Francesco Minni

Laparoscopic Versus Open Distal Pancreatectomy for Ductal Adenocarcinoma: A Systematic Review and Meta-Analysis

BackgroundLaparoscopic distal pancreatectomy was proposed as an oncologically safe approach for pancreatic ductal adenocarcinoma.MethodsA systematic review of the studies comparing laparoscopic and open distal pancreatectomy was conducted. The primary endpoint was an R0 resection rate. The secondary endpoints were intra- and postoperative results, tumour size, mean harvested lymph node, number of patients eligible for adjuvant therapy and overall survival.ResultsFive comparative case control studies involving 261 patients (30.7xa0% laparoscopic and 69.3xa0% open) who underwent a distal pancreatectomy were included. The R0 resection rate was similar between the two groups (Pu2009=u20090.53). The laparoscopic group had longer operative times (Pu2009=u20090.04), lesser blood loss (Pu2009=u20090.01), a shorter hospital stay (Pu2009<u20090.001) and smaller tumour size (Pu2009=u20090.04) as compared with the laparotomic group. Overall morbidity, postoperative pancreatic fistula, reoperation, mortality and number of patients eligible for adjuvant therapy were similar. The mean harvested lymph nodes were comparable in the two groups (Pu2009=u20090.33). The laparoscopic approach did not affect the overall survival rate (Pu2009=u20090.32).ConclusionEven if the number of patients compared is underpowered, the laparoscopic approach in the treatment of PDAC seems to be safe and efficacious. However, additional prospective, randomised, multicentric trials are needed to correctly evaluate the laparoscopic approach in PDAC.

Laparoscopic distal pancreatectomy: what factors are related to the learning curve?

AbstractPurposeThe factors related to the learning curve for laparoscopic distal pancreatectomy have rarely been evaluated.MethodsA retrospective study of 32 patients who underwent a laparoscopic distal pancreatectomy performed at a high-volume center by a single pancreatic surgeon experienced with laparoscopic surgery was conducted. Pre-, intra- and postoperative data were collected. The primary endpoint was the length of the operation. The secondary endpoints were the conversion and reoperation rates, overall postoperative morbidity and mortality rates, the length of hospital stay and rate of unplanned splenectomy.ResultsThe length of the operation and the cumulative sum of the procedures presented a logarithmic correlation (Pxa0=xa00.048). The learning curve appeared to have been completed after 17 procedures (Pxa0=xa00.040). The multivariate analysis confirmed that the completion of the learning curve (CLC) reduced the length of the operation by 18xa0% (Pxa0=xa00.009), but extended resection increased the length of the operation (Pxa0=xa00.023). The conversion and reoperation rates, overall postoperative morbidity and mortality rates and length of the hospital stay were not related to the CLC. Unplanned splenectomy was more frequently performed during the first 17 procedures.ConclusionsThe length of the operation seems to be the main factor related to the CLC for laparoscopic distal pancreatectomy. The learning curve could be considered to be completed after about 17 procedures if performed by surgeons experienced with laparoscopic techniques at high-volume centers.n

Neoadjuvant Chemoradiotherapy and Surgery Versus Surgery Alone in Resectable Pancreatic Cancer: A Single-Center Prospective, Randomized, Controlled Trial Which Failed to Achieve Accrual Targets

ObjectiveThe objective of the study is to evaluate the usefulness of neoadjuvant chemoradiotherapy in resectable pancreatic cancer.MethodsA single-center RCT of patients affected by resectable pancreatic adenocarcinoma which included arm A (surgery alone) and arm B (neoadjuvant chemoradiation and surgery). The primary endpoint was R0 resection; the secondary endpoints were toxicity; number of patients who completed the neoadjuvant therapy; radiological and pathological response after chemoradiation; and pTNM stage, postoperative morbidity, mortality, and overall and disease-free survival. A sample size of 32 patients was required for each group.ResultsThe study was terminated early, and 38 patients were randomized: 20 in arm A and 18 in arm B. There was no significant difference regarding R0 resection rate in the two groups (intention-to-treat, ORu2009=u20091.91, Pu2009=u20090.489). Neoadjuvant chemoradiotherapy was completed in 14 out of 18 cases (77.8xa0%) and the radiological and pathological response was efficacious in 72.3 and 90.9xa0% of cases, respectively.ConclusionsNeoadjuvant chemoradiation was feasible, safe, and efficacious, although non-significant results were obtained as a result of the underpowered data due to the difficulty in recruiting patients. Additional multicenter RCTs are needed in the future.

