Pancreatic Head Research Articles

Bots in white coats: are large language models the future of patient education? a multi-center cross-sectional analysis.

Every year, around 300 million surgeries are conducted worldwide, with an estimated 4.2 million deaths occurring within 30days after surgery. Adequate patient education is crucial, but often falls short due to the stress patients experience before surgery. Large language models (LLMs) can significantly enhance this process by delivering thorough information and addressing patient concerns that might otherwise go unnoticed. This cross-sectional study evaluated ChatGPT-4o's audio-based responses to frequently asked questions (FAQs) regarding six general surgical procedures. Three experienced surgeons and two senior residents formulated seven general and three procedure-specific FAQs for both preoperative and postoperative situations, covering six surgical scenarios (major: pancreatic head resection, rectal resection, total gastrectomy; minor: cholecystectomy, Lichtenstein procedure, hemithyroidectomy). In total, 120 audio responses were generated, transcribed, and assessed by 11 surgeons from six different German university hospitals. ChatGPT-4o demonstrated strong performance, achieving an average score of 4.12/5 for accuracy, 4.46/5 for relevance, and 0.22/5 for potential harm across 120 questions. Postoperative responses surpassed preoperative ones in both accuracy and relevance, while also exhibiting lower potential for harm. Additionally, responses related to minor surgeries were minimal, but significantly more accurate compared to those for major surgeries. This study underscores GPT-4o's potential to enhance patient education both before and after surgery by delivering accurate and relevant responses to FAQs about various surgical procedures. Responses regarding the postoperative course proved to be more accurate and less harmful than those addressing preoperative ones. Although a few responses carried moderate risks, the overall performance was robust, indicating GPT-4o's value in patient education. The study suggests the development of hospital-specific applications or the integration of GPT-4o into interactive robotic systems to provide patients with reliable, immediate answers, thereby improving patient satisfaction and informed decision-making.

Experience of surgical treatment of combat pancreatic trauma

Background. Pancreatic injuries is a complex challenge for trauma surgeons, especially if combat, due to the presence of combined injuries and complications. The aim: to provide a structure, peculiarities of diagnosis and treatment of combat pancreatic trauma. Materials and methods. A retrospective analysis was done of medical records of 58 inpatients who sustained combat pancreatic trauma during the war in Ukraine. Their average age was 37.4 ± 3.6 years (range 21–60 years). The mechanism of combat injury included gunshot wounds (87.9 %), explosive (10.3 %) and closed injuries (1.7 %). All the wounded underwent laboratory and instrumental investigations. Results. According to the nature of the combat injury, pancreatic injuries were categorised into gunshot shrapnel wounds — 50 (86.2 %), gunshot bullet wounds — 1 (1.7 %), explosive trauma — 6 (10.3 %), and closed combat trauma — 1 (1.7 %) case. Distribution by location of pancreatic injury: tail — 38 (65.5 %), head — 11 (19 %), body — 5 (8.6 %), body and tail — 2 (3.4 %), head and tail — 2 (3.4 %) cases. The following methods of surgical intervention were used: damage control surgery (DCS) — 51 (87.9 %) cases, one-stage surgery — 7 (12.1 %) cases. Distribution by the type of surgical intervention for pancreatic injury: drainage of the parapancreatic space — 45 (77.6 %), pancreatorrhaphy — 4 (6.9 %), distal pancreatosplenectomy — 3 (5.2 %), removal of foreign bodies (metal fragments) — 3 (5.2 %), distal resection of the pancreas with spleen preservation — 1 (1.7 %), pancreatoduodenectomy — 1 (1.7 %), subtotal resection of the body and tail of the pancreas with splenectomy — 1 (1.7 %) case. Common complications (n = 42): peritonitis — 9 (21.4 %), acute surgical sepsis — 8 (19 %), acute renal failure — 7 (16.7 %), multiple organ failure syndrome — 7 (16.7 %), pneumonia — 6 (14.3 %), bleeding — 4 (9.5 %), pulmonary embolism — 1 (2.4 %). Organ-specific complications (n = 28) were as follows: acute pancreatitis — 21 (75 %), pancreatic fistula — 4 (14.3 %), pseudocysts — 2 (7.1 %), abscess — 1 (3.6 %) case. Treatment outcomes: 33 patients (56.9 %) were transferred to the next stage of treatment, 19 (32.8 %) died, and 6 (10.3 %) were discharged with a definite outcome. Mortality rate: 5 (26.3 %) died in the first 3 days, 14 (73.7 %) cases died in the period from 4 to 15 days. Conclusions. The incidence of combat pancreatic trauma among abdominal wounds is 8.7 %. Surgical treatment for combat pancreatic trauma using the DCS is performed in 87.9 % of cases, and in the volume of a single-stage operation, in 12.1 %. The DCS leads to a reduction in the incidence of complications. The overall complication rate for combat pancreatic trauma is 72.4 %, and the incidence of organ-specific complications is 48.3 %. Mortality from pancreatic injuries is 32.8 %. Combat trauma to the head of the pancreas was mainly treated with closed drainage. Distal injuries were treated by resection or drainage.

