Periampullary Lesions Research Articles

Effectiveness and stability of robot-assisted anastomosis on minimally invasive pancreaticoduodenectomy

Reconstruction using robot in pancreaticoduodenectomy (PD) was expected to be an effective means to overcome the limitation of laparoscopic surgery. To our knowledge, a few comparative reports exist on the outcomes of totally laparoscopic pancreaticoduodenectomy (TLPD) and robot-assisted laparoscopic pancreaticoduodenectomy (RLPD). This retrospective study aimed to analyze the surgical results of TLPD and RLPD in a high-volume pancreatic center. We analyzed surgical results on consecutive patients between January 2016 and May 2020 who underwent minimally invasive pancreaticoduodenectomy (MIPD) for malignant or benign periampullary lesions. Forty-three patients of TLPD and 49 patients of RLPD were enrolled. There were no significant differences in demographics characteristics between the two groups except tumor size, which was significantly larger in the RLPD group than in the TLPD group (mean 3.1 cm vs. 2.5 cm, p = 0.035). RLPD had the shorter whole operative time (mean 400.4 minutes vs. 352.2 minutes, p = 0.003) and the shorter anastomosis time than TLPD (mean 94.5 minutes vs. 54.9 minutes, p < 0.001). There was no significant difference between the two groups in the rate of pancreatic fistula, morbidity, and mortality. But a significantly lower rate of wound infection was found in the RLPD group relative to the TLPD group (0% vs. 9.3%, p = 0.038). RLPD shows the advantage of reducing the operation time compared to TLPD as well as technical feasibility and safety.

Pancreatic enzyme replacement therapy in patients with pancreatic cancer: A national prospective study

ObjectiveUK national guidelines recommend pancreatic enzyme replacement therapy (PERT) in pancreatic cancer. Over 80% of pancreatic cancers are unresectable and managed in non-surgical units. The aim was to assess variation in PERT prescribing, determine factors associated with its use and identify potential actions to improve prescription rates. DesignRICOCHET was a national prospective audit of malignant pancreatic, peri-ampullary lesions or malignant biliary obstruction between April and August 2018. This analysis focuses on pancreatic cancer patients and is reported to STROBE guidelines. Multivariable regression analysis was undertaken to assess factors associated with PERT prescribing. ResultsRates of PERT prescribing varied among the 1350 patients included. 74.4% of patients with potentially resectable disease were prescribed PERT compared to 45.3% with unresectable disease.PERT prescription varied across surgical hospitals but high prescribing rates did not disseminate out to the respective referring network. PERT prescription appeared to be related to the treatment aim for the patient and the amount of clinician contact a patient has. PERT prescription in potentially resectable patients was positively associated with dietitian referral (p = 0.001) and management at hepaticopancreaticobiliary (p = 0.049) or pancreatic unit (p = 0.009). Prescription in unresectable patients also had a negative association with Charlson comorbidity score 5–7 (p = 0.045) or >7 (p = 0.010) and a positive association with clinical nurse specialist review (p = 0.028). ConclusionDespite national guidance, wide variation and under-treatment with PERT exists. Given that most patients with pancreatic cancer have unresectable disease and are treated in non-surgical hospitals, where prescribing is lowest, strategies to disseminate best practice and overcome barriers to prescribing are urgently required.

Does Pyloric-ring Resection in Pancreaticoduodenectomy Prevent Delayed Gastric Emptying?

Objective: Delayed gastric emptying (DGE) is a common, post pancreaticoduodenectomy (PD) complication, which prolongs hospital stay, increases the cost of treatment and delays adjuvant therapy. Although, pylorospasm is one of the proposed mechanisms, the results of pyloric ring resection PD remain controversial. Hence, this study investigated whether pyloric ring resection PD decreased the incidence of DGE.Material and Methods: Between June, 2015 and July, 2018; 74 patients underwent a PD for periampullary lesions, of whom 25 patients received pylorus-preserving PD (PPPD) and 49 patients received pyloric-ring resection PD (PRPD). DGE was classified according to the International Study Group of Pancreatic Surgery.Results: The incidence of DGE in the PPPD group and PRPD group were 48.0% (12 of 25 patients) and 20.4% (10 of 49 patients), respectively (p-value=0.029). Factors associated with DGE were pyloric preserving [adjusted Odds ratio (OR)=8.26, 95% confidence interval (CI): 1.96-34.82, p-value=0.002], preoperative biliary drainage (adjusted OR=0.19, 95% Cl: 0.05-0.78, p-value=0.013) and postoperative intraabdominal collection (adjusted OR=37, 95% Cl: 5.68-241.24, p-value&lt;0.001).Conclusion: PRPD demonstrated a significant decrease of DGE, and should be one of the standard surgical treatments for periampullary carcinoma.

