Carlo Alberto Pacilio

Laparoscopic Distal Pancreatectomy in Benign or Premalignant Pancreatic Lesions: Is It Really More Cost-Effective than Open Approach?

BackgroundData regarding the quality of life in patients undergoing laparoscopic distal pancreatectomy are lacking and no studies have reported a real cost-effectiveness analysis of this surgical procedure. The aim of this study was to evaluate and compare the quality of life and the cost-effectiveness of a laparoscopic distal pancreatectomy with respect to an open distal pancreatectomy.MethodsForty-one patients who underwent a laparoscopic distal pancreatectomy and 40 patients who underwent an open distal pancreatectomy were retrospectively studied as regards postoperative results, quality of life and cost-effectiveness analysis. The Italian neutral version of the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire C-30, version 3.0, was used to rate the quality of life.ResultsPostoperative results were similar in the two groups; the only difference was that the first oral intake took place significantly earlier in the laparoscopic group than in the open group (P < 0.001). Regarding quality of life, the laparoscopic approach was able to ameliorate physical functioning (P = 0.049), role functioning (P = 0.044) and cognitive functioning (P = 0.030) and reduce the sleep disturbance scale (P = 0.050). The cost-effectiveness analysis showed that the acceptability curve for a laparoscopic distal pancreatectomy had a higher probability of being more cost-effective than an open distal pancreatectomy when a willingness to pay above 5400 Euros/quality-adjusted life years (QALY) was accepted.ConclusionDespite the limitations of the study, laparoscopic distal pancreatectomy can be considered not only safe and feasible but also permits a better quality of life and is acceptable in terms of cost-effectiveness to Italian and European health care services.

Laparoscopic distal pancreatectomy: many meta-analyses, few certainties.

In recent years, an increasing of the level of evidence occurred with a significant number of meta-analyses. A question remains open: can LDP be considered the “new gold standard” for benign and malignant body–tail pancreatic disease? A systematic literature search was conducted to identify all meta-analyses published up to 2016. The primary endpoint was to evaluate the clinical safety of LDP. The secondary endpoints were to evaluate: the length of hospital stay (LOS), readmission rate, postoperative pancreatic fistula (POPF), overall postoperative morbidity and oncologic safety. Nine studies were found to be suitable for the analysis. Data regarding clinical safety were extractable in all meta-analyses but a “between study” homogeneity was available only in 7. The safety of LDP was sustained by six meta-analyses in benign/low grade of malignancy body–tail pancreatic lesions, by one in ductal adenocarcinoma (PDAC). LDP has a shorter LOS compared to open distal pancreatectomy (ODP), demonstrated by three meta-analyses. Readmission rate in LDP procedures was lower than in ODP; these data are sustained by one meta-analysis. LDP is not inferior to ODP regarding the occurrence of POPF (seven meta-analyses); overall morbidity rate was lower in LDP than ODP for benign or low-grade malignant tumor. The use of the LDP in PDAC is sustained from one study. In conclusion, LDP can be considered a safe alternative to ODP. LDP could have some advantages but the data do not permit to define this procedure as the first choice or as the new gold standard.

Risk Factors for Malignancy of Branch-Duct Intraductal Papillary Mucinous Neoplasms: A Critical Evaluation of the Fukuoka Guidelines With a Systematic Review and Meta-analysis.

Objectives This study aimed to evaluate the accuracy of the risk factors proposed by Fukuoka guidelines in detecting malignancy of branch-duct intraductal papillary mucinous neoplasms. Method Diagnostic meta-analysis of cohort studies. A systematic literature search was conducted using MEDLINE, the Cochrane Library, Scopus, and the ISI-Web of Science databases to identify all studies published up to 2014. Results Twenty-five studies (2025 patients) were suitable for the meta-analysis. The “high risk stigmata” showed the highest pooled diagnostic odds ratio (jaundice, 6.3; positive citology, 5.5; mural nodules, 4.8) together with 2 “worrisome features” (thickened/enhancing walls, 4.2; duct dilatation, 4.0) and 1 “other parameters” (carbohydrate antigen 19-9 serum levels, 4.6). Conclusions An “ideal risk factor” capable of recognizing all malignant branch-duct intraductal papillary mucinous neoplasms was not identified and some “dismal areas” remain. However, “high risk stigmata” were strongly related to malignancy, mainly enhancing mural nodules. Among the “worrisome features,” duct dilatation and thickened/enhancing walls were underestimated, and their diagnostic performance was similar to those of “high risk stigmata.” The carbohydrate antigen 19-9 serum level should be added to the Fukuoka algorithm because this value could help in carrying out correct management.

