Pancreaticoduodenectomy Group Research Articles

Pancreatic Regeneration and Changes in Endocrine Function after Pancreatectomy

Background: Limited evidence is available on the regeneration of and functional changes to remnant pancreas after pancreatectomy. Therefore, we investigated the correlation between changes in volume and endocrine function in the remnant pancreas. Methods: Ninety patients undergoing pancreaticoduodenectomy (PD) and 45 undergoing distal pancreatectomy (DP) from January 2009 to December 2017 were included in this prospective study. Computed tomography was used to determine the volume of remnant pancreas 3 months, 1 year, and 2 years after pancreatectomy. Findings: The remnant pancreas volume compared to the initial residual pancreas was 80·79%, 68·67%, and 65·34% in the PD patients (p<0·001), and 106·25%, 106·62%, and 110·43% (p=0·019) in the DP patients at 3 months, 1 year, and 2 years, respectively. The DP patients had a higher incidence of new-onset diabetes than PD patients (33·3% vs. 22·7%). In addition, PD patients had more pancreatic duct dilatation with severe atrophy of the remnant pancreas (p=0·027), whereas DP patients had better pancreas regeneration (p=0·084) with spleen preservation. The changes in pancreas volume did not correlate with postoperative new-onset diabetes. Interestingly, the PD group had significantly greater restoration of endocrine function based on secretion of C-peptide. Interpretation: Pancreatic regeneration is more predominant after DP than PD. The distal portion of the pancreas had greater restoration capacity, corresponding with a lower rate of new-onset diabetes. Funding Statement: The study was supported by Taiwan Ministry of Science and Technology (MOST108-2321-B-006-014), Ministry of Health and Welfare (MOHW 107-TDU-B-212-114026A), and HSU-YUAN Education Foundation (HY-2018-001). Declaration of Interests: The authors reported no conflict of interest. Ethics Approval Statement: IRB approved by the Institutional Review Board of the National Cheng Kung University Hospital (approval number of B-ER-108-312).

Luces y sombras de la duodenopancreatectomía cefálica laparoscópica

IntroductionLaparoscopic pancreaticoduodenectomy (PD) is not widely accepted, and its use is controversial. Only correct patient selection and appropriate training of groups experienced in pancreatic surgery and laparoscopy will be able to establish its role and its hypothetical advantages MethodsOut of 138 pancreatic surgeries performed in a two-year period (2017-2019), 23 were laparoscopic PD. We evaluate its efficacy and safety compared to 31 open PD. ResultsThere were no cases of B/C pancreatic or biliary fistula, nor any cases of delayed gastric emptying in the laparoscopic group, but hemorrhage required one reoperation. The conversion rate was 21% (five cases): one due to bleeding, and the remainder for non-progression. The converted patients showed no differences compared to those completed by laparoscopy. There were no differences between laparoscopic and open PD in surgical time, postoperative complications, reintervention rate, readmissions or mortality. R0 resection in tumor cases was 85% for laparoscopy and 69% in open surgery without statistical significance. The postoperative hospital stay was shorter in the laparoscopic PD group (eight vs. 15 days). ConclusionsIn a selected group, laparoscopic PD can be safely and effectively performed if carried out by groups who are experts in pancreatic surgery and advanced laparoscopy. The technique has the same postoperative results as open surgery and is oncologically adequate, with less hospital stay. Proper patient selection, a step-by-step program and a lax and early conversion prevents serious operating accidents.

Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy

BackgroundThere are no reports of performing mesopancreas dissections in robotic pancreaticoduodenectomy. This study evaluated the feasibility and justification for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy. MethodsSurgical outcomes after robotic pancreaticoduodenectomy and open pancreaticoduodenectomy were evaluated and compared. ResultsThere were 289 robotic pancreaticoduodenectomy and 162 open pancreaticoduodenectomy patients included in the study. Postoperative diarrhea occurred in 34.5% of mesopancreas level 3 dissection cases and was higher than in levels 2 and 1 dissection cases, P < .001. Blood loss in the robotic pancreaticoduodenectomy group was higher for mesopancreas level 3 dissection, with a median loss of 263 mL (P = .015). The rate of R0 resection with margin >1 mm was higher for mesopancreas level 3 dissection (93.8%) than for level 2 dissection (72.2%) (P < .001). The lymph node yield was higher for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy; the median lymph node yield was 21 for level 3, 18 for level 2, and 14 for level 1 (P < .001). Compared with mesopancreas levels 1 and 2 dissections in the robotic pancreaticoduodenectomy groups, level 3 dissection did not show increased surgical mortality or postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, chyle leakage, bile leakage, or wound infection. Compared with open pancreaticoduodenectomy, mesopancreas level 3 dissection in robotic pancreaticoduodenectomy had less blood loss, no delayed gastric emptying, and lower chyle leakage. ConclusionMesopancreas level 3 dissection in robotic pancreaticoduodenectomy is feasible without compromising surgical safety. Therefore, robotic pancreaticoduodenectomy can be recommended as a safe alternative to open pancreaticoduodenectomy for mesopancreas level 3 dissection.

Surgical Decisions Based on a Balance between Malignancy Probability and Surgical Risk in Patients with Branch and Mixed-Type Intraductal Papillary Mucinous Neoplasm.

Objective: To propose a decision tool considering both malignancy probability and surgical risk for intraductal papillary mucinous neoplasm (IPMN). Background Data Summary: Surgical risk and malignancy probability are both critical factors in making decisions about surgical resection of IPMN. Methods: We included 800 patients who underwent pancreatic resection for branch duct and mixed-type IPMN (April 1995 to June 2018). A nomogram was used to obtain the malignancy probability (MP-N). The surgical risks were estimated as the postoperative complication rate and serious complication from the ACS NSQIP surgical risk calculator (SC-ACS NSQIP). The risk–benefit analysis was conducted in two ways: calculation of the cutoff value of MP-N using the complication rate and directly comparing the MP-N and SC-ACS NSQIP results. Results: The optimal cutoff value of MP-N was 32% and 21% in the pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) groups, respectively, when using the major complication rate (Clavien grades III over). When we applied the optimal cutoff value to the two surgical methods, surgery was reduced by 51.7% in the PD group and 56% in the DP group, and the AUC value of the malignant predictions were 0.7126 and 0.7615, respectively. According to the direct comparison of MP-N and SC-ACS NSQIP, surgery was reduced by 31.7%, and the AUC value of malignant prediction was 0.6588. Conclusion: Our risk–benefit analysis model considering both malignancy probability and surgical risk is relatively acceptable, and it may help surgeons and patients make treatment decisions for a disease with a broad spectrum of malignancy rates.

Para-aortic lymph node metastasis detected intraoperatively by systematic frozen section examination in pancreatic head adenocarcinoma: is resection improving the prognosis?

BackgroundThis study aimed to evaluate the controversial benefit of a pancreaticoduodenectomy (PD) in patients with PALN metastasis intraoperatively detected by systematic frozen section examination in pancreatic adenocarcinoma. MethodsPALN intraoperative examination by frozen section was systematically performed from January 2006 to February 2018 prior to performing PD for pancreatic adenocarcinoma. Until June 2012, PALN + patients still underwent PD (PALN+/PD group) in the framework of a prospective study. Since July 2012, PALN+ was considered as contraindicating the planned PD (PALN+/No-PD group). Post-operative morbidity and survival were compared between these two groups. ResultsOf the 32 PALN + patients intraoperatively detected, the first 13 underwent a PD, while the last 19 did not undergo resection. Seven patients (54%) among 13 PALN+/PD patients developed a post-operative complication against 3 (16%) among 19 PALN+/No-PD patients (p = 0.049). The median length of stay was 5 days longer for PALN+/PD patients (p = 0.001). The median survival did not differ between PALN+/No-PD and PALN+/PD groups (respectively 13.4 months (95%CI:7.6–19.3) and 11.5 months (95%CI:5.9–17.1), p = 0.471). No patient was alive 4 years after surgery in both the PALN+/No-PD or PALN+/PD groups. ConclusionIn case of PALN detected intraoperatively in pancreatic adenocarcinoma, PD does not improve survival compared to current palliative treatment.

Comparison of pancreaticoduodenectomy and bile duct resection for middle bile duct cancer: A multi-center collaborating study of Japan and Korea.

