Type Of Pancreatic Resection Research Articles

An evidence-based model for predicting conversion to open surgery in minimally invasive distal pancreatectomy

BackgroundIntraoperative conversion to open surgery is an adverse event during minimally invasive distal pancreatectomy (MIDP), associated with poor postoperative outcomes. The aim of this study was to develop a model capable of predicting conversion in patients undergoing MIDP.MethodsA total of 352 patients who underwent MIPD were included in this retrospective analysis and randomly assigned to training and validation cohorts. Potential risk factors related to open conversion were identified through a literature review, and data on these factors in our cohort was collected accordingly. In the training cohort, multivariate logistic regression analysis was performed to adjust the impact of confounding factors to identify independent risk factors for model building. The constructed model was evaluated using the receiver operating characteristics curve, decision curve analysis (DCA), and calibration curves.ResultsFollowing an extensive literature review, a total of ten preoperative risk factors were identified, including sex, BMI, albumin, smoker, size of lesion, tumor close to major vessels, type of pancreatic resection, surgical approach, MIDP experience, and suspicion of malignancy. Multivariate analysis revealed that sex, tumor close to major vessels, suspicion of malignancy, type of pancreatic resection (subtotal pancreatectomy or left pancreatectomy), and MIDP experience persisted as significant predictors for conversion to open surgery during MIDP. The constructed model offered superior discrimination ability compared to the existing model (area under the curve, training cohort: 0.921 vs. 0.757, P < 0.001; validation cohort: 0.834 vs. 0.716, P = 0.018). The DCA and the calibration curves revealed the clinical usefulness of the nomogram and a good consistency between the predicted and observed values.ConclusionThe evidence-based prediction model developed in this study outperformed the previous model in predicting conversions of MIDP. This model could contribute to decision-making processes surrounding the selection of surgical approaches and facilitate patient counseling on the conversion risk of MIDP.Graphical abstract

Prognostic factors of postoperative morbidity in surgery for resectable pancreatic cancer. Regional institute of neoplastic diseases 'Dr. Luis Pinillos Ganoza' IREN Norte. 2007-2022.

To determine the prognostic factors associated with postoperative morbidity for resectable pancreatic cancer at the Instituto Regional de Enfermedades Neoplásicas del Norte 'Dr. Luis Pinillos Ganoza' - IREN Norte. 2007-2022. A study was conducted with a case-based (22 patients) and control (14 patients) design nested in a cohort that included 36 patients who underwent proximal duodenopancreatectomy (Whipple) or distal pancreatectomy for pancreatic cancer. In the present study, it was found that the total number of living patients represents 86.1% of the total (36 patients). Of the total population, patients who presented only 1 complication were 13.6% and more than 1 complication were 86.4%. It was also found that the most frequent complication in the general population was gastric emptying syndrome, which was present in 50% of all patients. In the bivariate analysis, a highly significant association was observed between the low prognostic nutritional index (p < 0.001, OD = 20.400, CI = 95%: (3.377-123.245)), the type of pancreatic resection (p < 0.001, OR = 52.500, CI = 95%: (5.174-532.669)) and postoperative morbidity. In contrast, no significant association was found between age ≥65 (p = 0.062), diabetes mellitus (p < 0.908), Wirsung diameter (p < 0.432), hospital stay (p < 0.075) and postoperative morbidity. In the multivariate analysis, serum total bilirubin level ≥20 μmol/L (p = 0.778), use of preoperative biliary drainage (p = 0.176), type of pancreatojejunal anastomosis (p = 0.533) and pancreaticogastric anastomosis (p = 0.504) were not statistically significantly associated with postoperative morbidity. The type of pancreatic resection and the nutritional prognostic index <40.5 are prognostic factors of postoperative morbidity in postoperative patients for resectable pancreatic cancer.

Comparison of postoperative pancreatic insufficiency among different types of pancreatic resection

Comparison of postoperative pancreatic insufficiency among different types of pancreatic resection

Predictors of In-Hospital Mortality Following Pancreatectomy.