Minimally Invasive Pancreaticoduodenectomy: What is the Best "Choice"? A Systematic Review and Network Meta-analysis of Non-randomized Comparative Studies.

BackgroundMany mini-invasive pancreaticoduodenectomy (MIPD) techniques have been reported, but their advantages with respect to an open technique (OPD) and with respect to each other are unclear.MethodA systematic literature search of studies comparing different types of MIPD was carried out: laparoscopic-assisted (LAPD), totally robotic (TRPD), totally laparoscopic (TLPD) or totally laparoscopic—robotic assisted (TLPD-RA) to OPD. The primary endpoint was postoperative mortality. The secondary endpoints were intraoperative, postoperative and oncological outcomes. A network meta-analysis was designed to generate direct, indirect and mixed estimate effects, between different approaches, for each variable. The effects were reported as pairwise comparisons and hierarchical ranking as to each approach could be the best or the worst for each outcome, expressed by the surface under the cumulative ranking curve.ResultsTwenty studies were identified, involving 2759 patients: 1813 OPDs, 81 LAPDs, 505 TRPDs, 224 TLPDs and 136 TLPD-RAs. No differences regarding postoperative mortality were found in pairwise comparison. The LAPD technique had a high probability of being the worst approach, while TRPD had a high probability of being one of the best. Regarding the secondary endpoints, OPD was the best regarding operative time and postoperative bleeding, but the worst regarding blood loss and wound infection. The TRPD or TLPD-RA techniques seemed to be the best for delayed gastric emptying, length of hospital stay, harvested lymph nodes and postoperative morbidity. The TLPD technique was often the worst approach, especially for overall and major complications, postoperative bleeding and biliary leak.ConclusionThe safest MIPDs are those involving a robotic system which seems to have a promising role in ameliorating the outcomes of OPD, especially when compared to a laparoscopic approach.

Prospective validation of a preoperative risk score model based on pancreatic texture to predict postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND In 2015, basing on objective preoperative factors related to pancreas remnant texture (body mass index, Wirsung duct size and preoperative diagnosis), we proposed a score model to predict the risk of postoperative pancreatic fistula after partial pancreatectomies. The aim of the present study was to prospectively validate this preoperative predictive risk score for postoperative pancreatic fistula after pancreaticoduodenectomy. METHODS Prospective study of consecutive patients who underwent pancreaticoduodenectomy in which a preoperative risk score, based on factors related to the pancreatic texture, was calculated. The risk score model was tested by comparison with subjective intraoperative assessment of the pancreas remnant texture and drain amylase value on postoperative day 1. Sensitivity, specificity, positive and negative likelihood ratio and area under the curve were calculated. RESULTS Eighty-four patients who underwent pancreaticoduodnectomy were analyzed. Clinically relevant pancreatic fistulas rate was 40.6%. The risk score model with a cut-off of 6 increased the odds of pancreatic fistula approximately 3 fold but it was not independently related to it. On the contrary, considering a cut-off of 5, the risk score model increased the odds of pancreatic fistula 11-16 fold and it was independently related to it. The new risk score model and pancreatic texture had high sensitivity (97% and 88%, respectively) and low specificity (34% and 60%, respectively) while the amylase drain value had low sensitivity (44%) and high specificity (92%). CONCLUSIONS The preoperative risk score model with a cut-off of 5 was a useful predictor of clinically relevant pancreatic fistula after pancreaticoduodenectomy. The drain amylase value represents a complementary factor to the risk score in predicting a pancreatic fistula.

Laparoscopic distal pancreatectomy: which factors are related to open conversion? Lessons learned from 68 consecutive procedures in a high-volume pancreatic center

BackgroundLaparoscopic distal pancreatectomy represents a difficult surgical procedure with an high conversion rate to open procedure. The factors related to its difficulty and conversion to open distal pancreatectomy were rarely reported. The aim of the present study was to identify which factors are related to conversion from laparoscopic to open distal pancreatectomy.MethodsA retrospective study of a prospective database of 68 patients who underwent laparoscopic distal pancreatectomy was conducted at a high-volume center by pancreatic surgeons experienced with laparoscopic surgery. Pre-intra and postoperative data were collected. Patients who completed a laparoscopic distal pancreatectomy were compared with those who needed a conversion to the open approach as regard demographic, clinical, radiological, and surgical data. Univariate and multivariate analyses were carried out.ResultsUnivariate analysis suggested that the site of the lesion, the extension of pancreatic resection, and the requirement for an extended procedure to adjacent organs were significantly associated with the risk of conversion to the open approach. Multivariate analysis showed that only the extension of the pancreatic resection (subtotal pancreatectomy) was significantly related to the odds of conversion [odds ratio (OR) 19.5; 95% confidence interval (CI) 1.1–32.3; P = 0.038]. Preoperative suspicion of malignancy differed between the two groups; however, this difference did not reach statistical significance (P = 0.078).ConclusionsDespite the limitations of the study, only the extension of pancreatic resection seemed to be the main factor related to conversion during laparoscopic distal pancreatectomy.