Robotic Pancreaticoduodenectomy for a Technically Challenging Pancreatic Head Cancer

BackgroundRobotic pancreaticoduodenectomy (RPD) is performed for resectable periampullary lesions with comparable outcomes to the open approach.1 Surgical therapy for borderline-resectable (BR) pancreatic tumors is technically challenging and poses a significant risk of bleeding and positive margins.2 As experience with RPD grows at high-volume centers, case selection can be carefully expanded to include complex vascular resections.3 We demonstrate a RPD performed for BR pancreatic adenocarcinoma with portal vein (PV) involvement and presence of anomalous hepatic arterial anatomy. MethodsA 75-year-old female presented with abdominal pain and obstructive jaundice. She was previously healthy and had a relatively normal body mass index (25.7 kg/m2). Endoscopic ultrasound and computed tomography imaging identified a pancreatic head mass measuring 2.3 cm with evidence of concomitant abutment of the PV (90–180 degree) and abutment of a replaced right hepatic artery (rRHA) originating from the superior mesenteric artery (SMA). Following four cycles of neoadjuvant gemcitabine/nab-paclitaxel, restaging imaging demonstrated partial radiographic response, represented by a lesser degree of PV abutment and resolution of rRHA abutment. RPD was performed with side-bite resection of the PV and preservation of rRHA. The video demonstrates the key steps followed in a robotic pancreaticoduodenectomy performed for a technically challenging pancreatic head cancer and highlights robotic control of bleeding from the PV and SMA obviating the need for conversion. Histopathology revealed a residual moderately differentiated ductal adenocarcinoma with 4-of-40 positive lymph nodes and negative surgical margins. The tumor was staged as ypT1cN2 (AJCC 8th edition). The patient had an uneventful postoperative course and was discharged on hospital day 8. ConclusionIn high-volume centers, the robotic approach can be safely used in selected cases of technically challenging BR pancreatic head cancers.

Minimally Invasive Pancreaticoduodenectomy in Elderly Patients: Systematic Review andMeta-Analysis.

Minimally invasive pancreaticoduodenectomy (MIPD) for pancreatic head or periampullary lesions is being utilized with increasing frequency. However, few data are available for the elderly. The objective of this study is to assess the safety and feasibility of MIPD in elderly population, by making a comparison with conventional open pancreaticoduodenectomy (OPD) and with non-elderly population. We conducted a systematic search to identify all eligible studies in Cochrane Library, Ovid, and PubMed from their inception up to April 2020. Seven retrospective studies involving 2727 patients were included. Of these, 3 compared MIPD and OPD in elderly patients, 2 compared MIPD in elderly and non-elderly patients, and 2 included both outcomes. Compared to those with OPD, elderly patients who underwent MIPD were associated with less 90-day mortality (OR 0.56, 95% CI 0.32-0.97; P = 0.04) and fewer delayed gastric emptying (OR 0.54, 95% CI 0.33-0.88; P = 0.01). On the other hand, no significant difference was observed in terms of 30-day mortality, major morbidity, postoperative pancreatic fistula (grade B/C), postoperative hemorrhage, reoperation, 30-day readmission, and operative time. For patients who have treated with MIPD, elderly did not reveal worse outcomes than non-elderly. MIPD is a safe and feasible procedure for select elderly patients if performed by experienced surgeons from high-volume pancreatic surgery centers. However, further randomized studies are required to confirm this.

