Total Pancreaticoduodenectomy Research Articles

The Learning Curve for Pancreaticoduodenectomy: The Experience of a Single Surgeon.

Pancreaticoduodenectomy (PD) is a complex and high-skill demanding procedure often associated with significant morbidity and mortality. However, the results have improved over the past two decades. However, there is a paucity of research concerning the learning curve for PD. Our aim was to report the outcomes of 100 consecutive PDs representing a single surgeon's learning curve and to depict the factors that influenced the learning process. We reviewed the first 121 PDs performed at our academic center (2013-2019) by a single surgeon; 110 were PDs (5 laparoscopic and 105 open) and 11 were total PDs (1 laparoscopic and 10 open). Subsequent statistics was performed on the first 100 PDs, with attention paid to the learning curve and survival rate at 5 years. The data were analyzed comparing the first 50 cases (Group 1) to the last 50 cases (Group 2). The most frequent histopathological tumor type was pancreatic ductal adenocarcinoma (50%). A total of 39% of patients had preoperative biliary drainage and 45% presented with positive biliary cultures. The preferred reconstruction technique included pancreaticogastrostomy (99%), in situ hepaticojejunostomy (70%), and precolic gastro-jejunal anastomosis (88%). Postoperative complications included biliary fistula (1%), pancreatic fistula (8%), pancreatic stump bleeding (4%), and delayed gastric emptying (13%). The mean operative time decreased after the first 50 cases (p < 0.001) and blood loss after 60 cases (p = 0.046). R1 resections lowered after 25 cases (p = 0.025). Vascular resections (17%) did not influence the rate of complications (p = 0.8). The survival rate at 5 years for pancreatic adenocarcinoma was 32.93%. Outcomes improve as surgeon experience increases, with proper training being the most important factor for minimizing the impact of the learning curve over the postoperative complications. Analyzing the learning curve from the perspective of a single surgeon is mandatory for accurate statistical results and interpretation.

Initial Experience of Pancreaticoduodenectomy in a Newly Developed Hepato-Pancreato-Biliary Unit Serving in a Lower-Middle-Income Country.

Pancreaticoduodenectomy (PD) is the only potentially curative treatment for pancreatic head adenocarcinoma. This study aimed to determine the short-term outcomes of PD performed over 1 year at a newly established hepato-pancreatico-biliary unit in Khyber Pakhtunkhwa province of Pakistan. A retrospective analysis of a prospectively maintained hospital information system (HIS) was undertaken of all patients referred to the unit between May 2021 and August 2022. Data were collected from the medical records of patients in the HIS. Data were analyzed for primary location, age, complications, and operative parameters. The primary sites of disease were ampulla (n = 18, 52.9%), pancreas (n = 11, 32.4%), and duodenum (n = 5, 14.7%). The median duration of surgery was 7 h. 16 (47.1%) patients required blood transfusion either intraoperatively or in the perioperative period. Patients with pre-operative biliary drainage (PBD) were more likely to have multidrug-resistant positive bile cultures with a P-value of 0.2 (n = 12 [35.3%] vs. n = 5 [14.7%]). Overall morbidity was 38.2%. The most common complications were wound infection (n = 12, 35.3%), delayed gastric emptying (n = 6, 17.6%), and type B pancreatic fistula (n = 3, 8.8%). The complication rate was higher in patients with biliary stenting (n = 11 [32.4%] vs. n = 2 [5.9%]; P = 0.06). The median length of hospital stay for patients without complications was less (6 vs. 12 days; P < 0.001). The complication rate was lower in total laparoscopic PD (TLPD) with P = 0.4 (TLPD: 2.9%, open: 23.5%, laparoscopic assisted: 11.8%). 90-day mortality was zero. Short-term outcomes for PD in our facility are comparable to high-volume centers. PBD can significantly increase operative time, hospital stay, and morbidity.

