Type Of Pancreatectomy Research Articles

Associations between pancreatectomy type, treatment sequence and textbook oncologic outcomes in patients with localized pancreatic adenocarcinoma

BackgroundPrior studies have shown that achievement of textbook oncologic outcomes (TOO) after pancreatectomy for pancreatic adenocarcinoma (PDAC) is associated with better survival outcomes. However, the associations between TOO, procedure type, and treatment sequence has not been examined. MethodsPatients with resected PDAC were identified within the National Cancer Database (2010–2018). We analyzed rates of TOO (defined as no 30-day readmission, no 90-day mortality, no prolonged length of stay, negative surgical margins, receipt of multi-agent chemotherapy, and nodal yield ≥12) stratified by procedure (pancreatoduodenectomy vs. distal pancreatectomy vs. total pancreatectomy) and treatment sequence (up-front surgery vs. neoadjuvant therapy). ResultsA total of 20,155 patients were identified. Patients who underwent distal pancreatectomy were less likely to have TOO compared to pancreatoduodenectomy (12.6% vs. 17.5%; OR=0.77, 95% CI: 0.68–0.88). There was no difference in TOO between patients who underwent total pancreatectomy compared to pancreatoduodenectomy (16.4% vs. 17.5%; OR=0.96, 95% CI: 0.84–1.11). Neoadjuvant chemotherapy was associated with a 5-fold increase in the odds of TOO (OR=5.07, 95% CI: 4.35–5.91). TOO was associated with improved OS regardless of surgical procedure (pancreatoduodenectomy: median OS: 33.7 vs. 20.5mo; HR=0.69, 95% CI: 0.65–0.73; distal pancreatectomy: median OS: 35.8 vs. 23.9mo; HR=0.73, 95% CI: 0.64–0.84; total pancreatectomy: median OS: 30.1 vs. 19.9mo; HR=0.69, 95% CI: 0.61–0.79). ConclusionsThe rate of TOO was lower for distal pancreatectomy as compared to pancreatoduodenectomy or total pancreatectomy. Neoadjuvant therapy was associated with higher likelihood of TOO. Regardless of pancreatectomy type, TOO was associated with improved OS.

De novo non-alcoholic fatty liver disease after pancreatectomy: A systematic review.

As operative techniques and mortality rates of pancreatectomy have improved, there has been a shift in focus to maintaining and improving the nutritional status of these patients as we continue to learn more about post-operative complications. Although pancreatic endocrine and exocrine insufficiencies are known complications of pancreatectomy, increased longevity of these patients has also led to a higher incidence of de novo fatty liver disease which differs from traditional fatty liver disease given the lack of metabolic syndrome. To identify and summarize patterns and risk factors of post-pancreatectomy de novo fatty liver disease to guide future management. We performed a database search on PubMed selecting papers published between 2001 and 2022 in the English language. PubMed was last accessed 1 June 2022. Various factors influence the development of de novo fatty liver including indication for surgery (benign vs malignant), type of pancreatectomy, amount of pancreas remnant, and peri-operative nutritional status. With an incidence rate up to 75%, de novo non-alcoholic fatty liver disease (NAFLD) can develop within 12 mo after pancreatectomy and various risk factors have been established including pancreatic resection line and remnant pancreas volume, peri-operative malnutrition and weight loss, pancreatic exocrine insufficiency (EPI), malignancy as the indication for surgery, and postmenopausal status. Since majority of risk factors leads to EPI and malnutrition, peri-operative focus on nutrition and enzymes replacement is key in preventing and treating de novo NAFLD after pancreatectomy.

Portal Vein Thrombosis After Venous Reconstruction During Pancreatectomy: Timing and Risks

BackgroundNumerous studies have shown that portal vein resection during pancreatectomy can help achieve complete tumor clearance and long term-survival. While the safety of vascular resection during pancreatectomy is well documented, the risk of superior mesenteric vein/portal vein (SMV/PV) thrombosis after reconstruction remains unclear. This study aimed to describe the incidence and risk factors of SMV/PV thrombosis after vein reconstruction during pancreatectomy. MethodsAll patients who underwent portal vein resection (PVR) during pancreatectomy (2007–2019) were identified from a single institution prospective clinical database. Demographic and clinical data, operative and pathological findings, and postoperative outcomes were analyzed. ResultsPancreatectomy with PVR was performed in 220 patients (mean age 65.1 years, male/female ratio 0.96). Thrombosis occurred in 36 (16.4%) patients after a median of 15.5 days [IQR 38.5, 1–786 days]. SMV/PV patency rates were 92.7% and 88.7% at 1 and 3 months, respectively. The rate of SMV/PV thrombosis varied according to SMV/PV reconstruction technique: 12.8% after venorrhaphy, 13.2% end-to-end anastomosis, 22.6% autologous vein, and 83.3% synthetic graft interposition (p < 0.0001). SMV/PV thrombosis was associated with increased 90-day mortality (16.7% vs 4.9%, p = 0.02) and overall 30-day complication rate (69.4% vs 42.9%, p = 0.006). Pancreatectomy type, neoadjuvant chemoradiation, pathologic tumor venous invasion, resection margin status, and manner of perioperative anticoagulation did not influence the incidence of PV thrombosis. SMV/PV thrombosis was associated with a nearly 5-times increased risk of postoperative sepsis after pancreatectomy. ConclusionPortal vein thrombosis developed in 16% of patients who underwent pancreatectomy with PVR at a median of 15 days. PVR with synthetic interposition graft carries the highest risk for thrombosis.

