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters. A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries. Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Pancreatic Surgery in Children: Complex, Safe and Effective.

The aim of this study is to assess indications for and report outcomes of pancreatic surgery in pediatric patients. Indications for pancreatic surgery in children are rare and data on surgical outcomes after pediatric pancreatic surgery are scarce. All children who underwent pancreatic surgery at a tertiary hospital specializing in pancreatic surgery between 2003 and 2022 were identified from a prospectively maintained database. Indications, surgical procedures, and perioperative as well as long-term outcomes were analyzed. In total, 73 children with a mean age of 12.8 years (range: 4 months-18 years) underwent pancreatic surgery during the observation period. Indications included chronic pancreatitis (n=35), pancreatic tumors (n=27), and pancreatic trauma (n=11). Distal pancreatectomy was the most frequently performed procedure (n=23), followed by pancreatoduodenectomy (n=19), duodenum-preserving pancreatic head resection (n=10), segmental pancreatic resection (n=7), total pancreatectomy (n=3), and others (n=11). Postoperative morbidity occurred in 25 patients (34.2%), including 7 cases (9.6%) with major complications (Clavien-Dindo≥III). There was no postoperative (90-day) mortality. The 5-year overall survival was 90.5%. The 5-year event-free survival of patients with chronic pancreatitis was 85.7%, and 69.0% for patients with pancreatic tumors. This is the largest single-center study on pediatric pancreatic surgery in a Western population. Pediatric pancreatic surgery can be performed safely. Centralization in pancreatic centers with high expertise in surgery of adult and pediatric patients is important as it both affords the benefits of pancreatic surgery experience and ensures that surgical management is adapted to the specific needs of children.

Ideal Outcome After Pancreatoduodenectomy: A Transatlantic Evaluation of a Harmonized Composite Outcome Measure.

Assessing outcome after pancreatoduodenectomy among centers and countries requires a broad evaluation which cannot be captured by a single parameter. Previously, two composite outcome measures (Textbook Outcome and Optimal Pancreatic Surgery) for pancreatoduodenectomy have been described from Europe and the United States. These composites were harmonized into one Ideal Outcome (IO). This analysis is a transatlantic retrospective study (2018-2020) of patients after pancreatoduodenectomy within the registries from North America, Germany, the Netherlands, and Sweden. After three consensus meetings, IO for pancreatoduodenectomy was defined as the absence of all six parameters: (1) in-hospital mortality, (2) severe complications - Clavien Dindo ≥3, (3) postoperative pancreatic fistula - ISGPS grade B/C), (4) reoperation, (5) hospital stay >75th percentile, and (6) readmission. Outcomes were evaluated using relative (RLD) and absolute largest differences (ALD), and multivariate regression models. Overall, 21,036 patients after pancreatoduodenectomy were included, of whom 11,194 (54%) reached IO. The rate of IO varied between 55% in North America, 53% in Germany, 52% in the Netherlands, and 54% in Sweden (RLD: 1.1, ALD: 3%, P<0.001). Individual components varied with an ALD of 2% length of stay, 4% for in-hospital mortality, 12% severe complications, 10% postoperative pancreatic fistula, 11% reoperation, and 9% readmission. Age, sex, absence of COPD, BMI, performance status, ASA score, biliary drainage, absence of vascular resection, and histological diagnosis were associated with IO. In the subgroup of patients with pancreatic adenocarcinoma, country and neoadjuvant chemotherapy also was associated with improved IO. The newly developed composite outcome measure 'Ideal Outcome' can be used for auditing and comparing outcomes after pancreatoduodenectomy. The observed differences can be used to guide collaborative initiatives to further improve outcomes of pancreatic surgery.