Comparison of Efficacy and Safety of 4 Combinations of Laparoscopic and Intraoperative Techniques for Management of Gallstone Disease With Biliary Duct Calculi: A Systematic Review and Network Meta-analysis

Importance Several techniques are used for surgical treatment of gallstone disease with biliary duct calculi, but the safety and efficacy of these approaches have not been compared. Objectives To compare the efficacy and safety of 4 surgical approaches to gallstone disease with biliary duct calculi. Data Sources MEDLINE, Scopus, and ISI-Web of Science databases, articles published between 1950 and 2017 and searched from August 12, 2017, to September 14, 2017. Search terms used were LCBDE, LC, preoperative, ERCP, postoperative, period, cholangiopancreatography, endoscopic, retrograde, rendezvous, intraoperative, one-stage, two-stage, single-stage, gallstone, gallstones, calculi, stone, therapy, treatment, therapeutics, surgery, surgical, procedures, clinical trials as topic, random, and allocation in several logical combinations. Study Selection Randomized clinical trials comparing at least 2 of the following strategies: preoperative endoscopic retrograde cholangiopancreatography (PreERCP) plus laparoscopic cholecystectomy (LC); LC with laparoscopic common bile duct exploration (LCDBE); LC plus intraoperative endoscopic retrograde cholangiopancreatography (IntraERCP); and LC plus postoperative ERCP (PostERCP). Data Extraction and Synthesis A frequentist random-effects network meta-analysis was performed. The surface under the cumulative ranking curve (SUCRA) was used to show the probability that each approach would be the best for each outcome. Main Outcomes and Measures Primary outcomes were the safety to efficacy ratio using overall mortality and morbidity rates as the main indicators of safety and the success rate as an indicator of efficacy. Secondary outcomes were acute pancreatitis, biliary leak, overall bleeding, operative time, length of hospital stay, total cost, and readmission rate. Results The 20 trials comprised 2489 patients (and 2489 procedures). Laparoscopic cholecystectomy plus IntraERCP had the highest probability of being the most successful (SUCRA, 87.2%) and safest (SUCRA, 69.7%) with respect to morbidity. All approaches had similar results regarding overall mortality. Laparoscopic cholecystectomy plus LCBDE was the most successful for avoiding overall bleeding (SUCRA, 83.3%) and for the shortest operative time (SUCRA, 90.2%) and least total cost (SUCRA, 98.9%). Laparoscopic cholecystectomy plus IntraERCP was the best approach for length of hospital stay (SUCRA, 92.7%). Inconsistency was found in operative time (indirect estimate, 19.05; 95% CI, 2.44-35.66; P = .02) and total cost (indirect estimate, 17.06; 95% CI, 3.56-107.21; P = .04). Heterogeneity was observed for success rate (&tgr;, 0.8), operative time (&tgr;, >1), length of stay (&tgr;, >1), and total cost (&tgr;, >1). Conclusions and Relevance The combined LC and IntraERCP approach had the greatest odds to be the safest and appears to be the most successful. Laparoscopic cholecystectomy plus LBCDE appears to reduce the risk of acute pancreatitis but may be associated with a higher risk of biliary leak.