Validation of the ISGLS classification of bile leakage after pancreatic surgery: A rare but severe complication

IntroductionHepaticoenterostomy is an important step of reconstruction during hepatopancreatobiliary (HPB) surgery with a subsequent bile leakage rate of up to 5%. The International Study Group of Liver Surgery (ISGLS) proposed a severity grading system for defining bile leakage after HPB surgery, which has not been validated after pancreatic surgery in a large patient cohort. The present study aimed to validate the ISGLS definition for bile leakage in pancreatic surgery and to investigate the postoperative outcomes of bile leakage after pancreatic resections. Materials and methodsData from the prospectively maintained database for pancreas surgery were extracted for any type of pancreatectomy with hepaticoenterostomy between 2006 and 2019. The severity of bile leakage was graded according to the ISGLS definition. The influence of our standardized hepaticoenterostomy technique and of the complexity of the surgical procedure on the rate of clinically relevant bile leakages (B and C) were assessed in three different timeframes. ResultsBile leakage was detected in 152 of 5,300 patients (2.9%). Clinically relevant bile leakages included seventy patients with grade B and eighty-two patients with grade C bile leakages (46.1% and 53.9%, respectively). During the study period, the overall rate of bile leakage showed to be stable (from 3.5% to 2.4%). Patients with grade C bile leakage had a higher rate of postoperative wound infection (P < 0.001) and longer ICU stays and hospital stays compared to patients with grade B bile leakage (P = 0.03 and P < 0.001 respectively). These parameters were significantly higher in patients with late grade C bile leakage but were similar between patients with grade B bile leakage and early grade C bile leakage (<5th day POD). In the whole patients’ cohort, the 90-day mortality rate was 3.2% (174/5,300), with a rate of 25% in patients with bile leakage (38/152). ConclusionThe ISGLS classification is a valid method for classifying postoperative bile leak after pancreas surgery. Standardization of our hepaticoenterostomy technique resulted in a stable rate of bile leakage. Although rare, bile leakage following pancreas surgery is a severe complication that has a major impact on patient outcomes and contributes significantly to morbidity and mortality, even in the absence of POPF.

Validation of the ISGLS Classification of Bile Leakage after Pancreatic Surgery: A Rare but Severe Complication

Introduction: Hepaticoenterostomy is an important step in hepatopancreatobiliary (HPB) surgery with a subsequent bile leakage (BL) rate of up to 5%. The International Study Group of Liver Surgery (ISGLS) proposed a grading system for BL after HPB surgery. This study aimed to validate this grading system for BL in pancreatic surgery (PS) and to investigate the postoperative outcomes of BL after PS. Methods: Data were extracted for any type of pancreatectomy with hepaticoenterostomy between 2006 and 2019. The BL was graded according to the ISGLS classification. The influence of our standardized hepaticoenterostomy technique and the complexity of the surgery on BL rate were assessed in different time frames. Results: BL was detected in 156 of 5,300 patients (2.9%, Table 1). During the study period, the overall rate of Type-B and C BL showed a slight reduction from 3.5% to 2.4%. Patients with Type-C BL had higher wound infection rate and longer ICU-stay. Patients with Type-C BL receiving late surgical revision (>5th day postoperative) had higher mortality rate compared to patients with Type-B and early Type-C BL (Table 2). Conclusion: The ISGLS classification is valid for classifying BL after PS. The BL rate is influenced by the complexity of surgery (Figure 1). Patients with early Type-C BL who undergo reoperation in the first five days have better outcomes than late onset Type-C BL patients. Although rare, BL following PS is a severe complication with a major impact on patient outcome contributing significantly to morbidity and mortality.Tabled 1EP02D-052Grade B(n= 70)Early grade C+(n= 39)Late grade C‡(n= 43)P-valuen (%) or median (range)Wound infection10 (14.3%)14 (35.9%)21 (48.9%)< 0.001Intervention (CT-guided drainage and/or PTCD)70 (100%)20 (51.3%)24 (55.8%)0.001Re-intubation14 (20%)12 (30.8%)16 (37.2%)0.16ICU stay (days)7 (0–76)10 (0–131)18 (2–173)<0.001*Hospital stay (days)40.5 (15–109)35 (9–182)43 (14–235)0.22∗30-day mortality9 (12.9%)7 (17.9%)14 (32.6 %)0.0390-day mortality13 (18.6%)9 (23.1%)16 (37.2%)0.08 Open table in a new tab