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 (Pu2009<u20090.001). Regarding quality of life, the laparoscopic approach was able to ameliorate physical functioning (Pu2009=u20090.049), role functioning (Pu2009=u20090.044) and cognitive functioning (Pu2009=u20090.030) and reduce the sleep disturbance scale (Pu2009=u20090.050). 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 in Italy: a systematic review and meta-analysis

BACKGROUNDnThe use of laparoscopic distal pancreatectomy (LDP) increased in the past twenty years but the real diffusion of this technique is still unknown as well as the type of centers (high or low volume) in which this procedure is more frequently performed.nnnDATA SOURCEnA systematic review was performed to evaluate the frequency of LDP in Italy and to compare indications and results in high volume centers (HVCs) and in low volume centers (LVCs).nnnRESULTSnFrom 95 potentially relevant citations identified, only 5 studies were included. A total of 125 subjects were analyzed, of whom 95 (76.0%) were from HVCs and 30 (24.0%) from LVCs. The mean number of LDPs performed per year was 6.5. The mean number of patients who underwent LDP per year was 8.8 in HVCs and 3.0 in LVCs (P<0.001). The most frequent lesions operated on in HVCs were cystic tumors (62.1%, P<0.001) while, in LVCs, solid neoplasms (76.7%, P<0.001). In HVCs, malignant neoplasms were treated with LDP less frequently than in LVCs (17.9% vs 50.0%, P<0.001). Splenectomy was performed for non-oncologic reason frequenter in HVCs than in LVCs (70.2% vs 25.0%, P=0.004). The length of stay was shorter in HVCs than in LVCs (7.5 vs 11.3, P<0.001). No differences were found regarding age, gender, ductal adenocarcinoma treated, operative time, conversion, morbidity, postoperative pancreatic fistula, reoperation and margin status.nnnCONCLUSIONSnLDPs were frequently performed in Italy. The HVC approach is characterized by a careful selection of patients undergoing LDP. The LVC approach is based on the hypothesis that LDPs are equivalent both in short-term and long-term results to laparotomic approach. These data are not conclusive and they point out the need for a national register of laparoscopic pancreatectomy.

Portal/Superior Mesenteric Vein Reconstruction during Pancreatic Resection Using a Cryopreserved Arterial Homograft.

Background: Portal-superior mesenteric vein (PV/SMV) resection during pancreatic resection has been widely applied in clinical practice. Methods: From a prospective data base of pancreatic resections, patients undergoing PV/SMV resection and reconstruction with a cryopreserved arterial homograft were extracted with the aim of evaluating the safety, feasibility and reproducibility of the procedure. Data regarding patient demographics, preoperative staging, surgery, histopathology and postoperative outcomes were analyzed. Results: Five patients were extracted in the last year. Indications for this technique were type IV-V degree of vein involvement and a 3.5 cm median length of vein infiltration. Median operative and clamping times were satisfactory (385 and 27 min, respectively), postoperative outcomes were good and there was no graft infection, thrombosis or stenosis occurred postoperatively and during the follow-up period. Conclusion: The use of a cryopreserved arterial homograft for PV/SMV reconstruction after pancreatic resection seems to be a feasible, safe and easily reproducible surgical technique in high-volume specialized centers and can be added to the pool of surgical solutions in selected patients.

Laparoscopic appendectomy: Which factors are predictors of conversion? A high-volume prospective cohort study

UNLABELLEDnAppendicitis represents one of the most frequent condition requiring surgery. In Italy almost 0.2% of the population will be affected by acute appendicitis every year. Laparoscopic appendectomy (LA) has gained acceptance over the past years and despite several meta-analyses, randomized studies and retrospective studies have been conducted, the indications and results are still conflicting especially in cases of complicated appendicitis. The aim of our study is to evaluate which factors are related to conversion to open appendectomy (OA) during laparoscopic appendectomy (LA).nnnMATHERIALS AND METHODSnFrom September 2011 to May 2013, appendectomy for acute appendicitis was performed on 434 patients in our Surgical Unit at S. Orsola-Malpighi Hospital, Bologna, Italy. Of these, 369 patients (85%) underwent LA. The clinical, demographic, surgical and pathological data of these patients were included in a prospective database. To note, only laparoscopic appendectomies were considered to be included in the analysis. The following factors were analyzed in order to identify which were associated with the conversion: age, sex, body mass index (BMI), previous abdominal surgery, comorbidities, clinical and laboratory parameters including Alvarado score, PCR, intraoperative findings such as anatomy and degree of inflammation. During our study period, laparoscopic appendectomies were performed by different surgeons both residents and attending surgeons. The decision to convert the intervention in an open procedure was taken by the individual surgeon. Regarding the postoperative period, were considered the time of hospitalization and related costs, time of oral intake of liquid and solid, time of passage of stool, readmissions and reoperations.nnnRESULTSnAt univariate analysis, the factors significantly related to the conversion were the presence of comorbidities (p < 0.001) and, among these, the presence of arterial hypertension (p = 0.006) or other cardiovascular diseases (p = 0.031) and the history of previous abdominal surgery (p = 0.023). Patients with higher mean age (33.9 ± 15.4 vs. 46.0 ± 19.3, p = 0.001) and higher body mass index (BMI) (23.5 ± 4.3 vs 25.8 ± 4.9 kg/m(2), p = 0.006) had a higher risk of conversion. Multivariate analysis finally showed that factors significantly related to the conversion were the presence of comorbidities (p = 0.029), the presence of an appendiceal perforation (p = 0.003), a retrocecal appendix (p = 0.004), the presence of appendicular abscess (p = 0.023) and the presence of diffuse peritonitis (p = 0.008).nnnCONCLUSIONnThe majority of patients with acute appendicitis can be successfully managed with laparoscopy. We found that the only preoperative independent factor related to conversion during laparoscopic appendectomy is the presence of comorbidities. Nevertheless surgeons should take into account that presence of peri-appendicular abscess and diffuse peritonitis are both independently related not only to higher rate of conversion but also to higher risk of postoperative complication.