In-hospital mortality rates following all types of pancreatic resections (PRs) have decreased over recent decades. Our aim was to identify predictors of in-hospital mortality following pancreatic resection. All patients undergoing pancreatic resection were sampled from the National Inpatient Sample (NIS) in the years 2007-2012. Predictors of in-hospital mortality were identified and incorporated into a binary logistic regression model. A total of 111,568 patients underwent pancreatectomy. Annual mortality rates decreased from 4.3% in 2007 to 3.5% in 2012. Independent predictors of in-hospital mortality included age ≥75 years (vs. <65 years, OR = 2.04; 95% CI: 1.61-2.58), nonelective procedure status (OR = 1.46; 95% CI: 1.19-1.80), resection other than distal pancreatic resection (vs. Whipple, OR = 2.14; 95% CI: 1.71-2.69; other partial, OR = 2.48; 95% CI: 1.76-3.48), lower hospital volume (OR = 1.28; 95% CI: 1.09-1.49), indication for pancreatic resection other than benign diseases (vs. malignant, OR = 1.63; 95% CI: 1.25-2.15; other, OR = 2.48; 95% CI: 1.76-3.48), pulmonary complications (OR = 12.36; 95% CI: 10.11-15.17), infectious complications (OR = 2.17; 95% CI: 1.78-2.64), noninfectious wound complications and pancreatic leak (OR = 1.94; 95% CI: 1.53-2.46), and acute myocardial infarction (OR = 2.03; 95% CI: 1.32-3.06). Our findings identify predictors of inpatient mortality following pancreatectomy, with pulmonary complications representing the single most significant factor for increased mortality. These findings complement and expand on previously published data and, if applied to perioperative care, may enhance survival following pancreatectomy.

Robotic versus open pancreatic surgery: a propensity score-matched cost-effectiveness analysis

BackgroundRobotic pancreatic surgery (RPS) is associated with high intraoperative costs compared to open pancreatic surgery (OPS). However, it remains unclear whether several advantages of RPS such as reduced surgical trauma and a shorter postoperative recovery time could lead to a reduction in total costs outweighing the intraoperative costs. The study aimed to compare patients undergoing OPS and RPS with regards to cost-effectiveness in a propensity score-matched (PSM) analysis.MethodsPatients undergoing OPS and RPS between 2017 and 2019 were included in this monocentric, retrospective analysis. The controlling department provided financial data (costs and revenues, net loss/profit). A propensity score-matched analysis was performed or OPS and RPS (matching criteria: age, American society of anesthesiologists (ASA) score, gender, body mass index (BMI), and type of pancreatic resection) with a caliper 0.2.ResultsIn total, 272 eligible OPS cases were identified, of which 252 met all inclusion criteria and were thus included in the further analysis. The RPS group contained 92 patients. The matched cohorts contained 41 patients in each group. Length of hospital stay (LOS) was significantly shorter in the RPS group (12 vs. 19 days, p = 0.003). Major postoperative morbidity (Dindo/Clavien ≥ 3a) and 90-day mortality did not differ significantly between OPS and RPS (p > 0.05). Intraoperative costs were significantly higher in the RPS group than in the OPS group (7334€ vs. 5115€, p < 0.001). This was, however, balanced by other financial categories. The overall cost-effectiveness tended to be better when comparing RPS to OPS (net profit—RPS: 57€ vs. OPS: − 2894€, p = 0.328). Binary logistic regression analysis revealed major postoperative complications, longer hospital stay, and ASA scores < 3 were linked to the risk of net loss (i.e., costs > revenue).ConclusionsSurgical outcomes of RPS were similar to those of OPS. Higher intraoperative costs of RPS are outweighed by advantages in other categories of cost-effectiveness such as decreased lengths of hospital stay.