Empirical coil embolization of splenic artery as a salvage life saving procedure in post pancreatectomy hemorrhage and hemosuccus pancreaticus

Introduction: Computerised Tomography Angiogram (CTA) is the diagnostic modality in Post pancreatectomy Haemorrhage (PPH) and Hemosuccus Pancreaticus (HP). However, occasionally, the offending aneurysm or the source of bleed may not be evident by CTA or conventional angiography. Intraluminal bleeds, especially after Dunking Pancreaticojejunostomy, may be from small pseudoaneurysms in the territory of splenic artery or from cut end of pancreas that are difficult to pick up by CTA. We evaluated the efficacy of empirical segmental Coil embolisation of pancreatic segment of splenic artery in the setting of intraluminal PPH as well as HP following Acute /Chronic pancreatitis. Methods: A cross sectional study was done by analysing the prospectively held pancreatic database from January 2009-december 2018. All consecutive patients with PPH following any type of Pancreatectomy as well as Hemosuccus Pancreaticus (in Acute and chronic pancreatitis) who underwent empirical coil embolization of splenic artery were included. Those who showed blush on CTA or conventional angiography and those who were managed primarily with surgery for PPH were excluded. The rebleeding and mortality rates were assessed at 72-hour and 30-days respectively. Results: There were 137 Pancreaticoduodenectomies, 68 Distal Pancreatectomies, 11 median pancreatectomies and 134 admissions for Acute pancreatitis/ exacerbation of Chronic pancreatitis during the period. Overall, 6/7 (85.7%) with negative CTA had successful coil embolization. No re-intervention/ continued bleed/ splenic infarcts/ no requirement of transfusion or abscess were seen in any of these six patients. Conclusion: Empirical coil embolization of splenic artery in pancreatic bleed holds promise as a salvage life-saving procedure.

Spanish multicenter study of surgical resection of pancreatic tumors infiltrating the celiac axis: does the type of pancreatectomy affect results?

Pancreatectomy plus celiac axis resection (CAR) is performed in patients with locally advanced pancreatic cancer. The morbidity rates are high, and no survival benefit has been confirmed. It is not known at present whether it is the type of pancreatectomy, or CAR itself, that is the reason for the high complication rates. Observational retrospective multicenter study. patient undergoing TP, PD or DP plus CAR for a pancreatic cancer. Sixty-two patients who had undergone pancreatic cancer surgery (PD,TP or DP) plus CAR were studied. Group 1: 17 patients who underwent PD/TP-CAR (13TP/4PD); group 2: 45 patients who underwent DP-CAR. Groups were mostly homogeneous. Operating time was longer in the PD/TP group, while operative complications did not differ statistically in the two groups. The number of lymph nodes removed was higher in the PD/TP group (26.5 vs 17.3), and this group also had a higher positive node ratio (17.9% vs 7.6%). There were no statistical differences in total or disease-free survival between the two groups. It seems that CAR, and not the type of pancreatectomy, influences morbidity and mortality in this type of surgery. International multicenter studies with larger numbers of patients are now needed to validate the data presented here.

En Bloc Celiac Axis Resection for Pancreatic Cancer: Classification of Anatomical Variants Based on Tumor Extent

En bloc celiac axis resection (CAR) for pancreatic cancer is considered increasingly after modern neoadjuvant chemotherapy (NAC). Appleby and distal pancreatectomy with CAR are anatomically inaccurate terms, as tumors can extend beyond celiac axis proper, requiring concurrent resection of the proper hepatic artery and/or superior mesenteric artery. A 3-level classification for CAR (class 1, 2, or 3) was developed after retrospective review of an arterial resection database describing anatomical variants that dictate pancreatectomy-type, formal arterial revascularization, and gastric preservation. Perioperative and oncologic outcomes were assessed. Of 90 CARs for pancreatic cancer, 89% patients received NAC, 35% requiring chemotherapeutic switch. There were 41 class 1, 33 class 2, and 16 class 3 CARs, with arterial and venous revascularization performed 62% and 66%, respectively. Ninety-day mortality decreased to 4% in the last 50 cases (p= 0.035); major morbidity was unchanged (55%). Any hepatic or gastric ischemia occurred in 20% and 10% patients, respectively, and arterial revascularization was protective. R0 resection rate (88%) was associated with chemoradiation (p= 0.004). Median overall survival was 36.2 months, superior with NAC (8.0 vs. 43.5 months). Predictors of survival after NAC included chemotherapy duration, carbohydrate antigen 19-9 response, pathologic response, and lymph node status. Major pathologic response (p= 0.036) and extended duration NAC (p= 0.007) were independent predictors on multivariate analysis. Current terminology for CAR inadequately describes all operative variants. Our classification, based on the largest single-center series, allows complex operative planning and standardized reporting across institutions. Extent of arterial involvement determines pancreatectomy type, need for arterial revascularization, and likelihood of gastric preservation. Operative mortality has improved, morbidity remains significant, and survival favorable after extended NAC with associated pathologic responses; given these factors, CAR should only be considered in fit patients with objective NAC responses at specialized centers.