Spectrum of periampullary lesions and the role of endoscopic retrograde cholangiopancreatography in their diagnosis

Context The periampullary area is a hot spot for neoplasia and lesions arising there often obstruct the biliopancreatic stream, so drainage and tissue diagnosis of any suspicious lesion are very important. Aims The aims were to estimate the frequency of different types of periampullary lesions, and assess the diagnostic accuracy of biopsy and brush cytology taken by endoscopic retrograde cholangiopancreatography (ERCP). Patients and methods A prospective study conducted at Assiut University Hospital over a period of 1 year starting from June 2017. The authors enrolled patients presented with clinical and radiological suspicion of periampullary lesions indicating ERCP. Physical, laboratory, and imaging data were recorded and data of ERCP examination as well as results of endoscopic biopsies were studied and compared with the final diagnosis after definitive surgical intervention and/or sufficient follow-up. Statistical Package for the Social Sciences, version 20, IBM. Results During the 1 year, periampullary lesions represented 18.8% of all cases who underwent ERCP (154 out of 818), including 25 cases with distal common bile duct (CBD) stone/s, 40 inflammatory, 15 benign, and 74 malignant lesions. The sensitivity and specificity of grasp biopsy were 67.5 and 70% when any dysplasia was regarded as a malignant lesion and they were 54 and 90% when only high-grade dysplasia was considered malignant. Sensitivity and specificity of brush cytology was 33 and 100%. Conclusion Periampullary area has a high potentiality for neoplastic changes and ERCP-guided biopsy has a reasonable diagnostic yield.

Palliative pancreaticoduodenectomy

Background: This study was to evaluate the surgical, oncological and survival outcomes after pancreaticoduodenectomy (DP) with superior mesenteric vein (SMV)/ portal vein (PV) resection for borderline resectable periampullary malignancy by either robotic PD (RPD) or open PD (OPD). Methods: Data for periampullary lesions undergoing PD were retrieved from a prospectively-collected computer database. Surgical risks, oncological and survival outcomes were compared between groups with and without SMV/PV resection. Results: A total of 391 patients undergoing pancreaticoduodenectomy were included for analysis, including 43 (11.0%) with and 384 (89.0%) without vein resection. Eleven (25.6%) of PDs with vein resection were performed by robotic approach. Operation time in vein resection group was significantly longer (median of 8 vs. 7 hours). Blood loss, curative resection (R0) rate, and harvested lymph node number were similar between these two groups. Surgical outcomes including postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), chyle leakage, wound infection and hospital stay were of no significant different between these two groups. There was no survival difference between these groups, with 1-year and 3-year survival rates of 92.6% and 26.5% respectively for the patients with vein resection, vs. 70.3% and 37.2% without vein resection. Conclusions: PD with vein resection is technically feasible not only by open approach but also by robotic approach in selected patients. Additional SMV/PV would not increase the surgical risks of PD, and moreover, could achieve similar survival outcomes for pancreatic head adenocarcinoma when compared to PD without vein resection.

Effectiveness and stability of robot-assisted anastomosis in minimally invasive pancreaticoduodenectomy.

PurposeReconstruction using robotic assistance in pancreaticoduodenectomy (PD) was expected to be an effective means to overcome the limitations of laparoscopic surgery. To our knowledge, few comparative reports exist on the outcomes of totally laparoscopic PD (TLPD) and robot-assisted laparoscopic PD (RLPD). This retrospective study aimed to analyze the surgical results of TLPD and RLPD in a high-volume pancreatic center.MethodsWe analyzed the surgical results of consecutive patients who underwent a minimally invasive PD for malignant or benign periampullary lesions between January 2016 and May 2020. Forty-three TLPD patients and 49 RLPD patients were enrolled.ResultsThere were no significant differences in the demographic characteristics between the 2 groups except for tumor size, which was significantly larger in the RLPD group than in the TLPD group (mean, 3.1 cm vs. 2.5 cm; P = 0.035). The RLPD group had shorter whole operative times (mean, 400.4 minutes vs. 352.2 minutes; P = 0.003) and shorter anastomosis times than the TLPD group (mean, 94.5 minutes vs. 54.9 minutes; P < 0.001). There was no significant difference between the 2 groups in the rate of pancreatic fistulas, morbidity, and mortality. However, a significantly lower wound infection rate was found in the RLPD group relative to the TLPD group (0% vs. 9.3%, P = 0.038).ConclusionRLPD showed the advantage of reducing the operation time compared to TLPD as well as technical feasibility and safety.