Severe gastroenteritis as presentation of a neuroendocrine tumor of pancreas

Pancreatic neuroendocrine tumors (PanNETs) are a very rare entity, corresponding to 1-2% of all pancreatic neoplasms, although incidence and prevalence are rising. According to hormonal production, they can be functional or nonfunctional, leading to a subset of symptoms. A 45-year-old man, came to our emergency department complaining of vomiting and profuse non-bloody diarrhea for a week, with asthenia and no improvement with medication. He presented with diminished muscular strength and severe electrolytic changes with electrocardiographic repercussion. Patient was admitted to our intensive care unit (ICU) for hypovolemic and distributive shock due to a severe gastroenteritis. Further research studies were carried out which have shown a nodular structure of 5x4cm in the pancreas tail on computed tomography scan. A biopsy was made, and a histopathological exam revealed a pancreatic well differentiated neuroendocrine tumor. Hormonal analysis showed an elevation on vasoactive intestinal polypeptide (VIP). On 68Ga-DOTA-NOC PET/CT, there were 2 nodular lesions with anomalous overexpression of somatostatin receptors, one in the pancreatic tail near splenic hilum and another in the pancreatic head. Patient underwent a total pancreaticoduodenectomy with en bloc splenectomy. Postoperative period was uneventful. Mostly, this kind of pancreatic neuroendocrine tumors are indolent, but till 39% can have an aggressive course, so they have variable prognosis.

Resection margin status at the portomesenteric axis may not determine oncologic outcome after pancreaticoduodenectomy for lymph node-positive pancreatic ductal adenocarcinoma

Lymph node and resection margin status are associated with oncologic outcomes after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. However, surgical radicality at the portomesenteric axis in case of suspected infiltration remains controversial. Clinicopathological data of patients who underwent a partial or total pancreaticoduodenectomy for PDAC between 2012 to 2019 in 2 major hepato-pancreato-biliary centers in Germany and Switzerland were assessed. We evaluated the impact of positive resection margins at the vascular, parenchymal, and retropancreatic surfaces on overall survival in patients with and without lymph node involvement. Margin-positive vascular resection included both patients with positive margins at the vascular groove and the resected venous wall. During the study period, 217 patients underwent partial/total pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. After excluding 7 patients suffering postoperative complications resulting in mortality within 90 days after surgery (3%), 169 patients had lymph node involvement (80%). In the entire study cohort, margin-positive resection (33%) was significantly associated with worse overall survival (3-year overall survival: margin-positive resection: 27% vs margin-negative resection: 43%, P= .014). Among patients with positive lymph nodes, margin-positive vascular resection (n= 48, 28%) was not significantly associated with impaired overall survival (3-year overall survival: margin-positive vascular resection: 28% vs margin-negative vascular resection: 36%, P= .065). On the contrary, margin-positive parenchymal resection (n= 7, 4%) (3-year overall survival: margin-positive parenchymal resection: 0% vs margin-negative parenchymal resection: 35%, P < .0001) and margin-positive retropancreatic resection (n= 21, 12%) (3-year overall survival: margin-positive retropancreatic resection: 6% vs margin-negative retropancreatic resection: 39%, P < .0001) significantly diminished overall survival in univariate and multivariate analysis in all patients. Among patients without lymph node involvement (n= 41, 20%), there were no margin-positive parenchymal or margin-positive retropancreatic resections. In contrast, only 5 patients had margin-positive vascular resection (12%), with overall survival compared to those with margin-negative vascular resection. In patients with pancreatic ductal adenocarcinoma and lymph nodal positivity, resection status at the parenchymal and retropancreatic surface but probably not at the portal and/or superior mesenteric vein is a determinant of survival. Therefore, margin-negative resection should be pursued during pancreaticoduodenectomy. However, radical venous resection and/or reconstruction for suspected tumor infiltration may not be necessary for patients with intraoperatively detected lymph node metastases.