T1 signal intensity ratio variability based on sampling strategies in the pancreas of children and young adults.

T1-weighted signal intensity ratios (SIR) comparing pancreas to spleen (SIRps) or muscle (SIRpm) can semiquantitatively assess T1 signal change associated with pancreatitis. However, there is no standardized methodology for generating these ratios. We set out to determine the impact of MRI sequence as well as region of interest (ROI) location, shape, and size on T1 SIR. Retrospective analysis of T1-weighted MR images from 118 patients acquired 2018-2023. A single observer placed ovoid ROIs in the pancreas body/tail and head/uncinate, spleen, and left erector spinae muscle and large irregular ROIs in the pancreas tail and spleen. ROIs were placed on images from two sequences: 3D radial 2 point mDIXON RF spoiled gradient recalled echo sequence (radial) and breath-hold 3D 2-point mDIXON RF spoiled gradient echo (BH). T1 SIR were calculated from mean signal intensity, and agreement was calculated with intraclass correlations coefficients (ICC) and Bland-Altman difference analyses. 118 participants, 57 (48%) female, withmean age 13.7 ± 5.6years (48%) were included. Agreement was good for SIRps based on irregular versus round ROIs (radial: ICC = 0.90; BH: ICC = 0.91). Agreement was moderate for SIR based on sampling the pancreas body/tail versus head/uncinate (ICC = 0.67-0.76) and poor to moderate based on reference organ (muscle vs. spleen) (ICC = 0.41-0.61). Between sequences, agreement was moderate (ICC = 0.55-0.72, mean difference 0.04-0.09). The size and shape of the ROI used to sample the pancreas does not meaningfully change T1 SIR but the location sampled, the reference organ used, and the MRI sequence used meaningfully change T1 SIR, potentially impacting disease diagnosis and staging.

Multimodal treatment combining neoadjuvant therapy, laparoscopic subtotal distal pancreatectomy and adjuvant therapy for pancreatic neck-body cancer: Case series.

Pancreatic cancer involving the pancreas neck and body often invades the retroperitoneal vessels, making its radical resection challenging. Multimodal treatment strategies, including neoadjuvant therapy, surgery, and postoperative adjuvant therapy, are contributing to a paradigm shift in the treatment of pancreatic cancer. This strategy is also promising in the treatment of pancreatic neck-body cancer. To evaluate the feasibility and effectiveness of a multimodal strategy for the treatment of borderline/locally advanced pancreatic neck-body cancer. From January 2019 to December 2021, we reviewed the demographic characteristics, neoadjuvant and adjuvant treatment data, intraoperative and postoperative variables, and follow-up outcomes of patients who underwent multimodal treatment for pancreatic neck-body cancer in a prospectively collected database of our hospital. This investigation was reported in line with the Preferred Reporting of Case Series in Surgery criteria. A total of 11 patients with pancreatic neck-body cancer were included in this study, of whom 6 patients were borderline resectable and 5 were locally advanced. Through multidisciplinary team discussion, all patients received neoadjuvant therapy, of whom 8 (73%) patients achieved a partial response and 3 patients maintained stable disease. After multidisciplinary team reassessment, all patients underwent laparoscopic subtotal distal pancreatectomy and portal vein reconstruction and achieved R0 resection. Postoperatively, two patients (18%) developed ascites, and two patients (18%) developed pancreatic fistulae. The median length of stay of the patients was 11 days (range: 10-15 days). All patients received postoperative adjuvant therapy. During the follow-up, three patients experienced tumor recurrence, with a median disease-free survival time of 13.3 months and a median overall survival time of 20.5 months. A multimodal treatment strategy combining neoadjuvant therapy, laparoscopic subtotal distal pancreatectomy, and adjuvant therapy is safe and feasible in patients with pancreatic neck-body cancer.