Preemptive light sedation in intensive care unit may reduce pulmonary complications in geriatrics receiving pancreaticoduodenectomy

Patients undergoing pancreaticoduodenectomy (PD) for periampullary lesions are usually elderly with a high risk of postoperative morbidity and mortality. This retrospective cohort study investigated whether postoperative preemptive light sedation aids in recovery of elderly patients following PD. Ninety-nine geriatric patients undergoing PD at one hospital were enrolled from 2009 to 2018. Patients in the sedation group received mechanical ventilation support and preemptively light sedation with fentanyl and propofol or dexmedetomidine in the first 5 days postoperatively in the intensive care unit (ICU). Patients in the control group underwent early extubation and received morphine for pain control but no postoperative sedatives in the ordinary ward. Patients in the two groups were matched 1:1 using propensity scoring. The postoperative complication rate, surgical mortality, and postoperative hospital length of stay (LOS) were recorded. We also tested inflammation in an immortal human bronchial epithelial cell line. After 1:1 matching, 40 patients in the sedation group were compared with 40 patients in the control group. The sedation group had a significantly lower pulmonary complication rate and fewer patients with postoperative gastroparesis. Both groups had similar postoperative hospital LOS and identical surgical mortality rates. Patients in the sedation group had significantly better postoperative quality of life, including less pain and less heartbeat variation. In vitro cell experiments supported the above clinical observations, showing that adequate use of sedatives could significantly elevate the cell viability rate, protect cells from damage, decrease interleukin-6 production, and reduce inflammation. Postoperative preemptive light sedation in the ICU in geriatric patients following PD may not only reduce the rates of postoperative pulmonary complications and gastroparesis but also improve postoperative quality of life without prolonging the postoperative hospital LOS.

Study Protocol of the ESAP Study: Endoscopic Papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodenectomy for Ampullary Neoplasm-A Pancreas2000/EPC Study.

Background: Lesions of the Ampulla of Vater are a rare condition and represent <10% of peri-ampullary neoplasms. Nevertheless, ampullary adenomas have the potential for malignant transformation to ampullary carcinomas by an adenoma-to-carcinoma sequence. Thus, adequate patient selection and complete resection (R0) of non-invasive ampullary lesions either by endoscopic papillectomy (EP), surgical ampullectomy (SA), or pancreaticoduodenectomy (PD) is essential. Although PD was traditionally performed, recent studies reported considerable efficacy and fewer complications following EP and SA. Since consistent comparative data are lacking, the Endoscopic Papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodectomy (ESAP) study will provide evidence for a therapeutic standard and post procedure morbidity in ampullary lesions.Methods: International multicenter retrospective study. Adult patients (>18 years of age) who underwent SA or PD for ampullary neoplasm between 2004 and 2018 or EP between 2007 and 2018 will be evaluated. Main inclusion criteria are ampullary lesions strictly located to the ampulla. This includes adenoma, adenocarcinoma (T1 and T2), neuroendocrine tumors, gastrointestinal stroma tumors and other rare conditions. Exclusion criteria are peri-ampullary lesions, e.g., from the duodenal wall or the head of the pancreas, and interventions for tumor stages higher than T2. The main objective of this study is to analyze rates of complete resection (R0), recurrence and necessity for complementary interventions following EP, SA, and PD. Treatment-quality for each procedure will be defined by morbidity, mortality and complication rates and will be compared between EP, SA, and PD. Secondary objectives include outcome for patients with incomplete resection or initially understated tumors, lesions of the minor papilla, hereditary syndromes, neuroendocrine tumors, mesenchymal lesions, and other rare conditions. Additionally, we will analyze therapy by argon plasma coagulation and radiofrequency ablation. Furthermore, outcome in curative and palliative interventions can be distinguished.Conclusion: The ESAP study will provide evidence for therapeutic algorithms and data for the implementation of guidelines in the treatment of different types of ampullary tumors, including recurrent, or incomplete resected lesions.