Outcomes of Pancreatic Surgery in the Elderly Patients with Pancreatic Adenocarcinoma: Case Series Analysis

Outcomes of Pancreatic Surgery in the Elderly Patients with Pancreatic Adenocarcinoma: Case Series Analysis

Effect of Present at Time of Surgery (PATOS) on Outcomes in Pancreatic Surgery

IntroductionWhile there is some data available on the importance of accounting for the effect of present at time of surgery (PATOS) when estimating unadjusted postoperative complication rates, little is known about the impact of PATOS on outcomes in patients undergoing pancreatic surgery specifically. By taking PATOS into account, we hypothesized that unadjusted, observed postoperative complication rates might be reduced, with these reductions being different across outcomes; however, we expected fewer differences in risk-adjusted results, i.e., observed to expected ratios (O/E ratios). MethodsWe retrospectively analyzed the ACS NSQIP Participant Use Files (PUFs) from 2015 to 2019. PATOS data were analyzed for the 8 postoperative complications of superficial, deep, and organ space surgical site infection; pneumonia; urinary tract infection; ventilator dependence; sepsis; and septic shock. Postoperative complication rates were compared by ignoring PATOS vs. taking PATOS into account. ResultsOf the 31,919 patients in the ACS NSQIP PUFs who underwent pancreatic surgery, 1120 (3.51%) patients had one or more PATOS conditions. The event rates after taking PATOS into account declined for all outcomes—superficial surgical site infection (SSI) rates reduced by 2.56%, deep SSI rates reduced by 4.28%, organ space SSI rates reduced by 9.31%, pneumonia rates reduced by 2.91%, urinary tract infection rates declined by 4.69%, and septic shock rates declined by 9.27%. ConclusionOur paper highlights that accounting for PATOS is important for estimating unadjusted postoperative complication rates in patients undergoing pancreatic surgery. Risk adjustment is essential to any attempt at quality assessment and benchmarking. Failure to account for PATOS may penalize surgeons who care for the sickest and most complicated patients and subsequently encourage cherry-picking of less risky patients and procedures.

Associations Between Patient Characteristics and Whipple Procedure Outcomes Before and After Implementation of an Enhanced Recovery After Surgery Protocol

PurposeThe Enhanced Recovery After Surgery (ERAS) protocol is a multimodal perioperative care bundle aimed to improve pancreatic surgery outcomes. This work evaluates whether a Whipple ERAS protocol can be safely implemented at a quaternary care center. We also aimed to assess if race and socioeconomic factors are associated with disparities in outcomes in patients undergoing a Whipple ERAS protocol. MethodsA retrospective review identified demographic and clinical data for 458 patients undergoing pancreaticoduodenectomies (PDs) at a single institution from October 2017 to May 2022. Patients were split into two cohorts: pre-ERAS (treated before implementation) and ERAS (treated after). Outcomes included length of stay (LOS), 30-day readmission and mortality rates, and major complications. ResultsThere were 213 pre-ERAS PD patients, and 245 were managed with an ERAS protocol. More ERAS patients had a BMI > 30 (15.5% vs. 8.0%; p = 0.01) and received neoadjuvant chemotherapy (15.5% vs. 4.2%; p < 0.001). ERAS patients had a higher rate of major complications (57.6% vs. 37.6%; p < 0.001). Medicaid patients did not have more complications or longer LOS compared to non-Medicaid patients. On univariate analysis, race/ethnicity or gender was not significantly associated with a higher rate of major complications or prolonged LOS. ConclusionA Whipple ERAS protocol did not significantly change LOS, readmissions, or 30-day mortality. Rate of overall complications did not significantly change after implementation, but rate of major complications increased. These outcomes were not significantly impacted by race/ethnicity, gender, tumor staging, or insurance status.

Evolution of pancreatic surgery over time and effects of centralization-a single-center retrospective cohort study.