Long-term survival analysis based on tumor location in patients with pancreatic ductal adenocarcinoma who underwent pancreatectomy following neoadjuvant chemoradiotherapy

BackgroundThe study aimed at assessing whether long-term survival outcomes were different based on tumor location in pancreatic ductal adenocarcinoma (PDAC) patients who underwent pancreatectomy following neoadjuvant chemoradiotherapy (CRT).MethodsFollowing CRT, resection rate was 60.5% (286/473) and the resected patients had pancreatic head (n = 218), body (n = 34) and tail (n = 34) tumors. Survival analyses were conducted, independent predictors of disease-free survival (DFS) and overall survival (OS) were identified, and then survival outcomes were stratified by the predictors of DFS and OS.ResultsResection rates were; 64.7% (head) vs. 46.6% (body) and 54.0% (tail) cases, p = 0.009. Among these cases, pancreatic head patients exhibited a higher incidence of initial clinical stage 3 tumors; 48.2% (head) vs. 29.4% (body) and 0% (tail) cases, p < 0.001 with more unresctable-locally advanced tumors; 22.0% (head) vs. 11.8% (body) and 0% (tail), p < 0.001, but demonstrated a better response to CRT; Evans grades 3/4 in 49.1% (head) vs. 23.5% (body) and 26.5% (tail), p = 0.012. Five-year DFS rates were; 19.9% (head) vs. 11.8% (body) vs. 24.6% (tail), p = 0.565 and OS rates; 25.4% (head) vs. 27.7% (body) vs. 32.0% (tail), p = 0.341. Significant predictors of DFS and OS included post-CRT CA19-9 levels, tumor differentiation, resection margins and pathological portal vein invasion. Based on these predictors, survival outcomes were also comparable. Pathological nodal invasion influenced DFS, while pathological stage impacted OS.ConclusionPancreatic head patients had the best resection rate and long-term survival outcomes were comparable, attributable to the better response to CRT by pancreatic head than the body and tail PDAC patients.

Robot-assisted “Bridge” approach pancreatosplenectomy for “shoulder” pancreatic cancer: a new technique

Pancreatic body/ tail cancer has a worse prognosis because of late detection and early invasion into important vessels. Our team proposed the concept of “shoulder” pancreatic cancer (PC) and invented a new approach named Retrograde artery first approach pancreatosplenectomy (RAFAPS). However, we found that in some cases this approach may not be perfect. We encountered a patient who had previously undergone laparoscopic radical operation for hilar cholangiocarcinoma caused RAFAPS could not be performed. Hence, we used a new procedure based on RAFAPS to finish the pancreatosplenectomy and named it “Bridge”. After the operation, the patient recovered smoothly. We report the new technique, aiming to provide the experience for the surgical treatment of “shoulder” PC.

Motion-Compensated Multishot Pancreatic Diffusion-Weighted Imaging With Deep Learning-Based Denoising.

Pancreatic diffusion-weighted imaging (DWI) has numerous clinical applications, but conventional single-shot methods suffer from off resonance-induced artifacts like distortion and blurring while cardiovascular motion-induced phase inconsistency leads to quantitative errors and signal loss, limiting its utility. Multishot DWI (msDWI) offers reduced image distortion and blurring relative to single-shot methods but increases sensitivity to motion artifacts. Motion-compensated diffusion-encoding gradients (MCGs) reduce motion artifacts and could improve motion robustness of msDWI but come with the cost of extended echo time, further reducing signal. Thus, a method that combines msDWI with MCGs while minimizing the echo time penalty and maximizing signal would improve pancreatic DWI. In this work, we combine MCGs generated via convex-optimized diffusion encoding (CODE), which reduces the echo time penalty of motion compensation, with deep learning (DL)-based denoising to address residual signal loss. We hypothesize this method will qualitatively and quantitatively improve msDWI of the pancreas. This prospective institutional review board-approved study included 22 patients who underwent abdominal MR examinations from August 22, 2022 and May 17, 2023 on 3.0 T scanners. Following informed consent, 2-shot spin-echo echo-planar DWI (b = 0, 800 s/mm2) without (M0) and with (M1) CODE-generated first-order gradient moment nulling was added to their clinical examinations. DL-based denoising was applied to the M1 images (M1 + DL) off-line. ADC maps were reconstructed for all 3 methods. Blinded pair-wise comparisons of b = 800 s/mm2 images were done by 3 subspecialist radiologists. Five metrics were compared: pancreatic boundary delineation, motion artifacts, signal homogeneity, perceived noise, and diagnostic preference. Regions of interest of the pancreatic head, body, and tail were drawn, and mean ADC values were computed. Repeated analysis of variance and post hoc pairwise t test with Bonferroni correction were used for comparing mean ADC values. Bland-Altman analysis compared mean ADC values. Reader preferences were tabulated and compared using Wilcoxon signed rank test with Bonferroni correction and Fleiss κ. M1 was significantly preferred over M0 for perceived motion artifacts and signal homogeneity (P < 0.001). M0 was significantly preferred over M1 for perceived noise (P < 0.001), but DL-based denoising (M1 + DL) reversed this trend and was significantly favored over M0 (P < 0.001). ADC measurements from M0 varied between different regions of the pancreas (P = 0.001), whereas motion correction with M1 and M1 + DL resulted in homogeneous ADC values (P = 0.24), with values similar to those reported for ssDWI with motion correction. ADC values from M0 were significantly higher than M1 in the head (bias 16.6%; P < 0.0001), body (bias 11.0%; P < 0.0001), and tail (bias 8.6%; P = 0.001). A small but significant bias (2.6%) existed between ADC values from M1 and M1 + DL. CODE-generated motion compensating gradients improves multishot pancreatic DWI as interpreted by expert readers and eliminated ADC variation throughout the pancreas. DL-based denoising mitigated signal losses from motion compensation while maintaining ADC consistency. Integrating both techniques could improve the accuracy and reliability of multishot pancreatic DWI.