HPB P60 Pancreatic Carcinosarcoma as a rare cause of upper gastrointestinal bleeding requiring resection

Abstract Background Pancreatic carcinosarcoma is a rare malignant neoplasm and has a very poor prognosis. Diagnosis is mainly by pathological examination including immunohistochemistry (IHC) of the biopsy or resected specimen. Due to the rarity of the cancer, information regarding clinical presentation, pathology and management is limit to a few case reports. Methods We report a 61-year-old fit and healthy male, who presented to the emergency department with melaena and syncope. Initial CT scan showed a pancreatic body/tail tumour, likely pancreatic cancer without nodal or intra-abdominal metastasis. Upper GI endoscopy revealed a lesion in the second part of the duodenum, with a visible vessel, and evidence of recent bleeding . Two clips were applied, and a biopsy of the lesion showed ulcer slough only. Tumour markers and IgG4 levels were normal. An MRI pancreas showed no definite pancreatic mass, features of chronic pancreatitis and irregular bile ducts. HPB MDT consensus was to proceed for EUS, which confirmed a hypoechoic, vascular, 3cm mass lesion in D1-D2. Biopsies again, showed ulcer slough. A PET CT scan showed avidity in the second part of the duodenum and pancreatic head, neck and distal body. The patient presented to the surgical emergency unit twice during this time with symptoms of anaemia requiring IV iron and blood transfusions, and with early signs of obstruction, which settled with conservative management. Interval MRI showed increase in size of the duodenal mass, and stable appearance of the lesion in the head of the pancreas. Eventually, semi-emergency total pancreaticoduodenectomy and splenectomy was undertaken. Results Intraoperatively, a large D2 tumour was found extending into the pancreatic head posteriorly, compressing but not infiltrating the IVC. The rest of the pancreas was hard in consistency and nodular. Soft lymph nodes were found at the aorto-caval, common hepatic and around the SMA. There was no obvious intra-abdominal metastasis. The final histopathology showed a malignant, biphasic tumour favouring pancreatic carcinosarcoma staged pT3 N0 (0/29) L1 V1 R1 (posterior and SMV). On molecular cytogenetic analysis there was no evidence of rearrangement associated with synovial sarcoma in the cells examined. He recovered well post operatively and has commenced adjuvant chemotherapy of modified Folfirinox. Conclusions Pancreatic carcinosarcoma is a rare entity, which due to its unusual presentation, can be challenging to manage. Prompt MDT discussion is instrumental in such cases. The assessment of different radiological modalities, showing progressive increase in the size of the lesion within a short time period, raised the suspicion of an aggressive mitotic lesion, with the repeat biopsies unlikely to yield diagnosis in an otherwise operable lesion. Ultimately, the patient underwent a semi-emergency, total pancreaticoduodenectomy and splenectomy due to ongoing bleeding and the rapidly growing tumour size. In this case, surgery followed by adjuvant chemotherapy has been adopted as the optimum management strategy, for both bleeding control, and oncological benefit.

S366 Endoscopic Marsupialization of a Large Duodenal Duplication Cyst

Introduction: Duodenal duplication cysts are rare congenital malformations of the gastrointestinal tract. These malformations are usually diagnosed in infancy and childhood. Only one-third of adults are diagnosed after twenty years of age. Presenting symptoms and signs include abdominal pain and intestinal obstruction. These are generally found in the first and second parts of the duodenum. Although the majority are benign, case reports have demonstrated a risk of malignancy. The ideal treatment is complete surgical resection. Due to the proximity of structures including the biliopancreatic ducts, excision of the duodenal duplication cyst may require total pancreaticoduodenectomy. Advances in therapeutic endoscopy provide an alternative option for patients who are at a high risk of surgical complications. Endoscopic marsupialization is a management option in which the cyst cavity contents are drained into the duodenum. Complications include duodenal perforation and bleeding. However, the overall morbidity is low. Endoscopic surveillance is recommended in these patients to assess for recurrence. Case Description/Methods: We present a case of a 38-year-old female who was diagnosed with a large duodenal mass in the second part of the duodenum measuring 8 cm in the largest diameter. This was found incidentally during an upper endoscopy which was performed in July 2020 for hematemesis. The duodenal mass was cystic in appearance on cross-sectional imaging. She was offered endoscopic marsupialization in October 2020 due to morbid obesity which increased the risk of perioperative complications. Discussion: The procedure was performed successfully. Pathology from the lateral wall of the duodenal cyst was consistent with a duodenal duplication cyst. There were no early or delayed complications. The patient had a follow-up endoscopy one year later which did not demonstrate evidence of recurrence on biopsies. Watch the video at https://tinyurl.com/ACGAbstractS366