Multicolour versus monocolour inking specimens after pancreaticoduodenectomy for periampullary cancer: A single centre prospective randomised clinical trial

BACKGROUND R status represents an important prognostic factors in periampullary cancers. Thus, it is useful to verify if it can be influenced by different techniques of margination. METHODS Single-centre, randomised clinical trial of patients affected by periampullary cancer who underwent pancreaticoduodenectomies which included two different types of margination: arm A (multicolour inking) and arm B (monocolour inking). The primary endpoint was the overall R1 resection rate and its difference between the two arms. The secondary endpoints were the R1 resection rate in each margin and its difference between the two arms, and the impact of margin status on survival. RESULTS Fifty patients were randomised, 41 analysed: 22 in arm A, 19 arm B. The overall R1 status was 61%, without significant differences between the two arms. The margin most commonly involved was the superior mesenteric artery (SMA) (36.6%). A trend in favour of arm B was shown for the superior mesenteric artery margin (arm A = 22.7% versus arm B = 52.6%; P = 0.060). The anterior surface (P = 0.015), SMA (P = 0.047) and pancreatic remnant (P = 0.018) margins significantly influenced disease-free survival. CONCLUSIONS The R status was not influenced by different techniques of margination using a standardised pathological protocol. The SMA margin seemed to be the most important margin for evaluating both R status and disease-free survival.

Anterior transhepatic approach for total caudate lobectomy including spigelian lobe, paracaval portion and caudate process: A Brazilian experience

Nowadays, because of the infiltration of cholangiocarcinoma to he parenchyma and/or bile ducts of the caudate lobe, the incluion of caudate lobe combined with a major hepatectomy remains he gold standard approach for a resectable hilar cholangiocarcioma. Since the last years of the 20th century, some authors have egun to report isolated caudate lobe resection for hepatocellular arcinoma (HCC), in order to achieve a radical surgery by sparing t the same time hepatic parenchyma [1] . Moreover, caudate lobe an be an uncommon site of metastatic involvement. Without any oubt, caudate lobectomy is a very demanding procedure, mainly ecause of the deep and complex location of the caudate lobe beween major vessels. Hepatectomies performed for tumors located n this dangerous area may lead to massive hemorrage that can e difficult to control. In this setting, the so called anterior tranhepatic approach provides a very good exposure to the surgical eld. At our institution, between January 2011 and December 2017, our patients (two females and two males), were submitted to isoated complete caudate lobectomy using an anterior transhepatic pproach. Two patients were affected by HCC, one by fibrolamelar HCC and one by a metastasis from a previous renal cell carcioma. All patients had a normal liver function (Child A). Informed onsent was obtained from the patients for publication of this reort and any accompanying images. The characteristics of the paients are summarized in Table 1 . All cases were carefully evaluted with a CT scan completed with liver volumetry and virtual epatectomy. All patients underwent isolated complete caudate reection through anterior transhepatic approach ( Fig. 1 ). The mean ge of patients was 56 years, ranging from 28 to 74 years. The four ndications were, respectively: fibrolamellar HCC, HCC in a nonirrhotic liver affected by non-alcholic steatohepatitis, HCC in HCVelated cirrhotic liver with mild portal hypertension, and metastais from a bilateral renal cell carcinoma in a patient who was preiously submitted to bilateral nephrectomy (hemodialysis 4 times a eek). Mean tumor size was 5.4 cm (4.1–6.7). We decided to perorm the anterior transhepatic approach for total caudectomy in hese very selected cases due to the size and position of these umors. Conventional extesive major hepatectomies cause signifiant risk of morbidity and mortality due to posthepatectomy liver ailure. Pringle’s maneuver was used routinely, if needed. From a echnical point of view, in the first two cases middle hepatic vein emained attached to the left lobe: we found mild congestion in ight anterior sector during intraoperative Doppler ultrasound, but o related complication was observed postoperatively. In the sec-

Natural History of Branch-Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Case Report

CONTEXT The natural history of incidental branch-duct intraductal papillary mucinous neoplasm of the pancreas is still unknown. CASE REPORT The case of a 74-year-old man who had been diagnosed 14 years previously with an incidental branch-duct intraductal papillary mucinous neoplasm of the pancreatic head, 30 mm in size, without mural nodules and dilatation of the main pancreatic duct is herein reported. After an exploratory laparotomy at the time of diagnosis (when he was 60 year-old), the patient was enrolled in a surveillance program. Fourteen years after the diagnosis, the cystic lesion showed an increase in size, Wirsung duct dilatation and the presence of several mural nodules. A total pancreatectomy was performed and a diagnosis of mixed-intraductal papillary mucinous neoplasm diffused throughout the entire pancreas with high grade dysplasia, and a micro-invasive carcinoma (<1 mm) of the pancreatic head was reached. CONCLUSION The present case confirmed that the natural history of branch-duct intraductal papillary mucinous neoplasms is unpredictable. Thus, an appropriate surveillance program is required for prompt identification of the signs predictive of a malignant transformation of branch-duct intraductal papillary mucinous neoplasms. In high-volume centers, surgery should seriously be considered in young patients who are fit for surgery.