Complete Resolution of Frequent, Non-Specific Hypoglycemia Symptoms After Surgical Removal in a Patient With Pancreatic Tail Insulinoma: A Case Report

Complete Resolution of Frequent, Non-Specific Hypoglycemia Symptoms After Surgical Removal in a Patient With Pancreatic Tail Insulinoma: A Case Report

The effectiveness of a conservative approach in the management of groove pancreatitis.

Groove pancreatitis (GP) is a form of pancreatitis that affects the pancreaticoduodenal groove area, which lies between the head of the pancreas, the second part of the duodenum and the distal bile duct, presenting as abdominal pain and gastric outlet obstruction. In this study, we present the clinical and radiological characteristics of individuals diagnosed with groove pancreatitis at our center and discuss the use of a conservative treatment approach in managing GP. The data of patients with groove pancreatitis treated at our center between January 2012 and December 2021 was analyzed. The clinical, laboratory and radiological features were recorded and patients were followed up for at least sixmonths in the pancreatic clinic by a specialist doctor. Fifty patients were included in the study. Most patients were males (98%) in the middle age group (35 to 55years) (70%) with chronic alcohol use and/or smoking noted in 48 (96%) of them. Ninety-six percent presented with recurrent abdominal pain. The most common imaging features were the thickening of the medial duodenal wall (100%)followed by enhancement of the scar tissue in the groove (98%). All patients were initially treated conservatively with advice to abstain from addictions, of whom 35 patients were followed up. Twenty percent of the patients (seven out of 35) did not respond and required a step-up approach with endoscopic retrogradecholangiopancreatography (for biliary obstruction), celiac block (for ongoing abdominal pain) and surgery (gastrojejunostomy for gastric outlet obstruction, Frey's procedure for abdominal pain). Most patients were asymptomatic at follow-up (mean follow-up of 30months). The diagnosis of GP continues to be a challenge. A step-up approach appears to be a reasonable strategy in managing GP as most of them can be managed conservatively.

A Novel Method for Hemorrhage Control During Laparoscopic Distal Pancreatectomy with Splenic Vessel Preservation: Triple Occlusion.