BackgroundIt is currently unknown whether bile duct segmental resection (BDSR) is an acceptable method for localized middle bile duct cancer (mid‐BDC) when R0 resection can be achieved. This study aimed to investigate the short‐ and long‐term outcomes of mid‐BDC patients treated with pancreaticoduodenectomy (PD) compared to those for BDSR.MethodsThis was a retrospective, Japanese and Korean multi‐center collaboration study based on patients' medical records.ResultsA total of 663 patients, including 245 BDSR and 418 PD cases, were enrolled. The incidence of postoperative pancreatic fistula (3.3% vs 44.1%, P < .0001), surgical site infection in the organ space (6.1% vs 17.7%, P < .0001) and clinically problematic morbidities (15.9% vs 32.8%, P < .0001) was significantly higher in the PD group. There was no difference in the mortality rate (0.8% vs 1.7%, P = .3566). Local (33.9% vs 14.4%, P < .0001) and lymph node (22.4% vs 11.0%, P < .0001) recurrence rates were significantly higher in the BDSR group. Relapse‐free survival (25.0 vs 34.0 months, P = .0184) and overall survival (41.2 vs 60.1 months, P = .0019) were significantly longer in the PD group. The PD group had significantly better prognosis in stage IA/IB cases (58.3 vs 111.5 months, P = .0067), which were the best indicators for BDSR, even when R0 resection was achieved. In multivariate analysis, BDSR was an independent poor prognostic factor.ConclusionDespite the inferior perioperative short‐term outcomes, our data advocate that PD should be the standard procedure for mid‐BDCs and that BDSR should be avoided even if R0 resection can be achieved. (UMIN000017914).

Survival outcomes of pancreaticoduodenectomy versus extended pancreaticoduodenectomy procedure for pancreatic head carcinoma: a propensity score matching study.

BackgroundIt is unclear if the modified extended pancreaticoduodenectomy (PD) has better outcome superior the conventional PD for patients with pancreatic head carcinoma (PHC). The objective of this study is to compare the survival outcomes of the classic PD procedure and the modified extended PD procedure for PHC.MethodsA total of 7,084 resected PHC patients with PD and extended PD procedure from the SEER database from 2004 to 2014 were stratified. With the utilization of propensity score matching (PSM), patient baseline characteristics were balanced to decrease the bias. Overall survival (OS) and cancer-specific survival (CSS) were analyzed in both groups.ResultsOf the 7,084 patients, 6,541 (92.3%) and 543 (7.7%) patients received PD and extended PD surgical procedures, respectively. After 2:1 ratio of PSM, 543 patients with extended PD procedure and 1,084 patients with PD procedure were completely matched. The median CSS and OS for PD and extended PD group were 20.0 and 19.0 months, and 19.0 and 18.0 months, respectively. The 5-year CSS and OS rates for PD and extended PD group were 17.5% and 16.1%, and 13.9% and 13.1%, respectively.ConclusionsThere is no distinct difference in survival outcomes between PD and extended PD procedure in patients with PHC.

Changes in glucose tolerance after pancreatectomy in patients with pancreatic ductal adenocarcinoma.