A Safe Start Laparoscopic-assisted Pancreaticoduodenectomy in Songklanagarind Hospital, Thailand: Case Report

Total laparoscopic pancreaticoduodenectomy (PD) is a highly complex procedure. Evidence suggests laparoscopic-assisted PD (LAPD) might be an important link in the process of transition from open PD to total laparoscopic PD. We present the first successful LAPD in a female patient with distal cholangiocarcinoma at Songklanagarind Hospital, Thailand in July 2018. The postoperative course was satisfactory without the clinical relevance of complications. No evidence of recurrence was found after 35 months of follow-up. The results ensured the feasibility and safety of LAPD in the initial phase; regarding both complications and oncological outcomes in a high-volume center for open PD.

More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis

BackgroundPostpancreatectomy morbidity remains significant even in high-volume centers and frequently results in delay or suspension of indicated adjuvant oncological treatment. This study investigated the short-term and long-term outcome after primary total pancreatectomy (PTP) and pylorus-preserving pancreaticoduodenectomy (PPPD) or Whipple procedure, with a special focus on administration of adjuvant therapy and oncological survival.MethodsPatients who underwent PTP or PPPD/Whipple for periampullary cancer between January 2008 and December 2017 were retrospectively analyzed. Propensity score-matched analysis was performed to compare perioperative and oncological outcomes. Correspondingly, cases of rescue completion pancreatectomy (RCP) were analyzed.ResultsIn total, 41 PTP and 343 PPPD/Whipple procedures were performed for periampullary cancer. After propensity score matching, morbidity (Clavien-Dindo classification (CDC) ≥ IIIa, 31.7% vs. 24.4%; p = 0.62) and mortality rates (7.3% vs. 2.4%, p = 0.36) were similar in PTP and PPPD/Whipple. Frequency of adjuvant treatment administration (76.5% vs. 78.4%; p = 0.87), overall survival (513 vs. 652 days; p = 0.47), and progression-free survival (456 vs. 454 days; p = 0.95) did not significantly differ. In turn, after RCP, morbidity (CDC ≥ IIIa, 85%) and mortality (40%) were high, and overall survival was poor (median 104 days). Indicated adjuvant therapy was not administered in 77%.ConclusionsIn periampullary cancers, PTP may provide surgical and oncological treatment outcomes comparable with pancreatic head resections and might save patients from RCP. Especially in selected cases with high-risk pancreatic anastomosis or preoperatively impaired glucose tolerance, PTP may provide a safe treatment alternative to pancreatic head resection.

Endoscopic ultrasound-guided hepaticogastrostomy vs. ERCP for preoperative biliary drainage in patients undergoing pancreatic resection