Laparoscopic distal pancreatectomy (LDP) has the advantages of reduced blood loss, shorter hospital stays, and a better postoperative quality of life compared with open distal pancreatectomy (ODP).1 Meanwhile, spleen-preserving laparoscopic distal pancreatectomy is the preferred technique for low-grade malignant and benign tumors located in pancreatic body and tail, since it preserves the immune function of the spleen. The splenic-vessel-preserving (SVP) Kimura technique and splenic vessel resection Warshaw technique are the two primary procedures. Although the Kimura procedure and the Warshaw procedure were comparable in most postoperative outcomes, the former was superior to the latter in reducing the risk of gastric varices and splenic infarction.2,3 However, in cases of large tumors in the distal pancreas or those with tight adhesions of the tumor to the splenic vessels, laparoscopic Kimura procedure is technically challenging because of the higher risk of intraoperative hemorrhage.4 Herein, we present an effective surgical approach to laparoscopic SVP that minimizes the chances of vascular injury and maximizes the chances of a successful splenic preservation-triple occlusion strategy. A 46-year-old woman was admitted to our department owing to vague pain in the upper abdomen lasting for 6 months. Enhanced computed tomography (CT) scan revealed a 3.9 ✕ 4.3 cm cystic tumor in the distal pancreas, which has a smooth cystic wall without wall nodules; despite poor demarcation of the tumor from the splenic vein, tumor markers were all within normal limits (CA19-9, 5.78 U/ml; CEA, 1.14 ng/ml), so a benign tumor was considered. We present the triple-occlusion strategy during laparoscopic Kimura operation. This approach, as demonstrated in the video, includes triple occlusion of the proximal splenic artery, proximal splenic vein, and splenic pedicle; In addition, we use cold scissors to carefully dissect the tumor from the splenic vein, which minimizes the possibility of splenic vein injury and tumor rupture caused by thermal damage of ultrasonic scalpel, thus improving the safety of the surgery and the chances of spleen preservation. The operation lasted for 136 min with 10ml of estimated blood loss. Multiple sites of the cystic wall were sampled (including the margins of the splenic vein), and intraoperative freezing was conducted to consider mucinous tumors, with no cancer cells detected. The amylase in the drainage fluid on postoperative day (POD) 3 was 1410 U/l, and the drainage tube was removed on POD 4. The patient showed an uneventful recovery and was discharged on POD 5. Finally, mucinous cystadenoma with mild atypical hyperplasia was diagnosed by pathological examination. The laparoscopic triple-occlusion strategy may be helpful for selected patients with tumors located at the distal pancreas, especially for those with large tumor or tumors with tight adhesion to splenic vessels.

Pancreatic endometrioma in a post‐menopausal woman: A rare differential diagnosis for cystic lesions of the pancreas

AbstractBackgroundAlthough endometriosis is a relatively common condition affecting women, pancreatic endometriosis remains rare, with only a few cases reported in the literature. The primary challenges this condition poses today are its inability to be diagnosed radiologically and the difficulty in distinguishing it from other cystic lesions of the pancreas preoperatively.MethodsThis report presents a case of a 53‐year‐old female patient with 3 months long left upper quadrant pain and no previous medical history. Imaging revealed an enlarging cyst in the tail of the pancreas, with findings suggestive of a mucinous neoplasm.ResultsThe patient underwent a distal pancreatectomy and splenectomy. Histopathological analysis confirmed the presence of endometrial stroma.ConclusionsConsidering the possibility of pancreatic endometriosis may help avoid extensive surgery. However, as the definite diagnosis of endometriosis remains histopathological, surgical resection continues to be the treatment of choice if malignancy is suspected.

Single-docking robot-assisted radical antegrade modular pancreatosplenectomy with partial left nephrectomy in a patient with synchronous pancreatic neuroendocrine neoplasm and clear cell renal cell carcinoma.

The synchronous occurrence of pancreatic neuroendocrine neoplasm (PNEN) and clear cell renal cell carcinoma (ccRCC) in one patient is extremely rare. Synchronous resection of both tumours is preferred over a two-stage procedure if possible. The robotic da Vinci Xi platform allows for multi-quadrant surgery with oncological outcomes comparable to those of laparoscopic or open surgery. We present the case report of an 80-year-old male who underwent synchronous resection of a PNEN in the tail of the pancreas and ccRCC in the left kidney. To the best of our knowledge, this is the first case report on this topic.

Successful staged surgery for advanced esophageal cancer after conversion pancreatoduodenectomy with pancreaticogastrostomy.

Complex surgery during initial cancer treatment can limit surgical options when planning management of a secondary malignancy. Subtotal esophagectomy and pancreatoduodenectomy are the most invasive and difficult procedures in gastroenterological surgery. Surgical cases in which subtotal esophagectomy was performed after pancreatoduodenectomy with pancreaticogastrostomy are extremely rare and challenging procedures due to the resulting complicated anatomical changes. A 60-year-old man with a history of conversion pancreatoduodenectomy with pancreaticogastrostomy for advanced pancreatic head cancer was diagnosed as having advanced thoracic esophageal squamous cell carcinoma. After neoadjuvant chemotherapy, we chose a two-staged surgery with thoracoscopic subtotal esophagectomy. Following percutaneous endoscopic gastrostomy, we performed subtotal esophagectomy, systematic lymph-node dissection, and esophagostomy as the first-stage operation. Fifty-six days later, we performed gastrointestinal reconstruction with pedicle jejunum and microvascular anastomosis by the percutaneous route as the second-stage operation. Postoperatively, the patient was relieved without major complications, and the tumors were amenable to curative pathologic resection. The greatest advantages of staged surgery are to reduce surgical invasiveness and to circumvent the lower rate of curability. Our procedure reported here may be recommended as an option for staged resection and reconstruction in patients with advanced esophageal cancer after pancreatoduodenectomy with pancreaticogastrostomy.