668 Background: Diabetes mellitus (DM) is reported to be related to pancreatic ductal adenocarcinoma (PDAC). Long-standing DM is a risk factor for PDAC, meanwhile, quite a few patients with PDAC develop DM as a paraneoplastic disorder and some papers reported that DM affected prognosis for PDAC. In this study, we investigated pre- and post-operative glucose tolerance in patients with pancreatectomy for PDAC or other disease. Methods: This single-center prospective study included 69 patients with pancreatectomy (40 pancreaticoduodenectomy (PD) and 29 distal pancreatectomy (DP) ) who received 75-g oral glucose tolerance test (OGTT) and glucagon test pre- and one month postoperatively. Plasma glucose, insulin, and C-peptide (CPR) at 0-, 30-, 60-, and 120-min during OGTT; and 0- and 6-min during glucagon test were obtained. These data and survival outcomes were analyzed. Results: There were 20 (29%) PDAC patients: 12 (30%) in PD group and eight (28%) in DP group. Nine patients with PDAC (45%) and seven patients (18%) without PDAC demonstrated DM type in preoperative OGTT. After pancreatectomy, 11 patients (55%) with PDAC and seven patients (15%) without PDAC experienced improvement in OGTT (P=0.0005). Greater improvement in homeostasis model assessment insulin resistance that were obtained by OGTT and used to measure insulin resistance, was noted after surgery in PDAC patients compared with non-PDAC patients (-1.4 vs -0.5 in PD group, P=0.07; -0.8 vs +0.06 P=0.05 in DP group). Delta CPRs obtained by glucagon test were significantly decreased postoperatively (3.0 to 1.1 ng/mL, P&lt;0.0001 in PD group; 3.3 to 1.8 ng/mL, P&lt;0.0001 in DP group). In survival analysis, fasting plasma glucose &gt;110 mg/dL (HR 3.9, 95%CI 1.5-10, P=0.005) and the average of plasma insulin &gt; 25 µIU/mL during OGTT (HR 0.36, 95%CI 0.14-0.93, P=0.035) were significant prognostic factor for PDAC. Conclusions: Pancreatectomy impaired insulin secretion and improve insulin resistance especially in PDAC patients. About half of PDAC patients demonstrated the improvement of glucose tolerance after surgery. Of note, glucose tolerance differed between PDAC and other disease, and affect the survival outcome for PDAC patients.

Prognostic impact of simultaneous venous resections during surgery for resectable pancreatic cancer

BackgroundThe aim of this study was to evaluate the prognostic impact of simultaneous venous resection during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) that was preoperatively staged resectable according to NCCN guidelines. MethodsA retrospective analysis of 153 patients who underwent PD for PDAC was performed. Patients were divided into standard PD and PD with simultaneous vein resection (PDVR). Groups were compared to each other in terms of postoperative morbidity and mortality, disease free (DFS) and overall survival (OS). Results114 patients received PD while 39 patients received PDVR. No differences in terms of postoperative morbidity and mortality between both groups were detected. Patients in the VR group presented with a significantly shorter OS in the median (13 vs. 21 months, P = 0.011). In subgroup analysis, resection status did not influence OS in the PDVR group (R0 13 vs. R1 12 months, P = 0.471) but in the PD group (R0 23 vs. R1 14 months, P = 0.043). PDVR was a risk factor of OS in univariate but not multivariable analysis. ConclusionPDVR for PDAC preoperatively staged resectable resulted in significantly shorter OS regardless of resection status. Patients who require PDVR should be considered for adjuvant chemotherapy in addition to other oncological indications.

Utility of the Surgical Apgar Score in pancreatic cancer and modification

ObjectivesThe Surgical Apgar Score (SAS) can predict the incidence of complications in different surgical fields. However, it is rarely studied in pancreatic cancer. The aim of the present study was to assess the predictive value of the SAS in pancreatic ductal adenocarcinoma (PDAC), and then propose a modified SAS which was more suitable for pancreatic cancer patients. Materials and methodsA prospective cohort study of 160 PDAC patients was concluded. The primary endpoint was 30-day major complications. The SAS was calculated as described. The overall discriminatory power of the score was analyzed using receiver operating characteristic curves and the area under the curve (AUC) with respect to major complications or death. ResultsIt showed a significant predictive value of SAS in major complications or death in PDAC (p = 0.020, AUC = 0.606), especially in complication of pneumonia (p = 0.022) and pleural effusion (p = 0.023). In addition, the SAS exert significant predictive value in distal pancreatectomy group, but it has a weak predictive value for pancreaticoduodenectomy group. On multivariable analyses, occurrence of major postoperative complications was associated with lowest mean arterial pressure, estimated blood loss and operative time. Interestingly, as a characteristic of SAS, lowest heart rate was not involved. The modified SAS we proposed including lowest mean arterial pressure, estimated blood loss and operative time increased AUC from 0.606 to 0.743. ConclusionsThe SAS can be a simple, rapid scoring system that effectively predicts major postoperative complications. Besides, the modified SAS we proposed in this study, which included lowest mean arterial pressure, estimated blood loss and operative time, exert a better predictive value in PDAC patients.

Colorectal surgery in patients with prior pancreaticoduodenectomy.