Pancreatectomies Plus Celiac Trunk Resection: A Spanish Muticentre Study

Background: Total pancreatectomy (TP), pancreatoduodenectomy (PD) and distal pancreatectomy (DP) with celiac axis resection (CAR) are performed in patients with locally advanced pancreatic cancer. The morbidity and mortality rates of these procedures are very high and the real benefit in a better survival rates is not fully confirmed. Objective: measuring morbidity and mortality at 90 days, hospital stay and survival rates in patients in which we performed TP/PD and DP + CAR and comparing both groups Methods: Observational retrospective multicentre study. Inclusion criteria: patient operated from a pancreatic cancer performing TP, PD or DP plus CAR in Spanish Surgical Departments. Data collection was closed 31 March 2018. Several preoperative, intraoperative and postoperative data were studied (Table 1). Complications were measured with Clavien classification at 90 days. Specific pancreatic complications were measured using ISGPS classifications. Chi-square or Student’s t tests were used to compare categorical or continuous variables, respectively. Kaplan–Meier estimator was used to calculate overall survival and survival differences were compared with the log-rank test. Data were analyzed using R version 3.1.3 (http://www.r-project.org). Level of significance was set at 0.05. Results: Table 1 shows the Results of the whole series (62 patients), the PD+TP (17) and DP group (45). Both groups were homogeneous. Operative time was longer in TP/PD group. Series morbidity was 84,9%, major morbidity (>IIIA) was 45.2 % and mortality 17.7%. Comparing morbidity and mortality of both groups, we did not find statistical differences. Series survival at 2 years is 40% but disease free survival is 0%. No statistical difference related to survival between both groups was found. Conclusion: CAR combined with pancreatectomy is a surgical procedure with high morbidity and mortality. In our series, 2-year survival is 40% but disease free survival is 0% Type of pancreatectomy is not related with survival, morbidity and mortality.Tabled 1Table 1.

The short-term outcomes of primary tumor resection with synchronous metastases from pancreas neuroendocrine tumors: an analysis of the ACS-NSQIP registry

Background: The incidence of pancreatic neuroendocrine tumors (PNET) is rising worldwide, with many patients developing metastatic disease. Resection of the primary tumor despite of unresectable metastases is suggested to improve long-term oncologic outcomes. Assessments of the morbidity of this approach are scarce and limited to small, single-institutional studies. We sought to determine the patient characteristics and short-term outcomes of pancreatectomy for metastatic (M1) PNET, and compare them to non-metastatic (M0) PNET. The comparison was undertaken to provide a reference with which providers are familiar – i.e. outcomes of pancreatectomy for M0 disease, to better appreciate the burden of complications with M1. Methods: We conducted a retrospective cohort study using the ACS-NSQIP targeted pancreatectomy registry. We included all adults undergoing pancreatectomy for PNET between 2014-2016, with complete staging information. M1 and M0 PNET groups were created. Primary outcomes were 30-day major morbidity, mortality, and prolonged length of stay (>75th percentile). The characteristics and outcomes of M1 and M0 groups were compared using Pearson Chi square, Fisher exact test, and Student t test, as appropriate. A propensity score was created with the following potential confounders defined a priori: age, sex, body mass index, ASA classification, T and N stage, surgical procedure, open approach, and functional histology. The association between M1 and outcomes was adjusted for the propensity score using logistic binomial regression. Results: Of 1,381 included patients, 148 (12%) had M1 disease. Patients with M1 were more likely to be younger, have lower hematocrit, higher ASA class, lower body mass index, and have pre-operative weight loss, than M0 patients (all p < 0.05). T1/2 (75.7% vs. 28.8%, p < 0.01), node positive (72.3% vs. 25.9%, p < 0.01), and functional (29.7% vs. 22.1%, p = 0.04) tumors were more common in the M1 group. There were no differences in the type of pancreatectomy (distal pancreatectomy 60.1% Vs. 57.3%, p = 0.46), but there were more open resections (78.4% vs. 55.5%, p < 0.01) and longer median operating time (322.5 vs. 261 minutes, p < 0.01) for M1. No significant difference was detected in overall 30-day major morbidity (38.5% vs. 39.7%, p = 0.77) and mortality (2.7% vs. 1.0%, p = 0.06) between groups. Prolonged length of stay was more common with M1 (35.1% vs. 25.8%, p = 0.01). Adjusted regression analysis revealed no independent association between M1 and 30-day morbidity (relative risk 0.90, 95% confidence interval: 0.71–1.14), or prolonged length of stay (relative risk 2.89, 95% confidence interval: 0.78–10.7). Regression was not conducted on mortality due to too few events. Conclusion: In a multi-institutional analysis of prospectively collected data, resection of the primary tumor for M1 PNET was not associated with different post-operative morbidity and mortality than for M0 disease. The knowledge of short-term outcomes provided herein is important to weigh perioperative risks against the potential benefits of PNET primary tumor resection in the setting of M1 disease. This can support both decision-making and patient counselling.