Abstract Objective Preoperative bile drainage in patients with obstructive jaundice due to pancreatic head malignancy is needed, if pancreatic head resection cannot be performed in a timely fashion. The safety and efficacy of ultrasound-guided hepaticogastrostomy (HGS) as an alternative to the established endoscopic retrograde cholangio-pancreatography (ERCP) with stent placement needs further investigation. Methods Clinicopathological data of patients who underwent partial or total pancreaticoduodenectomy between January 2017 and December 2019 in a major swiss hepatopancreatobiliary center were assessed. We compared the HGS with ERCP/stent regarding the kinetics of bilirubin decrease, the procedure-related morbidity, and the postoperative surgical outcomes. Results During the study period, 102 patients underwent pancreaticoduodenectomy or total pancreatectomy for pancreatic malignancy. Preoperative bile drainage was performed in 65 patients (20 HGS, 45 ERCP). HGS was associated with a faster (6 vs. 10 days, P = 0.042) and more effective (133 µmol/L vs. 101 µmol/L, P = 0.037) reduction of the serum bilirubin levels. HGS was safe and did not differ from ERCP with stent placement concerning post-interventional complications (P = 0.565), postoperative mortality (P = 0.996) and postoperative morbidity (P = 0.896), including infectious complications (wound infection, P = 0.662/ intra-abdominal abscess, P = 0.587), severe pancreatic fistula (P = 0.587), bile leak (P = 0.131), and postoperative hemorrhage (P = 0.886). Conclusion HGS performed in a specialized multidisciplinary hepatopancreatobiliary center is feasible and safe and may result in more accelerated and effective bile drainage compared to the established ERCP. In patients with obstructive jaundice related to pancreatic malignancy unable to undergo adequate bile drainage by ERCP, HGS may be an effective alternative method enabling surgery in a timely manner.

Surgical Management of Large Gastrinomas in a Young Patient With MEN1

Multiple Endocrine Neoplasia 1 (MEN1) is a well-described hereditary disorder that requires a multidisciplinary approach. Gastrinomas are the most common enteropancreatic tumors found in MEN1. They often appear as small (< 0.5 cm) multifocal lesions and are rarely found as large masses in the pancreas. The crossroads of deciding between medical versus surgical management when treating these tumors requires an evidenced-based- and patient-centered approach. We describe a rare case of a young patient with MEN1 and large pancreatic gastrinomas. A 23-year-old female patient with MEN1 (prolactinoma, primary hyperparathyroidism) was evaluated for the development of hypocalcemia after surgical excision of 3 parathyroid glands. A prior history of a perforated peptic ulcer prompted further evaluation that revealed gastrin levels of 481 pg/ml (13 - 115 pg/ml) off any acid suppression therapy, and an abdominopelvic MRI that revealed two T1 hypointense lesions measuring 2.4 cm and 1.4 cm at pancreatic head and tail, respectively. Both lesions resulted to be grade 2/3 neuroendocrine tumors consistent with gastrinoma. Abdominopelvic CT scan for staging showed 6 isodense lesions distributed within the pancreas measuring up to 3.2 cm without lymphadenopathy nor metastatic liver lesions. After extensive discussion regarding management, the patient opted for a surgical approach. A total pancreaticoduodenectomy was performed. The pathology revealed 7 grade 2 well-differentiated neuroendocrine tumors (6 in pancreas and 1 in duodenum) and 18 of 22 positive lymph nodes. Post-surgically she experienced multiple admissions due to surgical complications and the expected endocrine and exocrine dysfunction. Eight weeks after surgery gastrin remained elevated [652 pg/ml (13 - 115 pg/ml)]. The surgical management of gastrinomas in MEN1 remains without consensus. Due to the multifocality of gastrinomas associated with MEN1 and the high probability of persistent hypergastrinemia, surgery is not usually recommended. However, most guidelines are in favor of surgical excision for tumors > 2 cm to decrease their associated risk for liver metastasis and improve long-term survival. In this young patient with a 3.2 cm tumor, a surgical approach was favored to improve prognosis. Persistent hypersecretion may occur, as in our patient, due to residual hypertrophy of gastric parietal cells, although the possibility of remaining tumors still exists, especially in view of high lymph node positivity. The best available evidence-based treatment alternatives were offered to our patient; unfortunately, both the disease itself and surgical treatment options impose high morbidity and decreased quality of life. More studies reporting on the long-term outcomes after surgical resection of gastrinomas in MEN1 are needed to identify predictors to help recognize patients which benefit from a surgical approach.