Sequence of Chemotherapy May Not Impact Survival After Resection of Pancreatic Tail Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) of the body/tail is notably different than PDAC in the head of the pancreas. Surgery plus chemotherapy is known to improve outcomes for all PDAC. The sequence of this therapy is well studied in head cancers yet has never been evaluated systematically in relation to distal pancreatectomy (DP). Patients receiving DP for PDAC and who received chemotherapy were included. Patients were compared receiving neoadjuvant systemic therapy (NAST) only, adjuvant (AST) only, both NAST + AST, and who received total neoadjuvant therapy (TNT), defined as > 24 weeks NAST before DP. PSM was performed 1:1 between AST and each other group creating quadruplets of patients for analysis. Matching factors were determined by multivariate cox-regression analysis of factors independently affecting survival. Survival was considered from diagnosis and from surgery to account for potential biases. In total, 4677 patients were selected with 400 (8.6%) receiving TNT, 536 (11.5%) NAST, 3235 (69.2%) AST, and 506 (10.8%) NAST + AST. A total of 341 quadruplets were selected after PSM. There were no differences in comorbidities, T/N-stage, retrieved or positive lymph nodes, and margin status after matching. Kaplan-Meier analysis showed no difference in median OS between the matched treatment groups (33.71 ± 2.07 vs. 35.22 ± 1.62 vs. 32.53 ± 3.31 vs. 37.88 ± 1.90, respectively; log-rank p = 0.464). Five-year OS was not different between the groups (21% vs. 18% vs. 20% vs. 25%, respectively; p = 0.501). The sequence of chemotherapy and surgery did not impact survival in distal PDAC. Providers should tailor an individualized approach designed to maximize the chance of completing both treatments.

Identification of the course of plastic stent-induced pancreatic duct mucosal change in chronic pancreatitis using peroral pancreatoscopy (with video).

Stent-induced ductal change is a complication of endoscopic treatment of the main pancreatic duct in chronic pancreatitis. Most previous reports have been based on morphological duct changes observed via pancreatography. Here, we describe a case of stent-induced ductal change in which the course of the mucosal changes was observed through peroral pancreatoscopy with a videoscopy. The patient presented with chronic alcoholic pancreatitis. Main pancreatic duct stenosis in the pancreatic head was identified and a 10-Fr plastic stent was inserted. Follow-up pancreatography revealed a focally elevated duct change of approximately 4.5mm at the distal tip of the stent, and peroral pancreatoscopy was performed. The elevated ductal change was identified as a clear villiform-like nodular mucosal change with the spread of pale papillary and granular mucosa. Reassessment after stent removal showed an improvement in the elevated mucosal lesion, with residual discoloration and mucosal retraction suggestive of scarring. The stent may cause irreversible changes, undetectable morphologically by pancreatography, likely underestimating stent-induced ductal change in chronic pancreatitis.

Application and advantage analysis of triangular gastric suspension technique in laparoscopic distal pancreatectomy.

Laparoscopic distal pancreatectomy is a safe and effective surgical method for treating benign and malignant tumors of the pancreatic body and tail. However, laparoscopic surgery requires good intraoperative exposure, and since the pancreas is obstructed by the stomach and duodenum, making surgical operations and the management of intraoperative emergencies challenging. Therefore, gastric traction is crucial in laparoscopic distal pancreatectomy. Common gastric suspension techniques include single and double gastric suspension. Here, we propose a new, simple, and effective gastric suspension method called the triangular gastric suspension. We retrospectively analyzed the clinical data of 62 patients who underwent laparoscopic distal pancreatectomy at the Hepatobiliary and Pancreatic Surgery Department, The Affiliated LiHuiLi Hospital of Ningbo University from February 2017 to March 2024. The patients were divided into two groups based on whether triangular gastric suspension with silk sutures was used during surgery: the suspension group (28 cases) and the control group (34 cases). We analyzed various perioperative indicators between the two groups both before and after propensity score matching (PSM). With or without PSM, there were no statistically significant differences between the two groups in terms of age, gender, body mass index, American Society of Anesthesiologists classification, surgical approach, tumor pathological type and tumor length. Meanwhile, there were no statistically significant differences between the two groups in terms of pancreatic stump anastomosis, intraoperative transfusion, intraoperative R0 rate, postoperative pancreatic fistula grade, postoperative severe hemorrhage, reoperation, and delayed gastric emptying rate. However, the differences in operative time, intraoperative blood loss, and total hospital stay were statistically significant, with the suspension group showing better outcomes. The triangular gastric suspension method provides significant advantages in reducing intraoperative blood loss and shortening operative time during laparoscopic distal pancreatectomy. It is a new, simple, and effective suspension method.