Feasibility of robotic-assisted pancreatic resection in patients with previous minor abdominal surgeries: a single-center experience of the first three years

BackgroundRobotic-assisted pancreatic surgery is limited to specialized high-volume centers and selected patient cohorts. Especially for patients with a history of previous abdominal surgeries, the standard procedure remains open surgery due to the fear of complications caused by abdominal adhesions.MethodsClinical data of all consecutive patients undergoing robotic-assisted pancreatic surgery using the daVinci Xi system (Intuitive Surgical) at our center (Department of Surgery, Universitätsmedizin Berlin, Germany) were collected prospectively and further analyzed from October 2017 to October 2020. Prior abdominal surgeries were specified according to the surgical approach and localization. In univariate and multivariate analysis, baseline and perioperative parameters of patients with a history of prior abdominal surgeries (PS) were compared to those of patients with no history of prior abdominal surgeries (NPS).ResultsOut of 131 patients undergoing robotic-assisted pancreatic surgery, 62 (47%) had a history of abdominal surgery. Previous procedures included most often appendectomy (32%) followed by gynecological surgery (29%) and cholecystectomy (27%). 24% of PS had received multiple surgeries prior to the robotic-assisted pancreatic resections. Baseline characteristics and comorbidities were comparable between the groups. We did not detect differences in the duration of surgery (262 min), conversion rates (10%), and postoperative complications between NPS and PS. Postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), and in-house mortality showed no significant differences between the two groups. Multivariate analysis revealed male sex and high BMI as a potential predictive factor for severe postoperative complications. Other characteristics like the type of pancreatic resection, ASA, and underlying malignancy showed no difference in the multivariable analysis.ConclusionsWe propose robotic-assisted pancreatic surgery to be safe and feasible for patients with a history of minor prior abdominal surgery. Hence, each patient should individually be evaluated for a minimally invasive approach regardless of a history of previous operations.

Evaluation of Postoperative Quality of Life After Pancreatic Surgery and Determination of Influencing Risk Factors.

The postoperative quality of life (QoL) after pancreatic surgery is frequently impaired. The aim of this study was to evaluate the QoL after pancreatic surgery and its influencing risk factors. Furthermore, an age-adjusted comparison with the normal population of Germany was performed. A total of 94 patients were surveyed. The Short Form-36 questionnaire was sent to all patients undergoing pancreatic surgery between 2013 and 2017. All pathologies and types of pancreatic resections were included. Statistical analyses were performed, and an analysis by the Robert Koch-Institute to determine the health-related age-adjusted QoL in Germany served as control group. Response rate was 29%. Median time of survey was 28 months. As compared with a normative population, QoL after pancreaticoduodenectomy was significantly impaired. Distal pancreatic resection showed no significant differences. Univariate and Lasso analyses showed that the following factors had a negative impact: coronary artery disease, chronic pancreatitis, and open access. Postoperative enzyme supplementation seemed to have a positive impact. Pancreatic surgery leads to long-lasting negative effect on QoL. Distal pancreatic resections and laparoscopic access seemed to be the best tolerated. Complications seems to have less impact, whereas maintaining exocrine and endocrine function seems to have a positive effect.

Do somatostatin-analogues have the same impact on postoperative morbidity and pancreatic fistula in patients after pancreaticoduodenectomy and distal pancreatectomy? – A systematic review with meta-analysis of randomized-controlled trials

ObjectivePostoperative pancreatic fistula/POPF is the most feared complication in pancreatic surgery. Although several systematic reviews investigated the impact of somatostatin analogues on POPF, no stratification was performed regarding type of pancreatic resection (pancreaticoduodenectomy/PD; distal pancreatectomy/DP) and different somatostatin analogues. MethodsThis study was planed according to the Preferred-Reporting-Items-for-Systematic –Review-and-Meta-Analysis/PRISMA-guidelines. After screening databases for randomized controlled trials/RCT, studies were stratified into pancreatic resection techniques and data were pooled in meta-analyses containing subgroups of octreotide, somatostatin, lanreotide, pasireotide and vapreotide. ResultsThe meta-analysis of studies with a mixed cohort of patients after pancreatic resection revealed a protective effect of somatostatin analogues for morbidity (RR: 0.71, p < .00001) but not for mortality (RR: 1.07, = 0.78) or intra-abdominal abscesses (RR: 1.00, p = 1.00). Moreover, no effect was visible for mortality (RR: 1.57, p = .15), morbidity (RR: 0.87, p = .15) and intra-abdominal abscesses (RR: 0.92, p = .48) after PD. The meta-analysis of patients after PD revealed no impact of somatostatin analogues on POPF (RR: 0.87, p = .19) and clinically relevant POPF (RR: 0.69, p = .30). However, treatment with somatostatin analogues in the mixed cohort showed less POPF (RR: 0.60, p < .00001) and clinically relevant POPF (RR: 0.47, p = .02), which was also the case after DP (RR: 0.41, p = .03). ConclusionSomatostatin analogues did not affect POPF and clinically relevant POPF after PD, but seemed to be associated with less POPF after DP. As no sufficiently powered RCT could be identified by the systematic review, further RCTs are urgently needed to investigate the effect of somatostatin analogues after DP. Study registrationCRD42018099808.

