Guido M. Sclabas

Major venous resection during total laparoscopic pancreaticoduodenectomy

BACKGROUND The feasibility of total laparoscopic pancreaticoduodenectomy (TLPD) has been established. Laparoscopic major venous resection during TLPD has not been reported. The aim of the present study was to describe the technique and outcomes of patients undergoing TLPD with major venous resection. METHODS Retrospective review of all consecutive patients undergoing TLPD and major venous resection from July 2007 to December 2010 was performed. Patient demographics and peri-operative outcomes were retrieved. Data are presented as mean ± standard deviation (SD) or median with range. RESULTS Out of 129 patients undergoing TLPD, major venous resection was performed in 11 patients with a mean age of 71 years. Median operative time and blood loss was 413 (301-666) min and 500 (75-2800) ml, respectively. Venous resection included tangential (n= 10) and segmental resection (n = 1). Venous reconstruction included patch (n = 4), suture (n = 4), stapled (n = 2) and a left renal vein interposition graft (n = 1). Median mesoportal clamp time was 35 (10-82) min. There was no 30-day or in-hospital mortality. Post-operative imaging was available in 10 patients with 100% patency at the venous reconstruction site. CONCLUSIONS Laparoscopic major venous resection during TLPD is feasible in selected patients. Extensive experience with complex laparoscopic pancreatic resection and reconstruction is advocated before attempting this procedure.

Prosthetic Graft Reconstruction after Portal Vein Resection in Pancreaticoduodenectomy: A Multicenter Analysis

BACKGROUND Use of prosthetic grafts for reconstruction after portal vein (PV) resection during pancreaticoduodenectomy is controversial. We examined outcomes in patients who underwent vein reconstruction using polytetrafluoroethylene (PTFE). STUDY DESIGN Review of prospectively maintained databases at 3 centers identified all patients who underwent pancreaticoduodenectomy (PD) with vein resection and reconstruction using PTFE grafts between 1994 and 2009. Patient, operative, and outcomes variables were studied. Graft patency and survival were assessed using the Kaplan-Meier technique. RESULTS Thirty-three patients underwent segmental vein resection with interposition PTFE graft reconstruction. Median age was 67 years; median Eastern Cooperative Oncology Group score was 1. Most operations were performed for pancreatic adenocarcinoma (n = 28, 85%); 96% were T3 lesions or greater. Standard PD was performed in 12 (36%) patients, pylorus-preservation in 17 (52%), and total pancreatectomy in 4 (12%). Combined resection of portal and superior mesenteric veins (SMV) was required in 49%, with resection isolated to PV in 12% and SMV in 39%. Splenic vein ligation was necessary in 30%. Median graft diameter was 12 mm (range 8 to 20 mm), with the majority being ring-enforced (73%). Median operative and vascular clamp times were 463 and 41 minutes, respectively, with median blood loss of 1,500 mL. The negative margin rate was 64%. Overall morbidity rate was 46%, and 30-day mortality was 6%. No patients developed irreversible hepatic necrosis or graft infection. Pancreatic fistulas occurred in 3 (9.1%). With mean follow-up of 14 months, overall graft patency was 76%. Estimated median duration of graft patency was 21 months. Median survival was 12 months for pancreatic adenocarcinoma. CONCLUSIONS With careful patient selection, PTFE graft reconstruction of resected PV/SMV during pancreaticoduodenectomy is possible with minimal risk of hepatic necrosis or graft infection. Comparison studies to primary anastomosis and autologous vein reconstruction are necessary.

Prediction of pancreatic anastomotic failure after pancreatoduodenectomy: The use of preoperative, quantitative computed tomography to measure remnant pancreatic volume and body composition

Objective: To determine whether remnant pancreatic volume (RPV), subcutaneous/visceral adipose tissue(SAT/VAT) area, and skeletal muscle (SM) area calculated from preoperative computed tomography (CT) can predict the occurrence of pancreatic anastomotic failure (PAF) after pancreatoduodenectomy (PD). Background: Increased body mass index, small main pancreatic duct, and soft pancreatic texture are well-established predictors of PAF after PD. The impact on PAF of anthropomorphic measurements, such as RPV and body composition, is unknown. Methods: In 173 patients undergoing PD from 2004 to 2009, cross sections of SAT/VAT/SM area were quantitated volumetrically, respectively, from preoperative CT. RPV was calculated from the CT as the sum of pancreatic tissue area to the left of the presumed pancreatic transection site. The predictive ability for multiple models using combinations of body mass index, RPV, SAT/VAT area, SM area, main pancreatic duct size, and pancreatic gland texture was described using a concordance index (c-index). Results: Clinically relevant PAF occurred in 22 patients (13%). Multivariate logistic regression analysis identified RPV (P = 0.0012), VAT area (P = 0.0003), and SM area (P = 0.0006) as independent predictors of PAF. Using previously identified risk factors, the best 2-predictor model (body mass index and pancreatic duct size) resulted in a c-index of 0.748. Using anthropomorphic factors, however, the 2-predictor model using VAT and SM areas revealed a superior c-index of 0.959. Conclusions: Our 2-predictor model using VAT area and SM area based on volumetric quantification using preoperative CT may offer clinical benefit as an objective prognostic measure to predict clinically relevant PAF after PD.

