Mattia Berselli

Postoperative Pancreatic Fistulas : Preventing Severe Complications and Reducing Reoperation and Mortality Rate

Background:Postoperative pancreatic fistula (POPF) is responsible for severe complications and death in patients who underwent pancreatic surgery. The reported success rate of conservative treatment is around 80%. Therefore up to 20% of patients usually need surgical treatment that can be repeated in some. Uncontrolled sepsis and massive hemorrhage are the main causes for mortality in this setting. Method:Four hundred forty-five patients underwent surgery for pancreatic diseases (January 1993–August 2007); 70 of them developed a POPF. An early aggressive treatment based on interventional radiology was applied to all patients. The drains track and/or percutaneous approach was used to insert catheters into the peripancreatic fluid collection/s or abscess/es. The position of catheters was verified at least once a week. Surgery was performed in case of failure of conservative approach. Results:Conservative treatment (approach by drains track in 49, percutaneous in 16, mixed in 2) was successful in 67 patients. A patient under dialysis had the drains inserted during an emergency surgery for peritonitis 6 days after surgery; a second patient underwent repeated surgical debridement, and a third patient underwent a procedure on the abdominal wall to separate a POPF from a colonic fistula. No patient with diagnosed POPF died. Conclusions:Early aggressive interventional radiology allowed managing conservatively 95.7% of POPF preventing severe complications and avoiding death.

Distal pancreatectomy for body-tail pancreatic cancer: is there a role for celiac axis resection?

Background/Aims: Body-tail pancreatic cancer is an aggressive disease with a low resectability rate and a poor prognosis. Celiac axis invasion usually contraindicates resection. The aim of this study was to analyze the feasibility of distal pancreatectomy (DP) with celiac axis resection (DP-CAR) for locally advanced body-tail pancreatic cancer. Methods: All DPs performed between January 1989 and December 2007 were considered. DP and DP-CAR were reviewed for pre-, intra- and postoperative data. An extensive, detailed literature review on DP and DP-CAR was also performed. Results: DP was performed in 49 of our patients, and 745 cases were retrieved from the literature. The overall morbidity and mortality rates were 32.0 and 3.0%, respectively. We performed DP-CAR in 5 patients with no mortality but 80% morbidity. A further 90 patients were retrieved from the literature. Arterial reconstruction was needed in 1/5 of our patients and in 13/90 of patients in the literature. Collaterals from superior mesenteric artery maintained adequate hepatic artery blood flow in the remaining 81 patients. The overall morbidity and mortality rates were 40.6 and 2.1%, respectively. The median survival ranged between 4.5 and 25 months after DP and was 13 months after DP-CAR. Conclusions: DP-CAR improves resectability without increasing the mortality rate. The complication rate after DP-CAR was higher than after DP, but still within the range of extended DP. DP-CAR should be considered for the inclusion among the ‘extended’ procedures for the treatment of body-tail pancreatic cancers invading the celiac axis.

Metastasis to the Pancreas from Colorectal Cancer: Is There a Place for Pancreatic Resection?

PURPOSE: Pancreatic metastases from colorectal cancer are very rare, and the possible benefit of surgical treatment is not clearly defined. This study was designed to evaluate the outcome of patients undergoing pancreatic resection for metastatic colorectal cancer to the pancreas. METHODS: Nine patients underwent pancreatic resection for metastatic colorectal cancer between January 1980 and December 2006. The primary cancers were colon (n = 7) and rectal carcinoma (n = 2). The median interval between primary treatment and detection of pancreatic metastases was 32.5 months. In three cases pancreatic metastases were synchronous with the primary tumor. RESULTS: Five patients underwent pancreaticoduodenectomy, and four underwent distal pancreatectomy. A left lateral liver section and three colon resections were simultaneously performed in four patients. There was no postoperative mortality, and only two patients experienced complications. Survival averaged 19.8 (median, 17.0; range, 5-30) months: seven patients died of metastatic disease, one for unrelated disease after five months, and one is alive with liver metastases 30 months after surgery. CONCLUSION: Surgical resection can be performed safely in patients with isolated pancreatic metastases from colorectal cancer and in selected patients with associated extrapancreatic disease. Although long-term survival is rare, surgery should be included, whenever possible, in the multimodality approach to this disease.

Survival Rates and Cause of Death in 174 Patients with Chronic Pancreatitis

BackgroundThe natural history after surgery for chronic pancreatitis is rarely reported.MethodsBetween 1970 and 1999, 174 patients underwent surgery for chronic pancreatitis and were followed until December 2006. They were divided in four groups: (1) resection 62; (2) drainage 82; (3) external drainage 7; (4) non-pancreas-directed surgery 23. A second procedure was required by 25 patients and a third by four: group 1 = 6 + 0, group 2 = 10 + 2, group 3 = 3 + 1, group 4 = 6 + 1.ResultsHospital mortality was four of 174 (2.3%). Fifty-seven patients are alive; 49 of 170 developed cancer, and 38 died: lung (22), oral, pharynx, larynx (eight), esophagus, kidney, pancreas, colon, liver (two each), breast, stomach, mediastinum, prostate, melanoma, chronic myelogenous leukemia, squamous cancer of the auricle (one each), liver metastasis from unknown primary (two). Fifteen patients died of liver cirrhosis, 13 of myocardial infarction/decompensation, six of vascular problems, five each of acute renal insufficiency or cerebral diseases, four each of acute pancreatitis, accidental trauma, complications of diabetes, bronchopneumonia, and 19 of other causes. The overall 5-, 10-, 15-, 20-, 25-, and 30-year survival rate was 84.7, 65.6, 51.6, 38.0, 28.1, and 23.5.ConclusionsIncidence of pancreatic cancer was 1.2%. The high incidence of smoking cancers (18.8%) is explained by the smoking habits of almost 100% of our patients. Eliminating smoking and increasing tests on organs at risk may prolong survival.