Short-term outcomes of pancreatic surgery have improved globally during the last two decades. Long-term survival of resectable pancreatic ductal adenocarcinoma (PDAC) has also shown slight improvement. We describe a cohort of 566 consecutive pancreatectomies performed at a Northern Finnish tertiary center. We analyze the trends in short-term outcomes of all-cause pancreatic surgery and long-term survival of PDAC patients. All pancreatic resections performed at the Oulu University Hospital during years 2000-2020 were included. Patient data was analyzed in four time periods (2000-2005, 2006-2010, 2011-2015 and 2016-2020). Clinicopathological parameters of patients and tumors, complication data and short-term mortality were recorded for all patients and compared between time quartiles. Long-term survival and administration rates of neo-, and/or adjuvant therapy of PDAC patients were analyzed. A total of 566 pancreatectomies were performed during the study period: 359 (63%) pancreatoduodenectomies (PDs), 130 (23.0%) open left pancreatectomies (LPs), 45 (8.0%) laparoscopic LPs, 26 (5.1%) total pancreatectomies (TPs), and 6 (1.1%) enucleations. Median age of patients was 63 [57-71] years, and 49% [267] of patients were men. Number of pancreatectomies per time period increased from 67 in 2000-2005 to 266 in 2016-2020. American Society of Anesthesiologists (ASA) Physical Classification III patients and T3 tumors were more frequently operated on in later time periods. Complication rates remained at constant low levels throughout the study period, but reoperation rate increased from 9.4% in 2000-2010 to 16.2% in 2011-2020. Short-term (90-day) mortality after pancreatectomy decreased from 3.1% to 0.74%, while 5-year survival improved from 14.3% in 2006-2011 to 21.4% in 2011-2015. Resection rate of diagnosed PDAC cases, as reported by the Finnish Cancer Registry (FCR) for the catchment area, increased from 3.2% to 14.9% over the study period. The hospital volume of pancreatectomies has increased substantially, while complications and postoperative mortality have remained at acceptable levels. Long-term survival and resection rate of PDAC patients showed notable improvement over two decades.

Iron deficiency in patients scheduled for pancreatic resection: implications for prehabilitation practice in pancreatic surgery

Background: Preoperative anemia is a common finding in cancer patients and it is associated with postoperative allogeneic blood transfusions and increased morbidity and mortality. Iron deficiency (ID) is a frequent cause of anemia in cancer patients and constitutes a modifiable risk factor. Preoperative screening for ID and iron suppletion as part of a prehabilitation program can potentially have great impact on postoperative outcomes in pancreatic surgery.

Implementation of an enhanced recovery after surgery program for pancreaticoduodenectomy at a UK HPB unit

Objectives: Enhanced recovery after surgery (ERAS) has been shown to improve postoperative outcomes in pancreatic surgery. An ERAS program after pancreaticoduodenectomy (PD) was introduced at our unit in July 2020 with multimodal pathways implemented in line with existing guidance through a dedicated ERAS team. The aim of this study was to evaluate the early phase of implementation of ERAS based on existing guidance for PD and compare outcomes with a pre-ERAS cohort.

The Effect of Goal‐Directed Fluid Administration on Outcomes After Pancreatic Surgery

We evaluated the effect of an Enhanced Recovery After Surgery protocol on intraoperative fluid administration and postoperative outcomes in pancreatic surgery. Pancreatic cancer resections at our institution from 2012 to 2018 were grouped according to pre- or post-protocol initiation. Preoperative characteristics and postoperative outcomes were compared with Fisher's exact test and chi-square for categorical variables, and Mann-Whitney U test for continuous variables. Further analysis separated patients that had a Whipple from those who had distal pancreatectomy. A total of 263 patients underwent pancreatic cancer resection during the study period (169 Whipples, 84 DPs, 92 pre-ERAS and 171 post-ERAS). Intraoperative fluid administration significantly decreased after protocol implementation (mean 6,277ml vs. 3870ml, p &lt; 0.001). This held true when separating patients that had a Whipple procedure from those that had a DP (6,929ml vs. 4,513ml, p &lt; 0.001, 5,060ml vs. 2,833cc, p = 0.002, respectively). Intensive care unit (ICU) admission (41.3% vs. 20.5%, p &lt; 0.001) and length of stay (9.4 vs. 8.1days, p &lt; 0.01) were significantly reduced after ERAS implementation for all patients and in Whipple patients alone (47.5% vs. 23.6%, p = 0.002 and 10.7 vs. 6.6days, p = 0.004). DP patients also had significantly decreased ICU admissions (41.3% vs. 20.5%, p = 0.045). All other postoperative outcomes were not significantly different. For patients undergoing pancreatic cancer resection, goal-directed fluid management is associated with decreased intraoperative fluid administration, decreased ICU admission, and decreased length of stay without an increase in postoperative complications or readmission.