Liver-directed therapy for hepatic metastases in patients undergoing pancreaticoduodenectomy: A dual-center analysis

Objectives:To analyze the perioperative and long-term outcomes of patients undergoing liver-directed therapy after pancreaticoduodenectomy in a large dual-center cohort of patients. Background:Although aggressive liver-directed therapy may be beneficial, liver-directed therapy may be associated with a high risk of complications after pancreaticoduodenectomy. Methods:Of 5025 patients who underwent pancreaticoduodenectomy at the Johns Hopkins Hospital and the Mayo Clinic between 1970 and 2008, 126 (2.5%), patients were identified who were also treated with either simultaneous or staged liver-directed therapy. Data on demographics, primary tumor, and hepatic metastasis characteristics, as well as details of the liver-directed therapy were collected and analyzed. Results:Primary tumor histology included neuroendocrine carcinoma (34.9%), pancreatic ductal adenocarcinoma (33.4%), distal cholangiocarcinoma (8.7%), ampullary carcinoma (7.1%), duodenal carcinoma (4.0%), or other (11.9%). Liver-directed therapies included hepatic resection alone (45.2%), hepatic resection plus ablation (11.1%), ablation alone (7.9%), transarterial chemoembolization (9.5%), and whole-liver irradiation (22.2%). The overall morbidity following liver-directed therapy was 34.1% and overall mortality was 2.4%. Patients undergoing staged liver-directed therapy (14.5%) versus simultaneous pancreaticoduodenectomy plus liver-directed therapy (7.0%) were more likely to develop a liver abscess (P < 0.05). Of those patients who developed complications, the majority (55.8%) were major (Clavien grade ≥3). Conclusions:Pancreaticoduodenectomy plus liver-directed therapy is associated with considerable morbidity. The incidence of hepatic abscess is increased in patients undergoing staged pancreaticoduodenectomy followed by liver-directed therapy.

Dual-Phase Computed Tomography for Assessment of Pancreatic Fibrosis and Anastomotic Failure Risk Following Pancreatoduodenectomy

IntroductionDelayed or decreased computed tomography (CT) enhancement characteristics in pancreatic fibrosis have been described.MethodsA review of 157 consecutive patients with preoperative dual-phase CT between 2004 and 2009 was performed. Pancreatic CT attenuation upstream from the tumor was measured in the pancreatic and hepatic imaging phases. The ratio of the mean CT attenuation value [hepatic to pancreatic phase; late/early (L/E) ratio] and histological grade of pancreatic fibrosis was correlated with the development of a clinically relevant pancreatic anastomotic failure (PAF) and other clinical parameters.ResultsA clinically relevant PAF was observed in 21 patients (13.4%) with morbidity and mortality of 39.5% and 0%, respectively. The PAF group showed maximum enhancement in the pancreatic and washout in the hepatic CT phase, while the no PAF group showed a delayed enhancement pattern. Degree of pancreatic fibrosis and L/E ratio were significantly lower for the PAF group than the no PAF group (0.86 ± 0.14 vs. 1.09 ± 0.24; P < 0.0001 and 21.0 ± 17.9 vs. 40.4 ± 29.8; P < 0.0001); fewer PAF patients showed an atrophic histological pattern (14% vs. 39%; P = 0.046). The L/E ratio was positively correlated with pancreatic fibrosis. Pancreatic fibrosis and L/E ratio increased with larger duct size (P < 0.001), the presence of diabetes (P < 0.05), and the surgeon’s assessment of pancreas firmness (P < 0.001). In multivariate analyses, L/E ratio and body mass index were significant predictors for the development of a clinically relevant PAF; a 0.1-U increase of L/E ratio decreased the odds of a PAF by 54%.ConclusionPancreatic CT enhancement pattern can accurately assess pancreatic fibrosis and is a powerful tool to predict the risk of developing a clinically relevant PAF following PD.