A Modified Procedure to Improve Pancreatic Drainage in Chronic Pancreatitis with Pancreatic Head Dominant Disease.

Chronic pancreatitis is a debilitating and progressive inflammatory disease with an altered quality of life due to severe abdominal pain. Pancreaticoduodenectomy is a surgical option for patients with bulky disease involving the head of the pancreas, especially when this disease has progressed to stricture of the bile duct, duodenum, or both. A long term issue associated with this procedure is stricture of the pancreatic anastomosis. Re-operative and endoscopic interventions are difficult related to difficulty in reaching the anastomosis endoscopically. We describe a variation of this procedure with potential to lead to longer term improvement in drainage of the residual pancreas. We reviewed electronic medical records of patients undergoing pancreaticoduodenectomy for chronic pancreatitis performed by one surgeon at the University of Minnesota Medical Center, Minneapolis, MN, between 2014 and 2023. Information gathered from the patients' records included preoperative demographics, perioperative outcomes, and postoperative follow up information. The described procedure was performed in eight patients between 2014 and 2023. Three patients have died since surgery at 1.5, 5.5, and 8 years postop, with no deaths related to pancreatitis or surgical complications. Of the remaining five patients, median time from surgery is 7.5 years. We describe a surgical technique which may reduce the risk of pancreaticojejunal stricture in patients undergoing pancreaticoduodenectomy for chronic pancreatitis. In a small series of patients, this procedure can be performed safely with acceptable results.

Neural invasion severity is a strong predictor of local recurrence in pancreatic ductal adenocarcinoma.

In pancreatic ductal adenocarcinoma, neural invasion is being increasingly recognized as an unfavorable predictor of patient outcomes. Neural invasion severity seems to have a stronger clinical impact on patient prognosis than neural invasion status alone. Therefore, this study aims to assess the impact of severity of neural invasion on overall survival and disease-free survival in pancreatic ductal adenocarcinoma. To assess the impact of intrapancreatic neural invasion severity, tumor specimens resected from patients with pancreatic ductal adenocarcinoma between 2007 and 2014 were systematically re-evaluated, and neural invasion severity was determined using the standardized neural invasion severity score. In our cohort (n= 216), an increased neural invasion severity score was associated with markedly shorter overall survival in pancreatic head ductal adenocarcinoma (neural invasion severity score low: 22.8months vs neural invasion severity score high: 17.6months: P= .001). An external European validation cohort confirmed these results and showed significantly better survival of patients with lower neural invasion (20.5 vs 15.4months, P= .026). The disease-free survival time was also substantially decreased in patients with pancreatic head pancreatic ductal adenocarcinoma and increased neural invasion severity (neural invasion severity score low: 19.1months vs neural invasion severity score high: 10.4months; P= .004). Moreover, the neural invasion severity score was an important independent factor influencing overall survival (hazards ratio 1.024, P= .04) and disease-free survival (hazards ratio 1.03, P= .01) using an adjusted Cox proportional hazards model. Importantly, higher neural invasion severity score leads to significantly more and earlier local recurrence than to distant tumor recurrence. Neural invasion severity is a powerful independent factor influencing overall survival and local recurrence in patients with pancreatic ductal adenocarcinoma. Therefore, individuals with high neural invasion severity score values should be regarded as a specific subgroup of pancreatic ductal adenocarcinoma patients and may benefit from more tailored postoperative oncologic therapy.

Optimal virtual monoenergy for the detection of pancreatic adenocarcinoma during the pancreatic parenchymal phase on photon counting CT.