Impact of the COVID-19 pandemic on pancreatic surgery. Analysis in a public and a private institution

ABSTRACT Background: The COVID-19 pandemic has introduced dramatic changes in the health system. Elective surgeries are the surgical activities with greater decline during the pandemic. Objective: The aim of this paper is to analyze the impact of the COVID-19 pandemic in pancreatic surgery in a public and a private institution. The number of surgeries performed in each institution was compared with those performed in same period of the previous year. Material and methods: Data from a prospective database of all the patients who underwent pancreatic surgery between March 10, 2020, and June 3, 2020, were analyzed. The epidemiological data, type of pancreatic resection, pathology diagnosis, morbidity and mortality were determined in each institution and compared with patients who underwent pancreatic surgery in both institutions between March 3, 2019, and June 24, 2019. Results: 23 pancreatic resections were performed during the pandemic (13 cephalic pancreaticoduodenectomies, 9 left pancreatectomies and 1 total pancreatectomy); 70% (16/23) were adenocarcinomas. There were 34.7% complications and no deaths were reported. None of the patients was infected with coronavirus. The pandemic had no impact on the number of pancreatic resections in the private institution (22 vs. 20, p = 0.88), while the number of pancreatic surgeries was significantly lower in the public center (14 vs. 3, p = 0.009). Conclusion: Pancreatic surgery can be safely performed during the pandemic. The number of pancreatic surgeries did not decline during the pandemic. The priority for treating patients with COVID-19 at the public center resulted in a significant decrease in pancreatic surgeries. Keywords: pandemic, COVID 19, surgery, pancreas, pancreatic surgery, private center, public center, pancreaticoduodenectomy, left pancreatectomy.

Innovations in pancreatic anastomosis technique during pancreatoduodenectomies

PurposePancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem.MethodsA total of 130 patients (63 men, 67 women) with a mean age of 60 (range: 23–81) years were operated on between January 2013 and March 2020. The most frequent type of pancreatic resection was a Whipple procedure with partial antrectomy. During all operations, an innovative method was used, namely a modification of the purse-string suture pancreatojejunostomy. Moreover, an early drain removal policy was applied, based on the drain amylase level on the first and subsequent postoperative days.ResultsMean postoperative hospital stay was 13 days (range: 7–75). The overall morbidity rate was 43.8%; the clinically relevant (grade B/C) pancreatic fistula (CR-POPF) rate was 6.9%. Delayed gastric emptying (DGE) was observed in 4% of the patients. The ratio of operative mortality was 0.7%; the reoperation rate was 5.3%. Based on the drain amylase level on the first postoperative day, two groups could be established. In the first one, the drain was removed early, on the fourth day in average (range: 2–6). In the other group, the drain was left in situ protractedly or reinserted later on.ConclusionA single center’s experience proves that the refinement of the technique can improve the results of pancreatic surgery.

Risk factors for development of diabetes mellitus (Type 3c) after partial pancreatectomy: A systematic review.