Population-based epidemiology, risk factors and screening of intraductal papillary mucinous neoplasm patients.

Intraductal papillary mucinous neoplasm (IPMN) was first recognized in the 1980s with increasing publications over the last decade as the incidence increased sharply, especially at tertiary-care referral centers. Population-based studies have estimated the age and sex-adjusted cumulative incidence of IPMN to be 2.04 per 100 000 person-years (95% confidence interval: 1.28-2.80). It is now understood that IPMN can be classified anywhere along the spectrum of the adenoma to carcinoma sequence and often harbors mutations in genes such as KRAS early in the disease process. Many patients are diagnosed incidentally after imaging of the abdomen for other diagnostic purposes. Patients that present with a history of symptoms such as pancreatitis and abdominal pain are at high risk of harboring a malignancy. Clinicopathologic features such as involvement of the main pancreatic duct, presence of mural nodules, and side branch disease > 3.0 cm in size may indicate that there is an underlying invasive component to the IPMN. In addition, the incidence of extra-pancreatic neoplasms is higher in patients with IPMN, with reported rates of 25% to 50%. There are no current screening recommendations to detect and diagnose IPMN but once the diagnosis is made, screening for extrapancreatic neoplasms such as colon polyps and colorectal cancer should be considered. Surgical resection is the recommend treatment for patients with high-risk features while close observation can be offered to patients without worrisome signs and symptoms of carcinoma.

Does Body Mass Index/Morbid Obesity Influence Outcome in Patients Who Undergo Pancreatoduodenectomy for Pancreatic Adenocarcinoma?

IntroductionThe obesity epidemic coupled with epidemiologic evidence of the link between pancreatic cancer and obesity has raised the interest in the impact of body mass index (BMI) on outcomes for resected pancreatic cancer.MethodsAll patients who underwent pancreatoduodenectomy (PD) for pancreatic adenocarcinoma from 1981 to 2007 were categorized into four groups according to their BMI (<25, 25 to <30, 30 to <35, and ≥35). Associations of these BMI groups with perioperative (operating time, blood loss, complications, in-hospital mortality), pathologic (tumor diameter, tumor stage, differentiation, lymph node status, R0 status) features and long-term patient outcome were evaluated using Kruskal–Wallis and chi-square tests, logistic regression, and Cox proportional hazards regression. A second set of analyses were performed by dichotomizing patients into morbidly obese (BMI ≥ 35) in comparison to the rest.ResultsOf the 586 consecutive patients studied, there were 232 (39.6%) with BMI <25, 232 (39.6%) with BMI 25 to <30, 89 (15.2%) with BMI 30 to <35, and 33 (5.6%) with BMI ≥ 35. Operating time (P = 0.003) and intraoperative blood loss (P < 0.001) increased with BMI, although none of the remaining perioperative features differed significantly among the BMI groups. Similarly, there were no significant associations between BMI group and the pathological features studied, particularly lymph node status (P = 0.98). BMI was not associated with lymph node status even after adjusting for tumor diameter. All analyses were repeated for the morbidly obese. Cox regression did not demonstrate an impact of BMI or morbid obesity on overall or disease-free survival.ConclusionsBMI (and morbid obesity) does not appear to influence long-term outcomes for patients undergoing PD. Surgeons should be vigilant of the greater risk of perioperative blood loss with increasing BMI.

Hepatic Cysts and Liver Abscess

Benign pathologies of the liver often include several cystic diseases, such as simple cysts, autosomal dominant polycystic liver disease, and Carolis disease. The differential of hepatic cysts also includes infectious pathologies, such as pyogenic liver abscess, hydatid cysts, and parasitic infections if the appropriate clinic setting. Understanding of the various causes, clinical presentation, and treatment options is required to ensure the appropriate surgical management of these patients.