Objectives: Colorectal cancer (CRC) surgery after pancreaticoduodenectomy (PD) is difficult to perform, because PD involves dissection and complex reconstruction of the digestive tract. We evaluated the clinical outcomes of CRC surgery in patients with prior PD. Methods: Between January 2008 and March 2018, a total of 1727 patients received CRC surgery at our institution. Of these, 10 had previously undergone PD (PD group). As a control group, 280 patients were collected who had undergone resection without any history of previous abdominal surgery. The PD and control groups were further subdivided into four groups by right or left side. Outcomes of colorectal surgery were investigated in the PD and control groups. Results: The number of harvested lymph nodes was significantly lower in the PD group. In the right colectomy group, distance from the surgical margin was significantly shorter in the PD group. The rate of postoperative complications was higher in the PD group. Peritoneal dissemination originating from pancreatic cancer was found during CRC surgery for one patient, and one patient developed refractory ascites. Three patients died of pancreatic cancer, rectal cancer, and other disease. Seven patients were alive without recurrence. Conclusions: CRC surgery for patients with prior PD can involve difficulty in dissecting lymph nodes and higher postoperative morbidity rates but can provide sufficiently curative resection for CRC.

The value of combined vein resection in pancreaticoduodenectomy for pancreatic head carcinoma: a meta-analysis

BackgroundAlthough pancreaticoduodenectomy with vein resection (PDVR) is widely performed in selected patients with indications, its benefits remain controversial. In this meta-analysis, we evaluate the safety and efficacy of PDVR in comparison to standard pancreaticoduodenectomy (PD).MethodsWe searched PubMed, Embase, and Cochrane as well as the Chinese National Knowledge Infrastructure, Weipu, and Wanfang databases for studies that evaluate the value of PVDR. The data of the patients who underwent PD or PDVR were analyzed using Review Manager and STATA software.ResultsIn comparison with the PD group, the PDVR group had a lower R0 resection rate and higher rates of complications such as biliary fistula, reoperation rate, delayed gastric emptying, cardiopulmonary abnormalities, hemorrhage, in-hospital mortality, 30-day mortality. The blood loss, duration of operation, total hospital stay is higher in PDVR group.ConclusionsCompared to standard PD, PDVR was associated with a greater risk of some specific complications and increase the mortality rate, total hospital stay time, combine with vein resection have a lower R0 resection rate. Therefore, combine with vascular resection for pancreatic cancer needs to be carefully selected by the surgeon.

Total pancreatectomy compared with pancreaticoduodenectomy: a systematic review and meta-analysis.

Aim: To assess whether total pancreatectomy (TP) is as feasible, safe, and efficacious as pancreaticoduodenectomy (PD).Materials and Methods: Major databases, including PubMed, EMBASE, Science Citation Index Expanded, Scopus and the Cochrane Library, were searched for studies comparing TP and PD between January 1943 and June 2018. The meta-analysis only included studies that were conducted after 2000. The primary outcomes were morbidity and mortality. Pooled odds ratios (ORs), weighted mean differences (WMDs) or hazard ratios (HRs) with 95 percent confidence intervals (CIs) were calculated using fixed effects or random effects models. The methodological quality of the included studies was evaluated by the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool.Results: In total, 45 studies were included in this systematic review, and 5 non-randomized comparative studies with 786 patients (TP: 270, PD: 516) were included in the meta-analysis. There were no differences in terms of mortality (OR: 1.44, 95% CI: 0.66–3.16; P=0.36), hospital stay (WMD: −0.60, 95% CI: −1.78–0.59; P=0.32) and rates of reoperation (OR: 1.12; 95% CI: 0.55–2.31; P=0.75) between the two groups. In addition, morbidity was not significantly different between the two groups (OR: 1.41, 95% CI: 1.01–1.97; P=0.05); however, the results showed that the TP group tended to have more complications than the PD group. Furthermore, the operation time (WMD: 29.56, 95% CI: 8.23–50.89; P=0.007) was longer in the TP group. Blood loss (WMD: 339.96, 95% CI: 117.74–562.18; P=0.003) and blood transfusion (OR: 4.86, 95% CI: 1.93–12.29; P=0.0008) were more common in the TP group than in the PD group. There were no differences in the long-term survival rates between the two groups.Conclusion: This systematic review and meta-analysis suggested that TP may not be as feasible and safe as PD. However, TP and PD may have the same efficacy.