Robotic pancreaticoduodenectomy in the era of minimally invasive surgery.

Minimally invasive surgery has become a worldwide trend to reduce the wound and mitigate pain. However, the role of robotic pancreaticoduodenectomy (RPD) has not been well established in the era of minimally invasive surgery. It would be nearly impossible to apply minimally invasive surgery in the tedious and complicated Whipple operation without an experienced and dedicated pancreas team. The pancreatic team led by Shyr YM and Wang SE at Taipei Veterans General Hospital have already been highly accredited with a Copper Award of Symbol of National Quality (SNQ award), entitled with "Minimally Invasive Robotic Pancreatic Surgery-Small Wound for Major Pancreatic Surgery" in Taiwan in 2019. RPD was claimed to be associated with less blood loss, less delayed gastric emptying, shorter length of postoperative stay, and lower wound infection rate, but longer operative time, as compared with the traditional open pancreaticoduodenectomy (OPD). More than 99% of the patients undergoing minimally invasive RPD are satisfied with the surgical outcomes and would like to recommend RPD to those with periampullary lesions. RPD could be recommended not only to surgeons but also to patients in terms of surgical outcomes and patient satisfaction. Moreover, our study showed a survival benefit for pancreatic head adenocarcinoma in RPD group, with 1-year, 3-year, and 5-year survival of 82.9%, 45.3%, and 26.8%, respectively, as compared with 63.8%, 26.2%, and 17.4% in OPD.

Totally Laparoscopic Whipple’s Operation: Initial Report from the Caribbean

Oncologic surgery in the Caribbean has evolved over the past decade, with increasing reports of advanced minimally invasive operations being performed. However, the minimally invasive approach has not been used for peri-ampullary lesions. This is because a laparoscopic Whipple’s operation is a technically demanding and time-consuming operation. We report the first case of a totally laparoscopic Whipple’s operation to be performed in the Caribbean.

Surgical pathology of whipple pancreaticoduodenectomy: A 3-year experience at a tertiary cancer care center of marathwada region of India

The aim was to study and analyze in detail various parameters of Whipple resection specimen. Whipple procedure is a radical surgery performed for operable tumors of ampullary-periampullary region, head of pancreas, common bile duct and duodenum. Pathologic assessment of Whipple’s resection specimen needs special attention because of peculiar complex anatomy of head of pancreas and related structures, and also because of difference of opinion about grossing protocols of dissection of the specimen and confusion about terms like ‘margins’ and ‘surfaces’A histopathologist has to be aware of these intricacies so as to diagnose and accurately evaluate factors of prognostic importance.This is the first major mono-center surgical pathology study of Whipple resections reported from Department of Oncopathology, Government Cancer Hospital, Aurangabad, a newly started state level cancer hospital serving patients from Marathwada region of Maharashtra, India. This is surgical pathology study of total 31(thirty one) cases of Whipple resections performed during 2017-19. All relevant histopathologic details pertaining to grossing, microscopic diagnosis, grading and staging, and histopathologic prognostic factors were comprehensively studied. Dissection and grossing was done as per the protocols followed at Tata Memorial Hospital MumbaiOut of total 31 Whipple resections performed at this hospital, 01(one) was classical Whipple’s PD, seventeen (17) were pylorus preserving pancreaticoduodenectomy(PPPD) andthirteen (13) were of extended pancreaticoduodenectomy resections.The patients had age ranging from 38 to 76 years. There were 20 male patients and 11 female patients (M:F-2:1). As far as site of lesion is concerned 16(52%) cases had periampullary lesion. 06(19%)hadlesion in head of pancreas,07(22%) tumors were of common bile duct and there were 02(7%) cases of duodenal carcinoma. Histopathology revealed 29(94%) cases of malignant neoplasm and 02(6%) of benign lesion which included one(01) case of Brunner's gland hyperplasia withpancreatitis in adjacent pancreas, and the remaining 01 was of necrotizing pancreatitis( acute on chronic inflammation) with pseudocyst formation involving head of pancreas.Pathological stage of most of the tumors (55%) was T3, followed by T1(25%) and T2(20%)Amongst total 29 cases of malignant neoplasm, 08(28%) had well differentiated adenocarcinoma. 17 cases (58%) were of moderately differentiated adenocarcinoma and 02(7%) each were of mucinous carcinoma and neuroendocrine carcinoma. Microscopic involvement of margin/surface (CRM) was noted in 05 (17%)cases. In three(03) cases SMA surface and in 02 posterior surface were involved.PNI was noted in 12(41%) cases and LVI in 05(17%)cases. Peripancreatic lymph node metastasis was seen in 05(17%) cases. Specimens of regional lymphnodes were received separately &amp; were negative for deposits in all the cases. Retroperitoneal lymph nodes received along with specimen of Extended Whipple’s were negative for metastasis in all the cases.From this study we conclude that important prognostic factors were location, extension, pathologic stage, histologic grade, status of margins / surfaces, LVI, PNI, and lymph node status. Therefore pathologic assessment of surgical specimen of pancreaticoduodenectomy (Whipple resection) needs special attention to evaluate these factors. To fulfill this purpose there is need of evolving standardized grossing protocols as well as uniform terminology related to terms ‘margin’ &amp; ‘surface’.