Frequency of Subtypes of Biliary Intraductal Papillary Mucinous Neoplasm and Their MUC1, MUC2, and DPC4 Expression Patterns Differ from Pancreatic Intraductal Papillary Mucinous Neoplasm

BACKGROUND Biliary intraductal papillary mucinous neoplasm (B-IPMN) has been proposed as a unique clinicopathologic disease with distinct histopathologic features, although wide acceptance remains controversial. A recent consensus conference classified pancreatic IPMN (P-IPMN) into 4 subtypes (ie, gastric, intestinal, pancreatobiliary, oncocytic) based on morphologic appearance and mucin (MUC) staining properties. The aim of this study was to determine whether B-IPMN has similar histopathologic and immunologic subtypes to P-IPMN. STUDY DESIGN Specific immunostaining for MUC1, MUC2, and deleted for pancreas cancer, locus 4 were performed on specimens from 19 patients with a histopathologic diagnosis of B-IPMN. Immunostaining patterns of B-IPMN were correlated with histopathology. RESULTS Based on histopathology, the following subtypes of B-IPMN were identified: pancreatobiliary n = 9 (47%), intestinal n = 8 (42%), oncocytic n = 2 (11%), and gastric n = 0 (0%). Pancreatobiliary and oncocytic subtypes of B-IPMN were positive for MUC1 and negative for MUC2, and intestinal subtypes were positive for MUC2 and negative for MUC1. Thirteen of the 19 B-IPMN were associated with invasive carcinoma; loss of deleted for pancreas cancer, locus 4 was found in 6 of 13 invasive components and in 3 of 19 noninvasive components of B-IPMN. Five-year survival for patients with resected B-IPMN and invasive carcinoma was 38%, which is similar to that for resected P-IPMN with invasive carcinoma. CONCLUSIONS Histopathologic subtypes and type-specific MUC expression patterns of B-IPMN resemble those of P-IPMN. MUC1 expression and/or absence of MUC2 expression, which correlate with aggressive features of P-IPMN, were found in B-IPMN and correlate with invasive B-IPMN. Loss of deleted for pancreas cancer, locus 4 parallels the findings observed in P-IPMN. These findings provide additional support that B-IPMN is a unique entity with similarities to main duct P-IPMN.

Novel Prediction of Pancreatic Anastomotic Failure After Pancreatoduodenectomy Using Preoperative CT Imaging With the Evaluation of Remnant Pancreatic Volume and Body Composition

INTRODUCTION: An increased body mass index (BMI) and pancreatic duct size are known predictors of pancreatic anastomotic failure (PAF) after pancreatoduodenectomy (PD). However, the impact of anthropomorphic measurements (remnant pancreatic (parenchymal) volume (RPV) and body composition on PAF) are unknown. The aim was to determine if pancreatic remnant volume, subcutaneous/visceral adipose tissue (SAT/VAT) area, and skeletal muscle (SM) area calculated from the preoperative computed tomography (CT) predict PAF after PD. METHODS: In173 patients undergoing preoperative CT and PD at a single institution between 2004 and 2009, SM area and SAT/VAT cross-sectional area at the 3rd lumbar vertebra were quantitated using the preoperative CT. Muscle and adipose tissue were identified semi-automatically using the CT Hounsfield threshold method and remnant pancreatic volume as a volumetric sum of pancreatic parenchymal area to the left of the surgical margin (left border of SMA) over multiple cuts. Pancreatic duct size and parenchymal hardness were assessed by surgeon. The definition of PAF was the International Study Group of Pancreatic Fistula (ISGPF) Classification System; Grades B and C PAF were considered clinically-relevant PAF. Patient demographics of those with clinically relevant PAF were compared to those without PAF. Associations with PAF by univariate logistic regression models were summarized with odds ratios and 95% confidence intervals (CI). The predictive ability for several models was described using a concordance index (c-index). RESULTS: PAF occurred in 22 patients (13%); Grades B and C were present in 15 (9%) and 7 (4%) patients resp. In univariate logistic regression analysis, RPV, VAT, SM, BMI, SAT, pancreatic duct size, and pancreatic texture (soft or hard) were all predictors of PAF with P values of <0.001, <0.001, 0.001, 0.001, 0.02, 0.03, and 0.04, resp. A multivariate model with the known predictors using BMI and duct size had a c-index of 0.75 (BMI; Odds ratio (OR): 1.13, 95%CI: 1.04−1.24, P =0.005, duct size; OR: 0.71, 95%CI: 0.51−0.95, P =0.036). A better multivariate model included preoperative CT factors VAT and SM with a c-index = 0.96 (VAT; OR: 1.24, 95%CI: 1.16−1.37, P <.001, SM; OR: 0.02, 95%CI: 0.01−0.08, P <0.001). CONCLUSIONS: Compared to established risk factors for PAF, RPV and VAT were better predictors of PAF after PD. Prediction of the risk of PAF after PD may be best estimated by including these anthropomorphic measures from the preoperative CT as well as using intraoperative findings.