Robotic pancreaticoduodenectomy with right hepatic artery resection

Background: Pancreaticoduodenectomy(PD) with en bloc hepatic arterial resection and reconstruction remains a controversial topic. Although use of robotic surgery has been increasing worldwide in patients requiring PD, hepatic arterial resection and reconstruction has not been previously described. This video depicts a first in utilizing the Davinci Si robotic system to perform a hepatic arterial vascular resection and anastomosis during PD. Methods: A 69 year-old female, presenting with obstructive jaundice, was diagnosed with a distal common bile duct cancer by ERCP and brushing cytology. CT scan imaging revealed the suspected tumor mass involving the proximal right hepatic artery. We performed a total robotic PD. Right hepatic artery (RHA) was involved by the tumor and segmental resection was performed to achieve en bloc resection. End-to-end anastomosis of RHA stump to distal part was carried out by using 5-0 proline suture robotically. The reconstruction, including the modified Blumgart fashion pancreatojejunostomy, choledochojejunostomy and gastrojejunostomy, were all accomplished intracorporeally using the robotic platform. Results: The total operative time was 499 minutes and estimated blood loss was 500ml. The patient was discharged on post-OP day 4 without complications. The final pathology was moderately differentiated pancreatic adenocarcinoma with extensive perineural invasion. Metastatic carcinoma was found in one of the ten lymph nodes. Conclusion: PD with hepatic artery resection and reconstruction can be performed safely using robotic surgery. Restoration of the resected hepatic artery may ensure the bilio-enteric anastomosis in the immediate and late post-operative course.

Portal vein resection during pancreatic resection for inflammation instead of true tumor infiltration – A false positive benefit for overall survival?

Background: Extended pancreatic resections including resections of the portal (PV) may nowadays be performed safely. Limitations in distinguishing true tumor involvement from inflammatory adhesions however result in PV resections being performed without histological evidence of tumor infiltration. The aim of this study was to analyze the impact of these false positive resections on operative outcome and long-term survival. Methods: 40 patients who underwent pancreatic resection with PV resection for pancreatic adenocarcinoma (PA) without tumor infiltration of the PV (PVR-group) were identified. In a 1:3 match these patients were compared to 120 patients who underwent standard pancreatic resection without PV resection (PD-group) with regard to operative outcome and overall survival. Results: A pancreatic head resection was performed in 63% of the patients whereas 37% underwent a total pancreaticoduodenectomy. Overall postoperative complications > Clavien II were observed in 14 patients (35%) of the PVR group and 19 patients (16%) of the PD group (p = 0.01). Postoperative mortality occurred in 2 patients (5%) of the PVR group vs. 1 patient (1%) of the PD group (p = 0.10). Overall survival was significantly decreased in the PVR group (p = 0.00). Conclusion: Radical resection affords the best chance for long-term survival in patients with PA. Based on the results of this study a routine resection of the PV as recently proposed may however not be recommended.

The pancreas as a target of metastasis from renal cell carcinoma: Results of surgical treatment in a single institution.

Backgrounds/AimsMetastasis in the pancreatic gland is infrequent, representing between 2–5% of the tumors that affect this organ. However, secondary lesions of clear cell renal carcinoma (CCRC) can occur mainly in this location and it is frequently the only site of dissemination. Treatment of choice is resection in surgically fit patients, as it has been shown that it improves the quality of life and prognosis substantially. We retrospectively reviewed the clinical data of patients with pancreatic resections for metastatic CCRC since there are no reports of the treatment modality of this singular entity in Argentina.MethodsRetrospective cohort analysis over a 10-year period including eight patients who underwent pancreatic resection for metastatic CCRC.Results75% of patients were male with an average age of 65.5 years. The pancreatic surgery occurred at a median time of 9.2 years (1–24.8) from the renal operation. The pancreatic lesions were mostly solitary and asymptomatic. A pancreaticoduodenectomy (PD) was performed in 4 patients (50%). Distal pancreatectomy (DP) was performed in 3 patients (37.3%) and one patient (12.5%) underwent a total pancreaticoduodenectomy. All the patients presented a confirmatory biopsy of pancreatic metastasis of CCRC. Complications were recorded in 3 patients (42.85%). No intraoperative or postoperative mortality was registered. With a median follow-up of 45 months, three patients presented recurrence at 32, 46 and 51 months, respectively. Only one patient showed death due to recurrence at 7.8 month.ConclusionsCCRC pancreatic metastases treated surgically have a low morbidity and mortality rate in high volume centers, showing excellent long-term survival.