Duodenum-preserving subtotal or total pancreatic head resection and total pancreatic head resection with segmental duodenectomy in tumors and chronic pancreatitis

Objectives: To estimate Results of the duodenum-preserving pancreatic head resections as alternatives to pancreaticoduodenectomy. Material & Methods: 135 pts duodenum-preserving subtotal pancreatic head resection (DPSPHR), duodenum-preserving total pancreatic head resection (DPTPHR) and total pancreatic head resection combined with segmental duodenectomy (TPHRSD). DPSPHR (Beger’s or Kimura’s method) was performed in 83 pts with a preoperative diagnosis of chronic pancreatitis in case of suspected cancer. Alimentary tract reconstruction after DPSPHR was performed by pancreatojejunostomy (Roux-en-Y) with the distal and proximal stump of the pancreas (Beger’s procedure) (n=67) or with the distal stump of the pancreas only (Kimura’s procedure) (n=16). DPTPHR (n=25) was performed pts with a preoperative diagnosis of serous (n=7) and mucinous (n=6) cystadenomas, IPMN-BD (n=7), neuroendocrine adenoma (n=4) and metastatic renal cell carcinoma (n=1). Alimentary tract reconstruction after DPTPHR was performed by pancreatojejunostomy (Roux-en-Y) (n=22) and pancreatogastrostomy (n=3). Laparoscopic approach was chosen in 7 cases from all DPTPHR. TPHRSD (n=27) was performed in chronic pancreatitis complicated by duodenal dystrophy (n=23), large serous cystadenoma (n=3), neuroendocrine adenoma (n=1). Alimentary tract reconstruction was performed by duodenoduodenostomy combined with pancreaticojejunostomy and choledochojejunostomy (n=8); pancreatogastrostomy and choledochoduodenostomy (n=15); pancreaticooduodenostomy duct-to-mucosa and choledochoduodenostomy (n=4). Results: Surgical parameters, postoperative complications, endocrine function, exocrine function, and long-term outcomes were evaluated. No differences were noted in the mean operation time and estimated blood loss between this procedures and pylorus-preserving pancreaticoduodenectomy. Ischemia of duodenum didn’t note in one case of DPSPHR or DPTPHR. Postoperative complication constituted the following: bile duct stricture (n=4), postoperative bleeding (n=7), delayed gastric emptying (n=2). Newly developed diabetes mellitus occurred in 12 pts. Exocrine pancreatic insufficiency was observed in 2 pts. There was no hospital or long-term mortality. Conclusions: Periampullary lesions could be treated with DPSPHR, DPTPHR and TPHRSD, which could substitute for pylorus-preserving pancreaticoduodenectomy.