Utilization of end to side Inverted Mattress Pancreaticojejunostomy after three different type of pancreatectomy

Introduction: The continuity of pancreatic duct should be established after partial pancreatectomy such as pancreaticoduodenectomy and central pancreatectomy. It is also required after distal pancreatectomy if the drainage of pancreatic juice is impaired like Duval procedure. However pancreaticojejunostomy after any type of partial pancreatectomy accompany considerable risk of seriously life threatening complication such as grade B and C POPF despite various techniques of pancreaticojejunostomy (PJ) were devised to minimize the rate of POPF. Method: We presented a modification of Mattress PJ named “Inverted Mattress PJ” and published improved outcome after pancreaticoduodenectomy and central pancreatectomy in the aspects of POPF. Additionally, we present the utilization of Inverted Mattress PJ to establish the continuity of pancreatic duct after distal pancreatectomy. Result: Usually, PJ is not required after distal pancreatectomy because pancreatic juice can be drained through ampulla of Vater. However in particular condition in which the drainage of pancreatic juice through proximal duct is impaired by stricture, or stone etc, the distal pancreatic duct need to be drained. In such a case of IPMN of distal pancreas with proximal pancreatic duct obstruction, we performed distal pancreatectomy and pancreaticojejunostomy utilizing Inverted Mattress PJ. The patient was discharged 1 week after surgery without complications. Conclusion: In conclusion, the inverted mattress end-to-side pancreaticojejunostomy is a safe technique after pancreaticoduodenectomy and volume sparing central pancreatectomy and also can be utilized in particular condition after distal pancreatectomy safely.

Outcome of minimally-invasive versus open pancreatectomies for solid pseudopapillary neoplasms of the pancreas: A 2:1 matched case-control study.

Backgrounds/AimsSolid pseudopapillary neoplasm (SPPN) is typically seen in young healthy females who would likely benefit from minimally-invasive pancreatectomy (MIP). A few comparative studies have suggested that MIP is associated with favorable outcomes when compared to the open approach for SPPN. This study aims to mitigate potential selection bias by performing a matched case-control study comparing MIP vs open pancreatectomy (OP) for SPPN.MethodsWe performed a single-institution retrospective electronic chart review of all patients who underwent surgery for pathologically confirmed SPPN between 2000 and 2017. A 2:1 matched comparison using age, gender, tumor size and the type of pancreatectomy was performed between OP and MIP.ResultsA total of 40 patients with a median age of 40.3 years (range 16.5–64.4) and female sex predominance (n=34, 85.0%) underwent surgery during the study period. Nine patients underwent MIP. Matched comparison between 18 OP and 9 MIP demonstrated that MIP was associated with a longer median operating time (305 vs 180 min, p=0.046) and shorter median postoperative stay (6 vs 9 days, p=0.015). There were no significant differences in intraoperative blood loss, blood transfusion requirements, postoperative morbidity (including postoperative pancreatic fistula) and mortality, resection margins, lymph node yield and long-term survival.ConclusionsMIP is a safe and viable option in the management of SPPN with the benefit of a shorter postoperative length of stay at the expense of a longer operation time. There was no significant difference in oncologic outcomes between both groups of patients.