Type 3c diabetes mellitus (T3cDM) occurring post pancreatectomy can be challenging to treat due to the frequent combination of decreased circulating levels of insulin and glucagon and concurrent exocrine insufficiency. Relatively, little is known regarding the risk factors for development of T3cDM post pancreatectomy. Our aim was to review the literature and assess what is known of the risk factors for the development of new-onset DM following partial pancreatic resection and where possible determines the incidence, time of onset and the management approach to hyperglycaemia in this context. Medline and Embase databases were reviewed using specific keyword criteria. Original manuscripts published in 1990 or later included. Articles with study population <20, lacking information on new-onset DM, follow-up duration or specifically targeting rare procedures/pathology were excluded. The Newcastle Ottawa Quality Assessment form was applied. Results reported according to PRISMA guidelines. Pooled effect size calculated using random effects model. Thirty six articles were identified that described a total of 5636 patients undergoing pancreaticoduodenectomy, 3922 patients having distal pancreatectomy and 315 with central pancreatectomy. The incidence of new-onset DM was significantly different between different types of resection from 9% to 24% after pancreaticoduodenectomy (pooled estimate 16%; 95% CI: 14%-17%), 3%-40% after distal pancreatectomy (pooled estimate 21%; 95% CI: 16%-25%) and 0%-14% after central pancreatectomy (pooled estimate 6%; 95% CI: 3%-9%). Surgical site, higher preoperative HbA1c, fasting plasma glucose and lower remnant pancreatic volume had strongest associations with new-onset DM. This systematic review supports that risk of development of T3cDM is associated with type of pancreatic resection, lower remnant pancreatic volume and higher preoperative HbA1c.

Single Center Experience in Pancreatic Surgery.

Introduction: We present our department experience in pancreatic surgery over the last 6 years. From its inception the number of pancreatic resections has been continuously growing each year. Method: We performed a retrospective analysis of a prospectively maintained database where we included all the patients with pancreatic resections over the last 6 years. We present the main indication and the different types of pancreatic resections, postoperative morbidity, intrahospital and 90-day mortality and an analysis of survival for the patients with pancreatic ductal adenocarcinoma. Results: We analyzed 198 patients, 193 with pancreatic resections and 5 patients with open surgery microwave ablation. There were 145 pancreaticoduodenectomies, 37 distal pancreatectomies, one total pancreatectomy, 3 distal pancreatectomies with celiac axis resection and 7 surgical interventions for chronic pancreatitis. Conclusion: We presented our center's experience in pancreatic surgery with good overall results, however, there is still room for continuous improvement and refinements to achieve better shortterm outcomes, regarding postoperative morbidity and mortality.

Resection of complex pancreatic injuries: Benchmarking postoperative morbidity using the Accordion Severity Grading System

Background: This study benchmarked the severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing resection for severe pancreatic injuries. Methods: A prospective database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. 130 patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy (PD) n=20, distal pancreatectomy n=110), including 30 who had damage control laparotomy (DCL) and later definitive surgery. Uni- and multivariate logistic regression analysis was applied. Results: Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. 19 patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had RTS <7.8, were shocked on admission, had grade 5 pancreatic injuries with vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a PD and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS <7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant. Conclusion: ASGS-assessed morbidity after pancreatic resection for trauma was high. This detailed outcome analysis serves as a reference for future institutional comparisons.

Resection of complex pancreatic injuries: benchmarking postoperative morbidity using the accordion severity grading system

Background: This study benchmarked the severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing resection for severe pancreatic injuries. Methods: A prospective database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. 130 patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy (PD) n=20, distal pancreatectomy n=110), including 30 who had damage control laparotomy (DCL) and later definitive surgery. Uni- and multivariate logistic regression analysis was applied. Results: Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. 19 patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had RTS <7.8, were shocked on admission, had grade 5 pancreatic injuries with vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a PD and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS <7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant. Conclusion: ASGS-assessed morbidity after pancreatic resection for trauma was high. This detailed outcome analysis serves as a reference for future institutional comparisons.