Clinicopathologic Characteristics and Optimal Surgical Treatment of Duodenal Gastrointestinal Stromal Tumor

BackgroundThe clinicopathologic characteristics of duodenal gastrointestinal stromal tumor (GIST) were unclear and the optimal surgical procedure for duodenal GIST remains poorly defined. We aimed to analyze clinicopathological characteristics, survival outcomes based on the surgical procedure, and recommend optimal surgical treatment for duodenal GIST. MethodsFrom July 2000 to April 2017, 118 patients with localized duodenal GIST underwent curative surgical resection at a single institution. We retrospectively reviewed the clinicopathological characteristics and survival outcomes. ResultsThe 5-year overall survival (OS) and disease-free survival (DFS) rates were 94.9 and 79.2%, respectively. On multivariate analysis, the mitotic count was a statistically significant prognostic factor for DFS. Limited resection (LR) was performed in 20 patients with GIST in the first or fourth portion of the duodenum. Both LR and pancreaticoduodenectomy (PD) were performed in 98 patients with GIST in second or third portion of the duodenum. The patients in the LR group had less late complications than in the PD group and no postoperative newly developed diabetes mellitus. The minimally invasive LR (MI-LR) group had a shorter duration of surgery and shorter length of postoperative hospital stay. ConclusionLR is a feasible and effective surgical treatment for patients with small-sized and antimesenteric-sided duodenal GIST in terms of late complications and postoperative diabetic complications. MI-LR has better perioperative outcomes than open LR. Therefore, we should consider MI-LR as an optimal surgical treatment for selected patients with duodenal GIST.

Association of Increasing Frailty with Detrimental Outcomes after Pancreatic Resection

An association between detrimental outcomes and frailty has been documented; however, the impact specific to pancreatic surgery is unknown. Using NSQIP data, patients were classified as non-, mildly, moderately, or severely frail. A total of 16,028 patients were included in the study; most of the patients were white (78.5%) and underwent pancreaticoduodenectomy (PD) (67%). Complications occurred in 17.6 per cent cases, and the median length of stay (LOS) was 11.89 days. Prolonged LOS and mortality occurred in 9.1 and 2.3 per cent of the cases. In the PD group, most of the patients were mildly frail (40.6%), followed by nonfrail (39.83%), whereas in the distal pancreatectomy (DP) group, the majority were nonfrail (43.82%), followed by mildly frail (39.37%) (P < 0.0001). The 30-day complications, mortality, and LOS were significantly higher in patients undergoing PD compared with DP (19.5 vs 14.3%, 2.8 vs 1.2%, and 13.4 vs 8.7 days, respectively; P < 0.0001). PD conferred a significantly higher risk of death in all frailty groups compared with DP [nonfrail: odds ratio (OR) 1.76, mildly frail: OR 1.03, moderately frail: OR 2.03, P < 0.05], with the exception of severely frail patients. Compared with DP, PD conferred a significant risk of complication in all the frailty groups. Increases in frailty are associated with poorer outcomes after pancreatectomy.

The clinicopathologic features and optimal surgical treatment of duodenal gastrointestinal tumor.

