Mathias Worni

Roux-en-Y Drainage of the Pancreatic Stump Decreases Pancreatic Fistula After Distal Pancreatic Resection

Clinically relevant fistula after distal pancreatic resection occurs in 5–30% of patients, prolonging recovery and considerably increasing in-hospital stay and costs. We tested whether routine drainage of the pancreatic stump into a Roux-en-Y limb after distal pancreatic resection decreased the incidence of fistula. From October 2001, data of all patients undergoing pancreatic distal resection were entered in a prospective database. From June 2003 after resection, the main pancreatic duct and the pancreatic stump were oversewn, and in addition, anastomosed into a jejunal Roux-en-Y limb by a single-layer suture (nu2009=u200923). A drain was placed near the anastomosis, and all patients received octreotide for 5–7xa0days postoperatively. The volume of the drained fluid was registered daily, and concentration of amylase was measured and recorded every other day. Patient demographics, hospital stay, pancreatic fistula incidence (≥30xa0ml amylase-rich fluid/day on/after postoperative day 10), perioperative morbidity, and follow-up after discharge were compared with our initial series of patients (treated October 2001–May 2003) who underwent oversewing only (nu2009=u200920). Indications, patient demographics, blood loss, and tolerance of an oral diet were similar. There were four (20%) pancreatic fistulas in the “oversewn” group and none in the anastomosis group (pu2009<u20090.05). Nonsurgical morbidity, in-hospital stay, and follow-up were comparable in both groups.

Concomitant Vascular Reconstruction During Pancreatectomy for Malignant Disease: A Propensity Score–Adjusted, Population-Based Trend Analysis Involving 10 206 Patients

OBJECTIVEnTo assess trends in the frequency of concomitant vascular reconstructions (VRs) from 2000 through 2009 among patients who underwent pancreatectomy, as well as to compare the short-term outcomes between patients who underwent pancreatic resection with and without VR.nnnDESIGNnSingle-center series have been conducted to evaluate the short-term and long-term outcomes of VR during pancreatic resection. However, its effectiveness from a population-based perspective is still unknown. Unadjusted, multivariable, and propensity score-adjusted generalized linear models were performed.nnnSETTINGnNationwide Inpatient Sample from 2000 through 2009.nnnPATIENTSnA total of 10,206 patients were involved.nnnMAIN OUTCOME MEASURESnIncidence of VR during pancreatic resection, perioperative in-hospital complications, and length of hospital stay.nnnRESULTSnOverall, 10,206 patients were included in this analysis. Of these, 412 patients (4.0%) underwent VR, with the rate increasing from 0.7% in 2000 to 6.0% in 2009 (P < .001). Patients who underwent pancreatic resection with VR were at a higher risk for intraoperative (propensity score-adjusted odds ratio, 1.94; P = .001) and postoperative (propensity score-adjusted odds ratio, 1.36; P = .008) complications, while the mortality and median length of hospital stay were similar to those of patients without VR. Among the 25% of hospitals with the highest surgical volume, patients who underwent pancreatic surgery with VR had significantly higher rates of postoperative complications and mortality than patients without VR.nnnCONCLUSIONSnThe frequency of VR during pancreatic surgery is increasing in the United States. In contrast with most single-center analyses, this population-based study demonstrated that patients who underwent VR during pancreatic surgery had higher rates of adverse postoperative outcomes than their counterparts who underwent pancreatic resection only. Prospective studies incorporating long-term outcomes are warranted to further define which patients benefit from VR.

Incidence and management of biliary pancreatitis in cholecystectomized patients: results of a 7-year study

Data are lacking concerning the frequency of biliary acute pancreatitis in the postcholecystectomy patient. The aim of this study was to identify patients at risk for biliary pancreatitis after cholecystectomy and to describe the therapeutic management of these patients, based on an analysis of 278 unselected patients with acute pancreatitis during a 7-year period. A biliary etiology was presumed in the presence of laboratory findings of cholestasis that could not be explained by another disease, together with the absence of any other known etiology of acute pancreatitis. A biliary cause of disease was found in 132 (47%) of 278 patients. Seventeen (13%) of 132 patients had a history of cholecystectomy. Endoscopic retrograde cholangiopancreatography was performed in all patients with a suspected biliary cause of acute pancreatitis. It showed bile duct stones, microlithiasis, or sludge in 14 patients, and was consistent with typical findings at the papilla of Vater after stone passage in another three patients. No surgical bile duct exploration was necessary. One patient with severe disease and infected pancreatic necrosis died of septic multiorgan failure.