Outcome of Pancreatic Surgery During the First 6 Years of a Mandatory Audit Within the Dutch Pancreatic Cancer Group.

To describe outcome after pancreatic surgery in the first 6 years of a mandatory nationwide audit. Within the Dutch Pancreatic Cancer Group, efforts have been made to improve outcome after pancreatic surgery. These include collaborative projects, clinical auditing, and implementation of an algorithm for early recognition and management of postoperative complications. However, nationwide changes in outcome over time have not yet been described. This nationwide cohort study included consecutive patients after pancreatoduodenectomy (PD) and distal pancreatectomy from the mandatory Dutch Pancreatic Cancer Audit (January 2014-December 2019). Patient, tumor, and treatment characteristics were compared between 3 time periods (2014-2015, 2016-2017, and 2018-2019). Short-term surgical outcome was investigated using multilevel multivariable logistic regression analyses. Primary endpoints were failure to rescue (FTR) and in-hospital mortality. Overall, 5345 patients were included, of whom 4227 after PD and 1118 after distal pancreatectomy. After PD, FTR improved from 13% to 7.4% [odds ratio (OR) 0.64, 95% confidence interval (CI) 0.50-0.80, P <0.001] and in-hospital mortality decreased from 4.1% to 2.4% (OR 0.68, 95% CI 0.54-0.86, P =0.001), despite operating on more patients with age >75 years (18%-22%, P =0.006), American Society of Anesthesiologists score ≥3 (19%-31%, P <0.001) and Charlson comorbidity score ≥2 (24%-34%, P <0.001). The rates of textbook outcome (57%-55%, P =0.283) and major complications remained stable (31%-33%, P =0.207), whereas complication-related intensive care admission decreased (13%-9%, P =0.002). After distal pancreatectomy, improvements in FTR from 8.8% to 5.9% (OR 0.65, 95% CI 0.30-1.37, P =0.253) and in-hospital mortality from 1.6% to 1.3% (OR 0.88, 95% CI 0.45-1.72, P =0.711) were not statistically significant. During the first 6 years of a nationwide audit, in-hospital mortality and FTR after PD improved despite operating on more high-risk patients. Several collaborative efforts may have contributed to these improvements.

Perioperative and long-term outcome of en-bloc arterial resection in pancreatic surgery.

Pancreatic tumors are frequently diagnosed in a locally advanced stage with poor prognosis if untreated. This study assesses the safety and oncological outcomes of pancreatic surgery with arterial en-bloc resection. We retrospectively reviewed a prospectively maintained database of patients who underwent a pancreatic resection with arterial resection between 2011 and 2020. Univariable analyses were used to assess prognostic factors for survival. Forty consecutive patients (22 female; 18 male) undergoing arterial resections were included. Surgical procedures consisted of 19 pancreatoduodenectomies (PD, 48%), 16 distal splenopancreatectomy (DSP, 40%), and 5 total pancreatectomies (TP, 12%). Arterial resection included hepatic arteries (HA, N = 23), coeliac trunk (TC, N = 15) and superior mesenteric artery (SMA, N = 2). Neoadjuvant therapy was applied in 22 patients (58%). Major complications after surgery were observed in 15% of cases. 90-day mortality was 5%. Median disease-free survival and median overall survival were for the R0/CRM- group 22.8 months and 27.9 months, 9.5 and 19.8 months for the R0/CRM+ group, and 10.1 and 13.1 months for the R1 group, respectively. In highly selected patients, arterial en-bloc resection can be performed with acceptable mortality and morbidity rates and beneficial oncological outcome.