Outcome of minimally-invasive versus open pancreatectomies for solid pseudopapillary neoplasms of the pancreas: a 2:1 matched case-control study

Introduction: Solid pseudopapillary neoplasms (SPPN) is typically seen in young healthy females who would likely benefit from minimally-invasive pancreatectomy (MIP). A few comparative studies have suggested that MIP is associated with favorable outcomes when compared to the open approach for SPPN. This study aims to mitigate potential selection bias by performing a matched case-control study comparing MIP vs open pancreatectomy (OP) for SPPN. Method: We performed a single-institution retrospective electronic chart review of all patients who underwent surgery for pathologically confirmed SPPN between 2000 to 2017. A 2:1 matched comparison using age, gender, tumor size and the type of pancreatectomy was performed between OP and MIP. Result: A total of 40 patients with a median age of 40.3 years (range 16.5-64.4) and female sex predominance (n=34, 85.0%) underwent surgery during the study period. Nine patients underwent MIP. Matched comparison between 18 OP and 9 MIP demonstrated that MIP was associated with a longer median operating time (305 vs 180 min, p=0.046) and shorter median postoperative stay (6 vs 9 days, p=0.015). There were no significant differences in intraoperative blood loss, blood transfusion requirements, postoperative morbidity (including postoperative pancreatic fistula) and mortality, resection margins, lymph node yield and long-term survival. Conclusion: MIP is a safe and viable option in the management of SPPN with the benefit of a shorter postoperative length of stay at the expense of a longer operation time. There was no significant difference in oncologic outcomes between both groups of patients.

Indication for en bloc pancreatectomy with colectomy: when is it safe?

Aggressive en bloc resection of adjacent organs is often necessary to resect pancreatic or colonic lesions. However, it is debated whether simultaneous pancreatectomy with colectomy (P+C) is warranted as it potentially increases morbidity and mortality (MM). We hypothesized that MM would be increased in P+C, especially in cases of pancreatitis. All patients who underwent pancreatectomy (P) and simultaneous pancreatectomy with colectomy (P+C) at a high-volume center from November 2006 to 2015 were prospectively collected using ACS-NSQIP at our institution. Patients with additional multivisceral or enucleation procedures were excluded. Data were augmented to 90-day outcomes using our institutional database. Forty-three patients with a mean age of 62years (27:16 male: female) underwent P+C, accounting for 2.39% (43/1797) of pancreatectomies performed. Pancreatoduodenectomy (PD) was performed in 61% (n=26), distal pancreatectomy (DP) in 37% (n=16), and total pancreatectomy (TP) in 2% (n=1) of patients. The 30- and 90-day MM were higher in P+C than P (30-day: 54 vs. 37%, p=0.037 and 9 vs. 2%, p=0.022; 90-day: 61 vs. 42%, p=0.019 and 14 vs. 3%, p=0.002). Logistical regression modeling revealed an association between 90-day mortality and colectomy (p=0.013, OR=3.556). When P+C MM were analyzed according to intraoperative factors, there was no significant difference according to type of pancreatectomy (PD vs. DP vs. TP), origin of primary lesion (pancreas vs. colon), surgical indication (malignant vs. non-malignant), or case status (planned colectomy vs. intraoperative decision). Addition of colectomy to pancreatectomy substantially increased MM. Subanalysis revealed that type of resection performed, etiology, and planning status did not account for increased risk when performing P+C. However, colectomy was found to be an independent risk factor for mortality. Therefore, patients should be informed of the risk of increased postoperative complications until a further study can identify potential patients or perioperative factors that can be used for risk stratification.

External radiation is associated with limited improvement in overall survival in resected margin-negative stage IIB pancreatic adenocarcinoma

The absolute benefit of adjuvant external beam radiation therapy after a margin-negative resection in early stage pancreatic cancer has not been determined. We queried the National Cancer Data Base for patients with pathologic stage I-II pancreatic adenocarcinoma who underwent operative resection between 2004 and 2012. Multivariate Cox regression adjusted for age, race, comorbidities, facility type, location and volume, type of pancreatectomy, and tumor grade was used to estimate stage-specific survival. A total of 15,966 patients with stage I-II pancreatic adenocarcinoma underwent upfront operative therapy (no neoadjuvant treatment) and had a margin-negative resection during the study period. A total of 835 (5.2%) patients were pathologic stage IA, 1,539 (9.5%) were stage IB, 3,378 (20.9%) were stage IIA, and 10,214 (63.1%) were stage IIB. Chemoradiation utilization increased with increasing stage (22.8% in stage IA vs 39.6% in stage IIB, P<.01). Chemoradiation was more common at low-volume centers (39.0% vs 31.7% at high-volume centers, P<.01) and with younger age (43.3% of patients <70years old compared to 25.0%≥70years old, P<.01). Treatment at a high-volume center was associated with decreased mortality (hazard ratio 0.80-0.89) across all stages. Age ≥70years old (hazard ratio 1.18-1.29, P<.01) and higher grade (hazard ratio 1.68-2.69, P<.01) were associated with higher risk of mortality at all stages. Chemoradiation was associated with a benefit in median overall survival over chemotherapy alone for stage IIB disease (21.8months vs 19.5months, P<.01). Chemoradiation was not associated with a significant benefit in median overall survival for stage IA, IB, or IIA disease (P>.30). Addition of radiation to adjuvant chemotherapy after margin-negative resection of pancreatic adenocarcinoma is associated with a limited survival benefit in patients with pathologic stage IIB disease and should be weighed against its associated risks in these patient groups.