Audit of 62 cases of pancreatic resections for pancreatic cancer

Background: Varieties of pancreatic pathologies, needs resection of pancreatic tissue. Adenocarcinoma of the pancreatic duct is the most common malignancy presenting with early metastasis and seen as resistant to alternative treatment regimens currently available. Management and handling of such tumors is a complex and challenging task for a surgeon. Surgical resection offers an improved prognosis, with a median survival after resection of 14-20 months and up to 25% 5-year survival rates. Present study is aimed at presenting data of 62 pancreatic resections for various malignant pancreatic lesions.Methods: This is an ongoing longitudinal study which started in 2009 at teaching institute in central India. Though we had 109 patients for pancreatic resection, only 62 patients were considered suitable for the study. All patients after admission were thoroughly investigated and then considered for surgery. 48 patients were male and 14 patients were female. Age group was ranging from 33 to 65 years with mean age between 45 to 55 years. Spectrum of various malignancies and different types of pancreatic resections were done and results are presented here.Results: Pancreatic adenocarcinoma is an aggressive malignancy responds to surgical treatment better than other alternative modalities. In the present series out of 62 patients 27 patients with pancreatic head cancer, 22 patients with periampullary cancer, 2 patients with duodenal cancer, 6 patients with distal cholangio carcinoma, 1 patient with mucinous cystadenocarcinoma. 4 patients with body and tail of pancreas cancer. Average age 38 to 65 years, 47 males and 15 females. Commonest procedure was Whipple’s operation, and distal pancreatectomy. Survival in present series was 18 -24 months and 5-year survival was 12 % that is seen mainly with Periampullary cancer.Conclusions: Surgery is the only chance of cure or long-term survival in pancreatic cancer. Chemo radiation as a primary therapy is ineffective. But some reports suggest the improved quality of life with palliative chemotherapy. Biology of the disease is the king and dictates the survival, the type of surgical procedure had no impact on survival, nor on morbidity and mortality.

Resection of complex pancreatic injuries: Benchmarking postoperative complications using the Accordion classification.

AIMTo benchmark severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing operation for severe pancreatic injuries.METHODSA prospective institutional database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. One hundred and thirty patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy, n = 20, distal pancreatectomy, n = 110), including 30 who had an initial damage control laparotomy (DCL) and later definitive surgery. AAST injury grades, type of pancreatic resection, need for DCL and incidence and ASGS severity of complications were assessed. Uni- and multivariate logistic regression analysis was applied.RESULTSOverall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. Nineteen patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had a revised trauma score (RTS) < 7.8, were shocked on admission, had grade 5 injuries of the head and neck of the pancreas with associated vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a pancreatoduodenectomy (PD) and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS < 7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant.CONCLUSIONThis ASGS-based study benchmarked postoperative morbidity after pancreatic resection for trauma. The detailed outcome analysis provided may serve as a reference for future institutional comparisons.

Pancreatic Exocrine Insufficiency in Patients With Pancreatic or Periampullary Cancer: A Systematic Review.

The aim of this study was to determine the prevalence of pancreatic exocrine insufficiency in patients with pancreatic or periampullary cancer, both before and after resection. Systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA guidelines). We included studies reporting on pancreatic exocrine insufficiency in patients with pancreatic or periampullary cancer. Data on patient demographics, type of pancreatic resection, diagnostic test, and occurrence of pancreatic exocrine insufficiency were extracted. Prevalence of pancreatic exocrine insufficiency was calculated before and after pancreatic resections and in patients with locally advanced pancreatic cancer. Nine observational cohort studies with 693 patients were included. Median preoperative prevalence of pancreatic exocrine insufficiency was 44% (range, 42%-47%) before pancreatoduodenectomy, 20% (range, 16%-67%) before distal pancreatectomy, 63% before total pancreatectomy, and 25% to 50% in patients with locally advanced pancreatic cancer. The median prevalence of pancreatic exocrine insufficiency at least 6 months after pancreatoduodenectomy was 74% (range, 36%-100%) and 67% to 80% after distal pancreatectomy. Pancreatic exocrine insufficiency is diagnosed in approximately half of all patients scheduled to undergo resection for pancreatic or periampullary cancer. The prevalence increases markedly after resection. These data highlight the need of pancreatic enzyme suppletion in these patients.

The place of enucleation and enucleo-resection in the treatment of pancreatic metastasis of renal cell carcinoma.