Outcomes of pancreaticoduodenectomy in patients with obstructive jaundice with and without preoperative biliary drainage: a retrospective observational study

Abstract Background Preoperative biliary drainage (PBD) in patients with obstructive jaundice from periampullary neoplasms may reduce the untoward effects of biliary obstruction and subsequent postoperative complications. However, PBD is associated with bile contamination and increases infectious complications after pancreaticoduodenectomy (PD). Objectives To determine whether PBD is associated with more complications after PD. Methods Patients with obstructive jaundice from periampullary lesions who underwent PD from 2000 to 2015 at our institution were retrospectively enrolled. The cohort was divided into a group with PBD and a group without. PBD was performed using one of the following methods: endoprosthesis, percutaneous transhepatic biliary drainage, surgical biliary-enteric bypass, or T-tube choledochostomy. PDs were performed by the first author using uniform surgical techniques. Postoperative complications were recorded. Statistical analyses were conducted using an unpaired t, Fisher exact, or chi-squared tests as appropriate. Results There were 26 with PBD and 28 patients without. Patients in the 2 groups were similar in age, presenting serum bilirubin level, operative time, operative blood transfusion, and hospital stay. The group with PBD had longer duration of jaundice, more patients presenting with cholangitis, and more patients with carcinoma of the ampulla of Vater. The overall complications were higher in patients in the group with PBD than in the group without. Conclusions PBD was associated with more complications overall after PD. However, PBD was necessary and lifesaving in certain clinical situations and improved the condition of patients before they underwent PD. Routine PBD in patients with obstructive jaundice without definite indications is not recommended.

Combination of CEUS and MRI for the diagnosis of periampullary space-occupying lesions: a retrospective analysis

BackgroundThe value of magnetic resonance imaging (MRI), contrast-enhanced ultrasound (CEUS), and the combination of CEUS and MRI (CCWM) for the diagnosis of periampullary space-occupying lesions (PSOL) was investigated.MethodsA total of 102 patients diagnosed with PSOLs by surgery or biopsy were recruited retrospectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MRI, CEUS, and CCWM were analyzed.ResultsMRI, CEUS, and CCWM allowed for the accurate detection of 91.17, 92.15, and 99.01% of PSOLs, respectively. The specificity, PPV, and accuracy of CCWM were significantly different from MRI and CEUS (p < 0.05). However, there the sensitivity and NPV were not significantly different among the three diagnostic technologies. In addition, the specificity, PPV, and accuracy were not significantly different between MRI and CEUS (all p > 0.05).ConclusionsCCWM is valuable for differentiating benign and malignant PSOL, which provides important guiding significances for the clinic.

The efficacy of polyglycolic acid felt reinforcement in preventing postoperative pancreatic fistula after pancreaticojejunostomy in patients with main pancreatic duct less than 3\u2009mm in diameter and soft pancreas undergoing pancreatoduodenectomy (PLANET-PJ trial): study protocol for a multicentre randomized phase III trial in Japan and Korea

BackgroundPartial pancreatoduodenectomy is performed for malignant and benign diseases of the pancreatic head region. The procedure is considered highly difficult and highly invasive. Postoperative pancreatic fistula (POPF) is an important complication because of several consequent complications, including intraabdominal haemorrhage, often increasing hospital stays and surgical mortality. Although many kinds of pancreaticojejunostomy aimed at reducing POPF have been examined to date, the technique has not yet been standardized. We devised a new method using double-coated polyglycolic acid felt after pancreaticojejunostomy. The aim of the PLANET-PJ trial is to evaluate the superiority of polyglycolic acid felt reinforcement in preventing POPF after pancreaticojejunostomy in patients undergoing partial pancreatoduodenectomy to previous anastomosis methods.MethodsPatients diagnosed with pancreatic or periampullary lesions in whom it is judged that the main pancreatic duct diameter was 3 mm or less on the left side of the portal vein without pancreatic parenchymal atrophy due to obstructive pancreatitis are considered eligible for inclusion. This study is designed as a multicentre randomized phase III trial in Japan and the Republic of Korea. Eligible patients will be centrally randomized to either group A (polyglycolic acid felt reinforcement) or group B (control). In total, 514 patients will be randomized in 31 high-volume centres in Japan and Republic of Korea. The primary endpoint is the incidence of POPF (International Study Group of Pancreatic Surgery grade B/C).DiscussionThe PLANET-PJ trial evaluates the efficacy of a new method using double-coated polyglycolic acid felt reinforcement for preventing POPF after pancreaticojejunostomy. This new method may reduce POPF.Trial registrationClinicalTrials.gov, NCT03331718. University Hospital Medical Information Network Clinical Trials Registry, UMIN000029647. Registered on 30 November 2017. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000033874