Alternative hepatic arterial reconstruction technique in case of total pancreaticoduodenectomy after celiac artery resection in pancreas cancer: Iliac-hepatic bypass.

Surgery is the only treatment method in pancreatic cancer. Unfortunately, metastatic diseases or invasion of the main vascular structures are observed in a majority of cases at the time of diagnosis; these structures originate from the body, neck, and tail of the pancreas and are considered inoperable. The first celiac artery resection for the treatment of cancer was described by Appleby in 1953. Here, we describe our hepatic artery reconstruction technique in a case with pancreatic body cancer. A 37-year-old male patient was admitted to our emergency department owing to syncope. The patient was diagnosed with acute renal failure secondary to fluid loss. Thereafter, his general condition was stable and laboratory results improved. Abdominal computed tomography was performed. Pancreatic cancer originating from the pancreatic body was detected. A pancreatic biopsy was performed and neoadjuvant gemcitabine and paclitaxel chemoradiotherapy were initiated. Surgical treatment was recommended for the identification of regression after neoadjuvant chemoradiotherapy. Following intraoperative Doppler ultrasonography, en bloc distal pancreatectomy and splenectomy involving the celiac artery trunk and total gastrectomy were performed. However, the surgical margin reliability in a frozen section revealed that the tumor was still present. Therefore, the surgical procedure was replaced with total pancreaticoduodenectomy. The hepatic artery reconstruction was performed from the left main iliac artery using a 4-mm ringed GORE-TEX® graft. The iliac-hepatic bypass for hepatic artery reconstruction in pancreatic cancer could be an alternative surgical technique.

Pancreaticoduodenal resection for carcinoma head of pancreas – the influence of margin status on survival

Aim: To evaluate the influence of margin status on survival following resection for carcinoma head of pancreas (CaHOP). Methods: A retrospective analysis of prospectively maintained database of patients undergoing a Pancreaticoduodenal resection (PDR) for CaHOP. 547 patients underwent a PDR at a tertiary care center from Jan 2001 till Dec 2013. Of these, 24 patients (4.4%) operated for CaHOP form the study material. Margins were defined as macroscopically positive (R2), microscopically positive (R1), negative margins (R0) and close margins which were less than 1mm (Rc). Results: 13/24 (54.2%) patients were R0, 6/24 (25%) were R1, 3/24 (12.5%) were Rc. 2 (8.3%) patients had positive margins on intra-operative frozen section and underwent a total pancreaticoduodenectomy (TPD). 1 (4.2%) patient expired postoperatively following a classical PD . The postoperative morbidity included post pancreaticoduodenectomy hemorrhage (PPH)(n=3, 12.5%), pancreaticojejunostomy (PJ) leak (n=5, 22.7%), bile leak (n=2,8.3%) and DGE (n=4,16.7%) The overall survival of these patients was 15.3 months. The survival following R0 resection was 15.5 months, 13.9 months for R1 and Rc resection and 20 months for TPD. Patients undergoing TPD for positive intraoperative margin on frozen section had better survival than those with R1 or close surgical (Rc) margins (20 months vs 13.9 months) though there was no statistically significant difference based on margin status of the patients because of small group size. Conclusion: R1 and Rc resections fare similarly. TPD for positive resection margins provides better overall survival with acceptable morbidity. Larger prospective trials are required to validate these results.