Renal cell carcinoma has shown less response to systemic therapies including chemotherapy, radiotherapy and immunotherapy than other cancers. Metastasis of renal cell carcinoma to the pancreas occurs, even after long term radical nephrectomy, surgical resection remains the only potentially curative intervention. We performed surgery for pancreatic metastatic renal cell carcinoma and analyzed the results. We retrospectively analyzed 11 patients who had undergone pancreatic resection or metastasectomy at our hospital from January 1994 to January 2010. Patient's demographics, clinical variables, types of pancreatic resections (standard or atypical resection), primary histopathology, surgical outcomes, survival and disease free interval were examined. We compared the standard pancreatic resection to atypical resection (enucleation or enucleo-resection). Eleven patients underwent 14 pancreatic resections or metastasectomy (3 pancreaticoduodenectomy, 4 distal pancreatectomy, 1 completion of pancreatectomy, 4 enucleations and two enucleo-resections) for pancreatic renal cell carcinoma metastasis. The median age was 73 years, the median time period between nephrectomy and finding of pancreatic metastasis was 11.4 years. One patient showed synchronous pancreatic metastatic lesions on radiology. One patient died from a splenic artery pseudoaneurysm rupture 35 days after the surgery. Major complications occurred in 4 patients with standard resection (one hemoperitoneum, three pancreatic fistulas), and in one patient with atypical resection (duodenal fistula); six patients with standard resection presented postoperative diabetes mellitus. Median survival age was 6.5 years (range 1-9 years). Two patients died of metastatic disease 5 to 6 years, while 7 patients are alive and well 1 to 9 years after surgery. According to these results and regardless of the small number of cases, atypical resection of metastatic renal cell carcinoma has a high median survival rate even after pancreatic recurrence or distant metastasis. It seems reasonable to favor a good quality of life and less diabetes with a limited atypical resection.

Surgical management of pancreatic cancer

Pancreatic cancer is one of the top 10 cancers in terms of incidence, and continues to be associated with poor 5-year survival. Surgery for localized disease provides the best treatment option with potential for cure. This article discusses pre-operative management, and the evidence for and against biliary drainage prior to surgery, indications for the different types of pancreatic resections and variations in surgery based on evolution of techniques over time, including the extent of lymphadenectomy. The diverse options for reconstruction and their merits are highlighted and the evidence for and against post-operative drainage is presented. Aspects of perioperative management are discussed, with emphasis on complications specific to pancreatic surgery, the role for enhanced recovery and use of somatostatin analogues. The evidence for centralization is outlined, and measures to improve outcomes following these complex resections are detailed.

Interventional radiology procedures after pancreatic resections for pancreatic and periampullary diseases.

The use of interventional radiology has increased as the first-line management of complications after pancreatic resections. Patients in whom interventional radiology was performed were compared with those in whom interventional radiology was not performed as regards type of pancreatic resection, diagnosis, postoperative mortality and morbidity, postoperative pancreatic fistula postpancreatectomy haemorrhage, bile leakage, reoperation rate and length of hospital stay. Our aim was to evaluate the usefulness of interventional radiology in the treatment of complications after pancreatic resection. One hundred and eighty-two (62.8%) out of 290 patients experienced postoperative complications. Interventional radiology procedures were performed in 37 cases (20.3%): percutaneous drainage in 28, transhepatic biliary drainage in 8 and arterial embolisation in 3 cases. Technical success was obtained in all cases and clinical success in 75.7%. Reoperation was avoided in 86.5%. In patients with major complications, clinically relevant postoperative pancreatic fistula and bile leaks as well as those with late postpancreatectomy haemorrhage (P=0.030) and patients with postpancreatectomy haemorrhage grade C (P=0.029), interventional radiology was used (P<0.001, P<0.001 and P=0.009, respectively) significantly more frequently than in the remaining patients. The reoperation and mortality rates were similar in the two groups (P=0.885 and P=0.100, respectively) while patients treated with interventional radiology procedures had a significant longer length of hospital stay than those in the non-interventional radiology group (37.5 ± 23.4 vs. 18.7 ± 11.7 days; P<0.001). Interventional radiology procedures were useful, especially for patients with postoperative pancreatic fistulas and bile leaks in whom reoperation was very often avoided.