Frailty predicts risk of life-threatening complications and mortality after pancreatic resections

To assess the effect of frailty on morbidity and mortality after partial pancreatectomy. A retrospective analysis of National Surgical Quality Improvement Project from 2005-2010 was conducted. A modified frailty index was created based on previously validated methodology. Patients were classified as nonfrail, low frailty, intermediate frailty, and frail. Outcomes of pancreatoduodenectomy and distal pancreatectomy were examined. In the study, 13,020 patients were analyzed (8,729 pancreatoduodenectomy and 4,291 distal pancreatectomy). Among the pancreatoduodenectomy and distal pancreatectomy patients, frail patients regardless of the degree of frailty were older, more likely male, had a greater body mass index, lower serum albumin, and greater weight loss compared with the nonfrail patients (all P≤.05). Postoperatively, a stepwise increased risk of grade 4 complications (Clavien/Dindo) and mortality was noted from nonfrail to frail patients. Every 1-point increase in modified frailty index was associated with a significantly increased risk of grade 4 complications (∼2-6 times) and mortality (∼2-10 times) from low-frail to frail(adjusted for age, sex, body mass index, albumin, weight loss, and type of pancreatectomy). An abbreviated frailty index incorporating 8 variables was as predictive as the modified frailty index (P=.68). An 11-point frailty index as measured in National Surgical Quality Improvement Project predicts serious complications and death after pancreatectomy. A modification of this index with 8 factors continues to have similar predictive ability. Consideration of frailty may be beneficial prior to the pancreatic surgeon and particularly in discussion of operative risk and selection of patients who might receive benefit from pre-operative optimization.

Metabolic Syndrome is Associated with Increased Postoperative Morbidity and Hospital Resource Utilization in Patients Undergoing Elective Pancreatectomy

PurposeIn patients undergoing elective partial pancreatectomy, our aim was to evaluate the effect of metabolic syndrome (MS) on postoperative mortality, morbidity, and utilization of hospital resources. Our hypothesis was that MS is associated with worse surgical outcomes after pancreatectomy. MethodsFifteen thousand eight hundred thirty-one patients undergoing elective pancreatectomy from 2005 to 2012 were identified in the Participant User File of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Univariable and multivariable analyses were performed examining the association of MS (defined as body mass index ≥30 kg/m2, hypertension requiring medications, and diabetes requiring medications and/or insulin) and risk of 30-day mortality, morbidity, and utilization of hospital resources (risk of blood transfusion in the first 72 h after pancreatectomy and prolonged hospital stay, defined as ≥13 days, which was the 75th percentile of this cohort). Multivariable logistic regression models controlled for age, sex, race, pancreatectomy type (distal versus proximal), smoking status, alcohol consumption, functional status, dyspnea, cardiovascular disease, hematocrit, INR, serum albumin, bilirubin, and creatinine. Stratified analyses were conducted by type of pancreatectomy and indication for pancreatectomy (benign versus malignant). ResultsOn univariate analysis, 1070 (6.8 %) patients had MS. MS was associated with increased postoperative morbidity, major morbidity, surgical site infection, septic shock, cardiac event, respiratory failure, pulmonary embolism, blood transfusion, and prolonged duration of hospital stay (P < 0.05 for all analyses). After controlling for potentially confounding variables, there was a 26 % increased odds of postoperative morbidity (P < 0.001), 17 % increased odds of major morbidity (P = 0.034), 32 % increased odds of surgical site infection (P < 0.001), 34 % increased odds of respiratory failure (P = 0.023), 68 % increased odds of pulmonary embolism (P = 0.045), 26 % increased odds of blood transfusion (P = 0.018), and 21 % increased odds of prolonged hospital stay (P = 0.011) in patients with MS compared to patients without MS. MS was not associated with 30-day mortality after elective pancreatectomy (P = 0.465). When stratified by distal versus proximal pancreatectomy and benign versus malignant disease, the effect of MS on outcomes appears to be modified by type of pancreatectomy and indication with poorer outcomes observed for distal pancreatectomies and benign indications for resection. ConclusionMS is an under-emphasized predictor of increased postoperative morbidity and utilization of hospital resources in patients undergoing elective pancreatectomy. The effect of MS on these postoperative outcomes appears to be more pronounced for patients with benign rather than malignant indications for pancreatectomy and in patients undergoing distal rather than proximal pancreatectomy. These results may inform patient selection, optimization of comorbidities prior to elective pancreatectomy, and strategies for postoperative management.