Small bowel adenomyoma: an incidental intraoperative finding during hepatecojejunostomy for CBD injury

Background: Adenomyoma is a benign lesion that’s most commonly seen in the gallbladder, however, rare cases have been reported where this pathology was encountered in the vicinity of the gastrointestinal tract; most frequently in the pyloric region of the stomach, followed by the periampullary area of the small intestine, and only 26 cases reported to occur in the jejunum and the ileum. The pathogenesis of this lesion is still a controversy, with the previous reports suggesting it to be either a form of hamartoma or incomplete heterotopic pancreas Methods: Hereby we report a case of a 58 year-old gentleman who was referred to our HPB facility with CBD injury post laparoscopic cholecystectomy for hepatecojejunostomy. Intraoperatively, an intralumenal, jejunal mass was found measuring 2 x 2 cm and about 95 cm from the DJ junction. The lesion was resected with safety margins, and primary anastomosis was done. The final histopathology of the specimen was consistent with adenomyoma, and all of the surgical margins we free. Results: The patient was found incidentally to have a mass in the small bowel that was resected and confirmed to be adenomyoma. The usual clinical presentation is variable depending on the location of the lesion, with the periampullary lesions presenting with obstructive jaundice, while jejunal and ileal lesions may present with intussusception, GI bleeding, or can be an incidental finding during surgery or autopsy [2–6]. Although there is no specified management guidelines for this pathology due to the low incidence, the prognosis is all in all good, and simple surgical resection is all what is needed, however, aggressive surgical approaches, such as pancreaticoduodenectomy for periampullary adenomyoma, were done in the previous reports due to the misdiagnosis with carcinoma preoperatively; hence knowledge of the nature of the lesion is important to avoid unnecessary extensive surgery. Conclusion: Adenomyoma of the small bowel is a rare entity, it's worth reporting this finding to norish the litrature. The diagnosis was confirmed by histopathology and the patient needed no more treatment for this lesion after the resection.

Diagnostic value of ultra-deep targeted next-generation sequencing in patients with suspect pancreatic and periampullary lesions

Background: Radiologic imaging and morphological cytology assessment have limitations for preoperative classification of pancreatic and periampullary lesions, often resulting in surgical resection without definitive diagnosis. Our study aims to define the diagnostic value of targeted Next-Generation Sequencing (NGS) of DNA in cytology material. Methods: Cytology material (brush/fine-needle aspirate) of patients with a suspect pancreatic or periampullary lesion was analyzed with NGS, in which 50 genes were deep sequenced for the presence of pathogenic variants. Results were discussed by the multidisciplinary team and changes to treatment plan noted. Diagnostic accuracy of NGS analysis was calculated. Results: In total, 70 consecutive patients were included. The integration of NGS results led to a change in treatment plan in 7 patients (exploration to follow-up n=4; follow-up to resection n=2; palliation to resection, n=1), and supported the treatment plan in 59 patients. In 4 patients, the NGS results were negative but did not influence the treatment plan as sampling error of cytology was suspected; NGS analysis on resection material revealed pathogenic variants in all 4 patients. Diagnostic accuracy of NGS analysis was 94% (sensitivity=93%; specificity=100%). Conclusion: In our study, NGS analysis changed the treatment plan in 10% of the patients. Application of in-depth preoperative molecular analysis can optimize treatment selection and can conversely diminish unnecessary resections in patients with a benign disease.

Diagnostic value of ultra-deep targeted next-generation sequencing in patients with suspect pancreatic and periampullary lesions

Diagnostic value of ultra-deep targeted next-generation sequencing in patients with suspect pancreatic and periampullary lesions