Abdominal localization of Tangier disease mimicking a pancreatic neoplasm.

Tangier disease is a rare genetic disorder of lipid metabolism, characterized by severe deficiency of plasma high-density lipoprotein cholesterol, low-plasma total cholesterol, and accumulation of cholesteryl ester in macrophages. Abdominal manifestation of Tangier disease is extremely rare, being reported only once in the English literature. We describe a 55-year-old patient with this condition, who underwent splenectomy 37 years before, because of splenomegaly with thrombocytopenia, and subsequently presented with abdominal pain and pancreatic mass, simulating a pancreatic tumor. The preoperative diagnosis of endocrine or solid-cystic neoplasm was made, and the tumor was successfully resected with distal pancreatectomy. Histological examination showed that the mass was composed of histiocytic cells containing lipids; some aggregates of giant polynucleated histiocytes with intracytoplasmic cholesterol crystals. To our knowledge, this is the first report of pancreatic manifestation of Tangier disease. As suggested earlier, splenectomy in these patients seems to predispose to deposition of lipids and infiltration of the abdomen by inflammatory cells.

Pancreaticoduodenectomy with unusual artery reconstruction in a patient with celiac axis occlusion: report of a case

Celiac axis stenosis is a relatively common finding that may require major revascularization during pancreaticoduodenectomy. We present a patient that underwent pancreaticoduodenectomy for intraductal papillary mucinous neoplasm of the pancreatic head associated with celiac axis obstruction. To secure arterial blood flow to the upper abdominal organs, the superior posterior pancreaticoduodenal artery and the posterior-inferior pancreatic-duodenal artery were carefully preserved, and anastomosed. The postoperative course was complicated by a pseudoaneurysm of the splenic artery that was successfully treated with angiographic embolization through the vascular bypass. This may be a valid alternative procedure for revascularization of the common hepatic artery during pancreaticoduodenectomy in a patient with celiac axis stenosis.

Outcome of pancreatic resection in elderly patients

Clinical background The increasing aging of the Western population is obviously accomplished by an increasing number of older patients with cancer, including pancreatic cancer. Since surgical resection remains the treatment of choice for pancreatic and periampullary neoplasms, increasing number of elderly patients are being referred for pancreatic resection. Recently, some surgical experiences reported an acceptable morbidity rate and outcome in patients with advanced age. This retrospective study analyzes the effects of age on short-term and long-term outcome in a large series of patients who underwent resection for pancreatic or periampullary disease.

M1540 High Complication Rate After Pancreas Preserving Surgical Procedures for Benign or Borderline Pancreatic Lesions. Careful Selection of Patients Is Needed

in 23 pts, a third in 4 of them: Group 1: 6+0, Group 2: 11+2, Group 3: 3+1, Group 4: 3+1. The actual status at December 31 2006 of all pts was retrieved. The cause of death was retrieved for 111/117 pts. Of the 6 remaining, 1 died abroad, and privacy prevented us to retrieve the cause for the other 5. Results: Hospital mortality was 4/174 (2.3%). 57 pts (32.8%) are still alive. 49 pts (28.2%) developed cancer and 38 died of their cancer, 5 of another disease, 1 of unknown cause, and 5 are still alive. The more frequent was the lung cancer (22 pts) followed by oral, pharynx, larynx and esophageal cancers (10 pts). A small pancreatic cancer (PC) was found in the surgical specimen in 3 pts: 1 died of PC 18.3 years later, 1 died of unknown cause 30.5 years later, and 1 is alive & well 29 years later. A further patient died of PC 9 years after surgery. The other main causes of death were: liver cirrhosis (15 pts), vascular disease (11 pts), MI or failure (10 pts), acute pancreatitis, accidental trauma, complications of diabetes, bronchopneumonia (4 pts each). The overall 5, 10, 15, 20, 25 and 30 years survival rate was 82.8, 63.5, 49.7, 36.4, 27.5 and 23.1 and was the same for the 4 groups (P=0.8447). Conclusions: The incidence of PC was 2.3%, but only 1 (0.6%) appeared during follow-up. The high incidence of lung, oral, pharynx, larynx & esophageal cancers (32/170; 18.8%) during follow-up is due to the smoking habits of almost 100% of our pts (Int J Cancer 2008;122:155-64). Eliminating smoking and increasing tests on organs at risk of cancer during follow-up may prolong survival in these pts.