A Cohort Study of an Enhanced Recovery Pathway for Pancreatic Surgery at a Community Hospital.

Enhanced recovery after surgery (ERAS) pathways have been shown to improve pancreatic surgery outcomes, though feasibility in a community hospital remain unclear. We hypothesized that an ERAS protocol would reduce hospital length of stay (LOS) without increased morbidity. An ERAS pathway was initiated for patients undergoing pancreatic surgery at a community cancer center and compared to a historical cohort. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates, comprehensive complication index (CCI®), textbook outcomes (TO), and mortality. A total of 144 patients were included, with 63 patients in the ERAS group and 81 in the control group. The mean LOS decreased significantly in the ERAS group (6.85 [± 4.8]) vs 9.96 [±6.8] days, P = .001), without an increase in 30-day admission rates or CCI. Implementation of an ERAS protocol in a community setting reduced LOS without a corresponding increase in readmission rates or morbidity.

Opioid-free versus opioid-based anesthesia in pancreatic surgery

BackgroundOpioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear.MethodsPerioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes.ResultsCompared to OBA, NRS (3 [2–4] vs 0 [0–2], P < 0.001) and opioid consumption (36 [24–52] vs 10 [2–24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7–46] vs 10 [6–16], P < 0.001). OFA (P = 0.03), with postoperative pancreatic fistula (P = 0.0002) and delayed gastric emptying (P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups.ConclusionsIn this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

First Four Years of a Nationwide Audit: Did Clinical Practice and Outcomes in Pancreatic Surgery Improve?

Introducion: The Dutch Pancreatic Cancer Audit (DPCA) has been established to monitor and improve nationwide outcomes of pancreatic surgery. This study aimed to describe changes in clinical practice and outcomes of pancreatic surgery in the first four years of the DPCA. Methods: Consecutive patients who underwent pancreatoduodenectomy or distal pancreatectomy were registered in the mandatory nationwide DPCA. Results were analyzed in the time periods 2014-2015 and 2016-2017. Trends in patient, tumor, and treatment characteristics were assessed using univariable regression analyses. Short-term surgical outcomes were investigated using multilevel multivariable logistic regression analyses. Results: Out of 3508 patients, 2780 (79.2%) underwent pancreatoduodenectomy and 728 (20.8%) distal pancreatectomy. The median (IQR) annual hospital volume for pancreatoduodenectomy was 36 (28-44). Out of 19 centers, 17 performed ≥20 and 4 centers performed ≥40 pancreatoduodenectomies annually. Two low-volume hospitals stopped pancreatic surgery. Nationwide in-hospital mortality decreased from 3.6% to 2.8% (OR 0.65, 95%CI 0.43-0.98, p=0.04). Failure to rescue improved from 12.8% to 10.2% (OR 0.61, 95%CI 0.40-0.95, p=0.03). The rates of textbook outcome (59.0%), postoperative pancreatic fistula (ISGPS B/C, 14.8%), readmission (16.7%), and median hospital stay (11 days) did not change significantly. The use of neoadjuvant therapy (5.8% vs 10.4%, p<0.01) and minimally invasive pancreatoduodenectomy (6.7% vs 20.5%, p<0.01) increased whereas the use of adjuvant therapy (67.3%) did not change. Conclusion: Considerable changes were noted in the first four years of the DPCA, including improved in-hospital mortality and failure to rescue rates, and increased use of neoadjuvant therapy and minimally invasive pancreatoduodenectomy.