As the pancreas is a low contrast visibility organ, pancreatic ductal adenocarcinoma detection is challenging due to subtle attenuation differences between tumor and pancreatic parenchyma. Photon counting CT (PCCT) has superior iodine contrast-to-noise ratio than conventional CT and also affords the creation of low keV virtual monoenergetic images, both of which increase adenocarcinoma conspicuity. The purpose therefore was to identify the optimal virtual monoenergy for visualizing PDAC during the pancreatic parenchymal phase of enhancement at PCCT using both quantitative and qualitative analyses. Consecutive patients with pancreatic parenchymal phase PCCT source data were retrospectively identified by PACS search. For the quantitative analysis, region of interest (ROI) measurements were drawn in the pancreatic head, body, tail, pancreatic adenocarcinoma (if present), and psoas muscles on 40-120keV virtual monoenergetic images in 10keV increments. Based on the quantitative analysis results and vendor recommendations, four virtual monoenergies(40keV, 55keV, 70keV, and 85keV) were selected for additional qualitative analysis. Three radiologists blinded to four virtual monoenergies assessed overall image quality, image noise, pancreatic enhancement, and pancreatic mass conspicuity on 5-point Likert scales. 54 patients (28/54 male, mean[SD] age: 62 [13] years) were included. Quantitatively, 40keV had the highest pancreatic parenchymal CNR and attenuation difference between the adenocarcinoma and parenchyma, but also the highest noise (HUsd). Qualitatively, 70keV had the best overall image quality (Mean [SE]: 3.7[0.1]) and lower noise than 40 and 55keV (3.6[0.08] vs. 1.8[0.07] and 2.7[0.05], respectively, p < .001). 40keV had the greatest pancreatic enhancement (mean[SE] 4.6[0.11]). Adenocarcinoma conspicuity ratings were greatest at 40keV and 55keV, and not significantly different from each other (mean[SE] 4.4[0.13] and 4.3[0.14], respectively, Tukey adj-p =.20). 55keV had greater overall image quality and lower noise than 40keV (mean[SE] 3.4[0.08] vs. 2.5[0.08], Tukey adj-p < .001 and 2.7[0.05] vs. 1.8[0.07], Tukey adj-p < .001 respectively). 55keV pancreatic parenchymal phase virtual monoenergetic images afford optimal pancreatic assessment at PCCT for the visualization of pancreatic adenocarcinoma. Routinely viewing 55keV virtual monoenergetic images at PCCT may improve PDAC detection.

Correlation Between Systemic Inflammation, Gut Microbiome Dysbiosis and Postoperative Complications After the Modified Whipple Procedure.

(1) Background: The modified Whipple procedure, or pylorus-preserving pancreaticoduodenectomy, is a complex surgical intervention used to treat pancreatic head tumors. While preserving digestive function, it is associated with significant perioperative risks. This study explores the clinical, immunological, and microbiome-related factors influencing postoperative complications, focusing on the interplay between patient comorbidities, systemic inflammation, and gut dysbiosis. (2) Methods: A retrospective analysis was conducted on 123 patients undergoing the modified Whipple procedure for pancreatic head tumors. Patients were categorized into two groups based on the occurrence of significant postoperative complications (Group A: with complications; Group B: without complications). Data on demographics, comorbidities, inflammatory markers (CRP, IL-6, procalcitonin), and gut microbiome composition were collected. Microbial diversity was evaluated using the Shannon Index, and logistic regression was performed to identify independent predictors of complications. (3) Results: Patients in Group A had a significantly higher prevalence of diabetes mellitus (43.1% vs. 20.8%; p = 0.02) and cardiovascular disease (35.3% vs. 13.9%; p = 0.01). Elevated inflammatory markers (CRP ≥ 40 mg/L, IL-6 ≥ 30 pg/mL, procalcitonin ≥ 0.5 ng/mL) were strongly associated with higher complication rates. Microbiome analysis indicated dysbiosis in Group A, with reduced Lactobacillus and Bifidobacterium levels, increased Enterobacteriaceae abundance, and a lower Shannon Index (<2). Patients exhibiting both dysbiosis and elevated inflammation had the highest complication rate (60%). Multivariate analysis identified diabetes, elevated IL-6, and dysbiosis as independent predictors of adverse outcomes. (4) Conclusions: Postoperative complications after the modified Whipple procedure are influenced by systemic inflammation and gut dysbiosis. A systematic preoperative assessment of microbiome health and inflammatory markers enables accurate risk stratification and personalized interventions, potentially reducing the incidence of complications and improving overall surgical outcomes.