Interventional Radiology Procedures after Pancreatic Resections for Pancreatic and Periampullary Diseases

CONTEXTnThe use of interventional radiology has increased as the first-line management of complications after pancreatic resections.nnnMETHODSnPatients 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.nnnRESULTSnOne 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).nnnCONCLUSIONSnInterventional radiology procedures were useful, especially for patients with postoperative pancreatic fistulas and bile leaks in whom reoperation was very often avoided.

Is age a barrier to pancreaticoduodenectomy? An Italian dual-institution study.

AbstractThe aim of this study is to evaluate the role of age after pancreaticoduodenectomy. This is a retrospective study of 223 patients who underwent pancreaticoduodenectomy for periampullary diseases. Three age groups of patients were compared: ≤70xa0years of age (group A); between 71 and 79xa0years of age (group B) and 80xa0years of age or older (group C). The primary endpoint wasn the postoperative mortality rate. Secondary endpoints were the overall postoperative morbidity, postoperative pancreatic fistula, postoperative pancreatic haemorrhage, bile leakage, delayed gastric emptying rates, the length of hospital stay, intensive care unit stay, the type of discharge from hospital, reoperation rate and overall survival. Uni-multivariate analyses and Kaplan–Meier curve were carried out. At univariate analysis, only the type of discharge from hospital showed that group B and C patients required a period of rehabilitation more frequently than group A (Pxa0=xa00.047 and Pxa0<xa00.001, respectively). Multivariate analysis confirmed that age was not related to postoperative mortality (Pxa0=xa00.258), morbidity (Pxa0=xa00.912) and overall survival (Pxa0=xa00.658), but it was related to type of discharge (Pxa0<xa00.001). The present study seems to suggest that a pancreaticoduodenectomy is a feasible and safe procedure, even in elderly and very elderly patients even if the latter require a longer period of rehabilitation.

Locally advanced pancreatic cancer: open questions on terminology, diagnosis and management.

Locally advanced pancreatic cancer represents a wellknown disease [1]. Recently, we observed a 56-year-old asymptomatic man, with high blood levels of Ca 19.9 and a well-differentiated pancreatic head carcinoma, 38 9 35 mm in diameter, with a vascular involvement [180 of both superior mesenteric vein and artery. The disease was defined as locally advanced unresectable pancreatic cancer according to NCCN guidelines [1]. A 18-FDG-PET showed an FDG uptake (SUVmax = 4) of the pancreatic lesion. The patient started chemoinduction therapy with gemcitabine and oxaliplatinum (GEMOX) (four cycles), then a protocol of chemo-radiotherapy with Gemcitabine 40 mg/mq twice a week and radiotherapy with 49 Gy was performed for further 6 weeks. Re-staging of the tumor by CT scan showed a stable disease and a 18-FDG-PET confirmed an FDG uptake (SUVmax = 3) of the pancreatic lesion. Further, 10 cycles of GEMOX were performed. After 20 months, a CT demonstrated a decrease in size of the pancreatic mass (25 9 22 mm), while the vascular involvement of the mesenteric artery remained the same (Fig. 1); 18-FDG-PET did not show an FDG uptake of the pancreatic lesion and Ca 19-9 returned normal. Finally, mutations in the KRAS and P53 genes were not detected on the DNA tissue studies of the pancreatic cancer. Finally, the genomic characteristics of the patient’s Fig. 1 After 20 months from diagnosis, axial (a) and coronal (b) CT images showed a decrease in size of the pancreatic mass (from 38 9 25 to 25 9 22 mm), while the vascular involvement of the superior mesenteric vein and artery remained the same ([180 ). In axial CT image (a), the green arrows indicate the superior mesenteric vein (at the right of the patient) and the superior mesenteric artery (at the left of the patient) R. Casadei (&) C. Ricci F. Minni Department of Medical and Surgical Sciences, DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy e-mail: riccardo.casadei@aosp.bo.it