519 Background: Because of unclear clinicopathologic features, the optimal surgical procedure for duodenal gastrointestinal stromal tumor (GIST) remains poorly defined. We analyze clinicopathological features and recommend optimal surgical treatment of duodenal GIST. Methods: From July, 2000 to April 2017, 118 patients who had localized duodenal GIST were treated by curative surgical resection at a single institution. We retrospectively reviewed the clinicopathological characteristics and survival outcomes. Results: In survival analysis of all patients, 5-year overall survival (OS) and disease-free survival (DFS) rate were 94.9 and 79.2%, respectively. 19 patients developed recurrent disease at a median of 26.1 months from surgery and most common recurrence site was liver (63.2%). In multivariate analysis, mitotic count was the statistically significant prognostic factors of DFS. Our 20 cases of duodenal GIST in 1st or 4th portion were completely resected by limited resection(LR), regardless of tumor size. 98 patients with GISTs in 2nd or 3rd portion of duodenum underwent LR (n = 53) or pancreaticoduodenectomy (PD) (n = 45). Patients in the LR group had a smaller median tumor size (4.0 vs 5.3 cm, p = 0.026), more antimesenteric-sided location (41 vs 7cases, p &lt; 0.001), less late complications (1 vs 7 cases, p = 0.014) and no postoperative newly developed diabetes mellitus (0 vs 4 cases, p = 0.027) than those in the PD group. When 53 patients in LR group further divided into minimal invasive LR (MILR) (n = 12) and open-LR (n = 41), MILR group had shorter operation time (155.0 vs 218.8 minutes, p = 0.013) and postoperative hospital stay (12.0 vs 19.4 days, p = 0.036). Conclusions: Patients with duodenal GIST who underwent complete surgical resection have favorable survival outcomes. Predictor of disease recurrence at multivariate analysis was mitotic count. LR is feasible and effective surgical treatment for the patients with small-sized, and anti-mesenteric sided duodenal GIST in terms of long-term oncologic outcomes and quality of life. MILR has better perioperative outcomes than open LR. Therefore, we should consider MILR as optimal surgical treatment for the selected patients with duodenal GIST.

Clinicopathological and Prognostic Features of Surgical Management in Duodenal Gastrointestinal Stromal Tumors

Background and Objectives: The rarity of duodenal gastrointestinal stromal tumors (DGIST) led to only limited data being available on their management and prognosis. We retrospectively analyzed the clinicopathological features, surgical treatments, adjuvant therapy, and prognosis of DGIST. Methods: Sixty-one patients were identified at diagnosis of primary DGIST from February 2005 to December 2015. One hundred twenty six patients with small intestinal gastrointestinal stromal tutors (GIST) were selected as control groups. Survival analyses were calculated using the Kaplan-Meier method. Results: Three- and five-year recurrence/metastasis-free survival rates of patients with DGIST were similar to those of patients with small intestinal GIST (p > 0.05 for all). Out of 61 cases with DGIST, 45 patients were treated with Limited Resection (LR). Sixteen patients were treated with Pancreaticoduodenectomy (PD). The 3- and 5-year recurrence/metastasis-free survival rates of the PD group and LR group were of no significant difference (p > 0.05 for all). Univariate analysis indicated that factors including surgical approaches, mitotic count, size, and risk grades were significantly associated with recurrence/metastasis-free survival (log-rank test, p < 0.05). Multivariate analysis demonstrated that the mitotic count was independently correlated with a worse recurrence/metastasis-free survival. Conclusions: Patients with radical resected DGIST had a favourable prognosis, which is similar to that of small intestinal GIST. Both LR and PD were optimal choices for treating DGIST.

A case-matched comparison study of total pancreatectomy versus pancreaticoduodenectomy for patients with pancreatic ductal adenocarcinoma

BackgroundTotal pancreatectomy (TP) is considered a viable option in some selected patients with pancreatic ductaladenocarcinoma (PDAC). The aim of this study was to compare the clinical outcomes between TP and pancreaticoduodenectomy (PD) in patients with PDAC. Materials and methodsA total of 375 patients were selected from our center's database in China and classified into two groups: the PD group (n = 325) and the TP group (n = 50). A matched-pair analysis of the patients was conducted with a ratio of 1:1. Univariate and multivariate survival analyses were performed for overall survival. ResultsOverall morbidity was lower in the PD group than in the TP group (31.4% vs 52%, respectively, P = 0.004). However, no significant difference was observed in major morbidity between the two groups (24.9% vs 30%, P = 0.455). The rates of 5-year overall (P = 0.043) and disease-free (P = 0.037) survival were significantly higher in the PD group. Furthermore, the univariate and multivariate analyses revealed that adjuvant chemotherapy (HR = 0.684, 95%CI = 0.545–0.860, P = 0.001) and margin resection status (HR = 1.666, 95%CI = 1.196–2.321, P = 0.003) were significant prognostic factors. After the matched-pair analysis, there were no significant differences between the two groups regarding postoperative complications and overall survival. However, the matched PD group had greater estimated blood loss (P = 0.037) and blood transfusion (56% vs 36%, P = 0.045). ConclusionFrom our study, the postoperative outcomes and survival time of TP are similar to those of matched PD. It seems reasonable to suggest that TP can be considered as safe, feasible, and efficacious as PD for patients with PDAC.