Gastric stump carcinoma as a long-term complication of pancreaticoduodenectomy: report of two cases and review of the English literature

BackgroundGastric stump carcinoma is an exceptional and poorly known long-term complication after pancreaticoduodenectomy.Cases presentationTwo patients developed gastric stump carcinoma 19 and 10 years after pancreaticoduodenectomy for malignant ampulloma and total pancreaticoduodenectomy for pancreatic adenocarcinoma, respectively. Both patients had pT4 signet-ring cell carcinoma involving the gastrojejunostomy site that was revealed by bleeding or obstruction. Patient 1 is alive and remains disease-free 36 months after completion gastrectomy. Patient 2 presented with peritoneal carcinomatosis and died after palliative surgery. We identified only 3 others cases in the English literature.ConclusionsProlonged biliary reflux might be the most important risk factor of gastric stump carcinoma following pancreaticoduodenectomy. Its incidence might increase in the future due to prolonged survival observed after pancreaticoduodenectomy for benign and premalignant lesions.

A Matched-pair Analysis of Total Pancreatectomy versus Pancreaticoduodenectomy in Patients with Pancreatic Ductal Adenocarcinoma: A single centre experiment in China

A Matched-pair Analysis of Total Pancreatectomy versus Pancreaticoduodenectomy in Patients with Pancreatic Ductal Adenocarcinoma: A single centre experiment in China

The Origins of Oncological Pancreatic Surgery in Spain. A Tribute to Pioneers

Pancreaticoduodenectomy (PD) is a very complex operation. Its development took place very slowly at the most prestigious centers in the world. The aim of this investigation is to know who were the first surgeons to perform a PD in Spain as well as its historical circumstances. Despite all kinds of difficulties and very few resources, the first PD in Spain were carried out in Barcelona at the Hospital de la Santa Creu i Sant Pau where from the mid-50s a school of gastrointestinal surgery emerged with surgeons soon to become the spearhead of the Spanish surgery and a reference for the whole country: Pi-Figueras, Vicente Artigas, Antonio Soler-Roig and Antonio Llauradó. Almost simultaneously, in Oviedo, Luis Estrada also introduced the PD and total pancreaticoduodenectomy after a period of training with the pioneers of pancreatic surgery in the United States.

Two synchronous malignant tumors of the pancreas: a case report

BackgroundOnly a limited number of multiple synchronous primary malignancies of the pancreas have been reported in the medical literature. We report a case of two solid malignant tumors of the pancreas diagnosed preoperatively.Case presentationWe describe a 65-year-old Sri Lankan woman who presented with progressive obstructive jaundice. Initial contrast-enhanced computed tomography imaging detected a malignant tumor at the tail of her pancreas. A second tumor of the pancreatic head was detected with integrated imaging using multidetector computed tomography and multimodal magnetic resonance imaging. She underwent total pancreaticoduodenectomy and splenectomy. Gross examination of the specimen confirmed the presence of two separate tumors. Histology of the ampullary tumor showed pancreatic-type adenocarcinoma and the tumor in the tail of her pancreas showed a colloid-type adenocarcinoma. ConclusionThe possibility of multiple primary malignant solid tumors of different types with malignant potential has to be considered even without background pathology when managing multiple tumors in the pancreas.

Inicios de la cirugía pancreática oncológica en España. Un tributo a los pioneros

Pancreaticoduodenectomy (PD) is a very complex operation. Its development took place very slowly at the most prestigious centers in the world. The aim of this investigation is to know who were the first surgeons to perform a PD in Spain as well as its historical circumstances. Despite all kinds of difficulties and very few resources, the first PD in Spain were carried out in Barcelona at the Hospital de la Santa Creu i Sant Pau where from the mid-50s a school of gastrointestinal surgery emerged with surgeons soon to become the spearhead of the Spanish surgery and a reference for the whole country: Pi-Figueras, Vicente Artigas, Antonio Soler-Roig and Antonio Llauradó. Almost simultaneously, in Oviedo, Luis Estrada also introduced the PD and total pancreaticoduodenectomy after a period of training with the pioneers of pancreatic surgery in the United States.