Endoscopic intra-abdominal rescue therapy of a dislodged EUS-guided hepaticogastrostomy stent

EUS-guided hepaticogastrostomy (HGS) is a wellaccepted alternative treatment for patients with biliary obstruction and failed ERCP. The average technical success and adverse event rates of this EUS intervention have been reported to be 90% and 17%, respectively. Adverse events include abdominal pain, hemorrhage, pneumoperitoneum, infection, biliary leakage, and dislodged stents. In cases of dislodged stents, the patients have early acute biliary peritonitis, given a significant hole in the liver and the stomach. These patients can deteriorate quickly and need urgent surgical repair. However, most of those patients have advanced malignant diseases, and with its increased morbidity risk, an endoscopic approach would definitely be warranted. Here we report the case of an 86-year-old fragile woman who was admitted with painless jaundice and massively congested intrahepatic ducts (Fig. 1). An outside MRCP showed a suspicious-looking lesion in the tail of the

Tumour budding in pancreatic cancer revisited: validation of the ITBCC scoring system

Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal malignancy with rising incidence. Biomarkers that would help the prognostic stratification of patients are needed urgently. Although tumour budding (BD) is a strong and independent prognostic factor in PDAC it is not included in histopathology reports, due partly to the lack of a standardised scoring system. The aim of the present work is to assess the reliability and reproducibility of the BD scoring system proposed recently by the International Tumour Budding Consensus Conference (ITBCC) 2016 in a well‐characterised PDAC cohort (n = 120) with complete clinicopathological and follow‐up information.

Selective survival advantage associated with primary tumor resection for metastatic gastric cancer in a Western population.

BackgroundThe prognosis of metastatic gastric cancer (GC) remains dismal, with a median survival of 10xa0months. Historically, primary tumor resection was not thought to confer any survival benefit. Although high-level data exist guiding treatment of metastatic GC for patients in the East, no such data exist for Western patients despite inherent ethnic differences in GC biology.MethodsThe 2006–2012 National Cancer Database was queried for adult patients with metastatic gastric adenocarcinoma. Patients were classified into those who underwent primary tumor resection and chemotherapy (PTRaC) and those who received chemotherapy only. Groups were propensity score matched, and survival was compared using advanced statistical modeling.ResultsA total of 7026 patients met the inclusion criteria: 6129 (87%) patients were treated with chemotherapy alone and 897 (13%) patients were treated with PTRaC. After multivariable adjustment, patients who underwent PTRaC had a significantly better overall survival (OS) than patients who received systemic therapy only (HR, 0.60; 95% CI, 0.56–0.64; pxa0<xa00.001). Following full bipartite propensity score-adjusted analysis, 2-year OS for patients who received chemotherapy only was 12.6% (95% CI, 11.7–13.5%), whereas it was 34.2% (95% CI, 31.3–37.5%) for patients who underwent PTRaC (HR for resection: 0.52; 95% CI, 0.47–0.57; pxa0<xa00.001).ConclusionOur data suggest that there exists a subset of patients with metastatic GC for which PTRaC may improve OS. As significant uncertainty still remains, our results support the need for further prospective trials investigating the influence of palliative gastrectomy on survival among Western patients.

Minimally invasive gastrectomy for gastric cancer: A national perspective on oncologic outcomes and overall survival

BACKGROUNDnMinimally invasive (MI) gastrectomy has become increasingly common as a resection technique for gastric cancer; however, data are limited regarding peri-operative morbidity, oncologic outcomes and long-term survival, particularly in the Western patient population.nnnSTUDY DESIGNnThe 2010-2012 National Cancer Data Base was queried for adult patients who underwent gastrectomy for localized, intestinal-type gastric adenocarcinoma. Patients were classified by surgical approach (MI vs. open gastrectomy) on an intent-to-treat basis. Groups were propensity score matched using a 1:1 nearest neighbor algorithm, and outcomes were compared. Survival was estimated using the Kaplan-Meier method.nnnRESULTSnAmong 5420 patients, 1423 (26%) underwent MI gastrectomy. Following adjustment with propensity matching, all baseline characteristics were highly similar between 1175 patients in each treatment group. Between propensity-matched groups, MI gastrectomy patients had similar rates of margin-negative resections (91 vs. 90%, pxa0=xa00.447), median lymph node harvest (16 vs. 15, pxa0=xa00.104), and utilization of adjuvant therapies (28 vs. 28%, pxa0=xa00.748). MI gastrectomy was associated with shorter hospital stay (8 vs. 9 days, pxa0<xa00.001) without an increase in unplanned readmissions (7 vs. 6%, pxa0=xa00.456) or 30-day mortality (2 vs. 3%, pxa0=xa00.655). There was no difference in 3-year overall survival (50 vs. 55%, pxa0=xa00.359).nnnCONCLUSIONSnOn a national level, MI gastrectomy for gastric cancer appears to be associated with similar perioperative and long-term outcomes compared to the traditional open approach. While prospective studies remain essential, these data provide greater equipoise for ongoing trials and institutional efforts to further implement and evaluate this technique.

Evaluation of a 3D planning tool for irreversible electroporation treatmentin pancreatic cancer

Local ablation is a treatment alternative for patients with unresectable cancer. Irreversible-electroporation (IRE) is a non-thermal ablation technique that spares vessels and thus is predisposed for appropriate treatment of locally advanced pancreatic cancer. Correct needle positioning and parallel placement is a prerequisite for an efficient and complication-free IRE treatment. Therefore, we propose a 2D/3D planning and visualization solution to support the surgeon during this crucial procedure.