Functional and morphological evolution of remnant pancreas after resection for pancreatic adenocarcinoma.

Functional and morphological evolution of remnant pancreas after resection for pancreatic adenocarcinoma is investigated.The medical records of 45 patients who had undergone radical resection for pancreatic adenocarcinoma from March 2010 to September 2013 were reviewed retrospectively. There were 34 patients in the pancreaticoduodenectomy (PD) group and 10 patients in the distal pancreatectomy (DP) group. One patient received total pancreatectomy. The endocrine function was measured using the glucose tolerance index (GTI), which was derived by dividing daily maximum serum glucose fluctuation by daily minimum glucose. Remnant pancreas volume (RPV) was estimated by considering pancreas body and tail as a column, and head as an ellipsoid, respectively. The pancreatic atrophic index (PAI) was defined as the ratio of pancreatic duct width to total pancreas width. Representative indices of each patient were compared before and after resection up to 2 years postoperatively.The area under receiver operating characteristic curve of GTI for diagnosing DM was 0.823 (95% confidence interval, 0.699–0.948, P < .001). Overall, GTI increased on postoperative day 1 (POD#1, mean ± standard deviation, 1.79 ± 1.40 vs preoperative, 1.02 ± 1.41; P = .001), and then decreased by day 7 (0.89 ± 1.16 vs POD#1, P < .001). In the PD group, the GTI on POD#14 became lower than preoperative (0.51 ± 0.38 vs 0.96 ± 1.37; P = .03). PAI in the PD group was significantly lower at 1 month postoperatively (0.22 ± 0.12 vs preoperative, 0.38 ± 0.18; P < .001). In the PD group, RPV was significantly lower at 1 month postoperatively (25.3 ± 18.3 cm3 vs preoperative, 32.4 ± 20.1 cm3; P = .02), due to the resolution of pancreatic duct dilatation. RPV of the DP group showed no significant change. GTI was negatively related to RPV preoperatively (r = –0.317, P = .04), but this correlation disappeared postoperatively (r = –0.044, P = .62).Pancreatic endocrine functional deterioration in pancreatic adenocarcinoma patients may in part be due to pancreatic duct obstruction and dilatation caused by the tumor. After resection, this proportion of endocrine insufficiency is corrected.

Pancreatic head excavation for tissue diagnosis may reduce unnecessary pancreaticoduodenectomies in the setting of chronic pancreatitis

The necessity to obtain a tissue diagnosis of cancer prior to pancreatic surgery still remains an open debate. In fact, a non-negligible percentage of patients undergoing pancreaticoduodenectomy (PD) for suspected cancer has a benign lesion at final histology. We describe an approach for patients with diagnostic uncertainty between cancer and chronic pancreatitis, with the aim of minimizing the incidence of PD for suspicious malignancy finally diagnosed as benign disease. Eighty-eight patients (85.4%) with a clinicoradiological picture highly suggestive for malignancy received formal PD (group 1). Fifteen patients (14.6%) in whom preoperative diagnosis was uncertain between pancreatic cancer and chronic pancreatitis underwent pancreatic head excavation (PHEX) for intraoperative tissue diagnosis (group 2): those diagnosed as having cancer received PD, whereas those with chronic pancreatitis received pancreaticojejunostomy (PJ). No patient received PD for benign disease. All patients in group 1 had adenocarcinoma on final histology. Eight patients of group 2 (53.3%) received PD after intraoperative diagnosis of cancer, whereas 7 (46.7%) received PJ because no malignancy was found at introperative frozen sections. No signs of cancer were encountered in patients receiving PHEX and PJ after a median follow-up of 42 months. Overall survival did not differ between patients receiving PD for cancer in the group 1 and those receiving PD for cancer after PHEX in the group 2 (P=0.509). Although the described technique has been used in a very selected group of patients, our results suggest that PHEX for tissue diagnosis may reduce rates of unnecessary PD, when the preoperative diagnosis is uncertain between cancer and chronic pancreatitis.