Survival and Perioperative Outcomes Following Pancreatic Surgery in Super-Elderly (Aged ≥85 Years) Pancreatic Ductal Adenocarcinoma Patients

Introduction: The number of elderly pancreatic ductal adenocarcinoma (PDAC) patients is increasing worldwide. However, perioperative outcomes and postoperative survival of pancreatic surgery for super-elderly (aged ≥85 years) PDAC patients have not been entirely clarified. Here, we investigated the short-/long- term outcomes of pancreatic surgery for super-elderly PDAC patients. Methods: In our hospital, 134 consecutive PDAC patients underwent pancreatoduodenectomy (PD, n=76) or distal pancreatomy (DP, n=58) between 2009 and 2020. The relationships between age (≥85/<85 years) and short-/long- term outcomes were retrospectively analyzed. Results: Pancreatic surgery for ≥85 PDAC patients was performed in the 4/76 PD and 4/58 DP groups. Clinical-pathological properties and perioperative factors including hospital stay duration were comparable between ≥85 and <85 cases in both groups. In the PD group, the frequency of ISPGF grade B pancreatic fistula was low in both ≥85 (0/4) and <85 (4/72) cases (P=1.00). In the DP group, ISPGF grade B was occurred in ≥85 (2/4) and <85 (11/54) cases (P=0.17). No ISPGF grade C was observed in both groups. Survival analyses resulted that no significant differences of recurrence-free survival (RFS) and overall survival (OS) were confirmed between ≥85 and <85 cases in the PD and DP groups. In the whole cohort (n=134), RFS (median 12.5 vs 18.0 months, P=0.784) and OS (median 36.8 vs 38.3 months, P=0.964) were also comparable between ≥85 and <85 cases. Conclusion: This retrospective cohort study suggests that pancreatic surgery for super-elderly PDAC patients is feasible, and achieve comparable long-term outcomes to <85 years PDAC patients.

Evidence Map of Pancreatic Surgery–A living systematic review with meta-analyses by the International Study Group of Pancreatic Surgery (ISGPS)

BackgroundPancreatic surgery is associated with considerable morbidity and, consequently, offers a large and complex field for research. To prioritize relevant future scientific projects, it is of utmost importance to identify existing evidence and uncover research gaps. Thus, the aim of this project was to create a systematic and living Evidence Map of Pancreatic Surgery. MethodsPubMed, the Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for all randomized controlled trials and systematic reviews on pancreatic surgery. Outcomes from every existing randomized controlled trial were extracted, and trial quality was assessed. Systematic reviews were used to identify an absence of randomized controlled trials. Randomized controlled trials and systematic reviews on identical subjects were grouped according to research topics. A web-based evidence map modeled after a mind map was created to visualize existing evidence. Meta-analyses of specific outcomes of pancreatic surgery were performed for all research topics with more than 3 randomized controlled trials. For partial pancreatoduodenectomy and distal pancreatectomy, pooled benchmarks for outcomes were calculated with a 99% confidence interval. The evidence map undergoes regular updates. ResultsOut of 30,860 articles reviewed, 328 randomized controlled trials on 35,600 patients and 332 systematic reviews were included and grouped into 76 research topics. Most randomized controlled trials were from Europe (46%) and most systematic reviews were from Asia (51%). A living meta-analysis of 21 out of 76 research topics (28%) was performed and included in the web-based evidence map. Evidence gaps were identified in 11 out of 76 research topics (14%). The benchmark for mortality was 2% (99% confidence interval: 1%–2%) for partial pancreatoduodenectomy and <1% (99% confidence interval: 0%–1%) for distal pancreatectomy. The benchmark for overall complications was 53% (99%confidence interval: 46%–61%) for partial pancreatoduodenectomy and 59% (99% confidence interval: 44%–80%) for distal pancreatectomy. ConclusionThe International Study Group of Pancreatic Surgery Evidence Map of Pancreatic Surgery, which is freely accessible via www.evidencemap.surgery and as a mobile phone app, provides a regularly updated overview of the available literature displayed in an intuitive fashion. Clinical decision making and evidence-based patient information are supported by the primary data provided, as well as by living meta-analyses. Researchers can use the systematic literature search and processed data for their own projects, and funding bodies can base their research priorities on evidence gaps that the map uncovers.