Pancreatectomy with vein reconstruction: technique matters

BackgroundA variety of techniques have been described for portal vein (PV) and/or superior mesenteric vein (SMV) resection/reconstruction during a pancreatectomy. The ideal strategy remains unclear. MethodsPatients who underwent PV/SMV resection/reconstruction during a pancreatectomy from 2005 to 2014 were identified. Medical records and imaging were retrospectively reviewed for operative details and outcomes, with particular emphasis on patency. ResultsNinety patients underwent vein resection/reconstruction with one of five techniques: (i) longitudinal venorrhaphy (LV, n = 17); (ii) transverse venorrhaphy (TV,n = 9); (iii) primary end‐to‐end (n = 28); (iv) patch venoplasty (PV, n = 17); and (v) interposition graft (IG, n = 19). With a median follow‐up of 316 days, thrombosis was observed in 16/90 (18%). The rate of thrombosis varied according to technique. All patients with primary end‐to‐end or TV remained patent. LV, PV and IG were all associated with significant rates of thrombosis (P = 0.001 versus no thrombosis). Comparing thrombosed to patent, there were no differences with respect to pancreatectomy type, pre‐operative knowledge of vein involvement and neoadjuvant therapy. Prophylactic aspirin was used in 69% of the total cohort (66% of patent, 81% of thrombosed) and showed no protective benefit. ConclusionsPrimary end‐to‐end and TV have superior patency than the alternatives after PV/SMV resection and should be the preferred techniques for short (<3 cm) reconstructions.

Perioperative mortality after pancreatectomy: A risk score to aid decision-making

Undergoing a pancreatectomy obligates the patient to risks and benefits. For complex operations such as pancreatectomy, the objective assessment of baseline risks may be useful in decision-making. We developed an integer-based risk score estimating in-hospital mortality after pancreatectomy, incorporating institution-specific mortality rates to enhance its use. Pancreatic resections were identified from the Nationwide Inpatient Sample (1998-2006), and categorized as proximal, distal, or nonspecified by the International Classification of Diseases, 9th edition. Logistic regression and bootstrap methods were used to estimate in-hospital mortality using demographics, diagnosis, comorbidities (Charlson index), procedure, and hospital volume; 80% of this cohort was selected randomly to create the score and 20% was used for validation. Score assignments were subsequently individually fitted to risk distributions around specific mortality rates. Sixteen thousand one hundred sixteen patient discharges were identified. Nationwide in-hospital mortality was 5.3%. Integers were assigned to predictors (age group, Charlson index, sex, diagnosis, pancreatectomy type, and hospital volume) and applied to an additive score. Three score groups were defined to stratify in-hospital mortality (national mortality, 1.3%, 4.9%, and 14.3%; P < .0001), with sufficient discrimination of derivation and validation sets (C statistics, 0.72 and 0.74). Score groups were shifted algorithmically to calculate risk based on institutional data (eg, with institutional mortality of 2.0%, low-, medium-, and high-risk patient groups had 0.5%, 1.9%, and 5.4% mortality, respectively). A web-based tool was developed and is available online (http://www.umassmed.edu/surgery/panc_mortality_custom.aspx). To maximize patient benefit, objective assessment of risk for major procedures is necessary. We developed a Surgical Outcomes Analysis and Research risk score predicting pancreatectomy mortality that combines national and institution-specific data to enhance decision-making. This type of risk stratification tool may identify opportunities to improve care for patients undergoing specific operative procedures.

A Simple Risk Score to Predict In-Hospital Mortality After Pancreatic Resection for Cancer

Pancreatectomy for cancer continues to have substantial perioperative risk, and the factors affecting mortality are ill defined. An integer-based risk score based on national data might help clarify the risk of in-hospital mortality in patients undergoing pancreatic resection. Records with the diagnosis of pancreatic cancer were queried from the Nationwide Inpatient Sample for 1998-2006. Procedures were categorized as proximal, distal, or nonspecified pancreatectomies on the basis of ICD-9 codes. Logistic regression and bootstrap methods were used to create an integer risk score for estimating the risk of in-hospital mortality using patient demographics, comorbidities (Charlson comorbidity score), procedure, and hospital type. A random sample of 80% of the cohort was used to create the risk score with a 20% internal validation set. A total of 5715 patient discharges were identified. Composite in-hospital mortality was 5.8%. Predictors used for the final model were age group, Charlson score, sex, type of pancreatectomy, and hospital volume status (low-, medium-, or high-volume center). Integer values were assigned to these characteristics and then used for calculating an additive score. Three clinically useful score groups were defined to stratify the risk of in-hospital mortality (mortality was 2.0, 6.2, and 13.9%, respectively; P < 0.0001), with a 6.95-fold difference between the low- and high-risk groups. There was sufficient discrimination of both the derivation set and the validation set, with c statistics of 0.71 and 0.72, respectively. An integer-based risk score can be used to accurately predict in-hospital mortality after pancreatectomy and may be useful for preoperative risk stratification and patient counseling.