Michael G. Hurtuk

Does lymph node ratio impact survival in resected periampullary malignancies

BACKGROUND Lymph node ratio (LNR) has been associated with long-term survival in patients with pancreatic adenocarcinoma; however, this has not been demonstrated in other periampullary malignancies. The purpose of this study was to determine if LNR is associated with survival in other periampullary malignancies. METHODS A retrospective review of a prospective database of 522 pancreaticoduodenectomies (PDs) performed between 1988 and 2007 was undertaken. Clinicopathologic data were collected, and LNR was calculated. Patients with positive lymph node (LN) status were placed into the following groups: (1) LNR = 0; (2) LNR < or =0.2; (3) LNR < or =0.4; and (4) LNR >0.4. RESULTS Of the 364 malignancies identified, there were 219 (60%) pancreatic adenocarcinomas, 36 (10%) duodenal adenocarcinomas, 75 (21%) ampullary adenocarcinomas, and 35 (10%) cholangiocarcinomas. Positive LN status affected patient survival in all malignancies studied. Increasing LNR is associated with decreased survival in PA (P = .03) and AA (P = .04). CONCLUSIONS Positive LN status in all patients with periampullary malignancies is associated with worse survival rates than in those with no evidence of disease. LNR is inversely associated with survival rates in pancreatic and ampullary adenocarcinoma patients.

Pancreaticoduodenectomies in patients without periampullary neoplasms: lesions that masquerade as cancer

BACKGROUND Most pancreaticoduodenectomies (PDs) are performed to treat periampullary malignancies (PMs). Final pathologic analysis on these specimens does not always contain PMs. Our aim was to classify diseases that preoperatively mimic PMs. METHODS A prospective database of PDs performed at a single institution was reviewed. Clinicopathologic data on patients without PM on pathologic review with preoperative suspicion of PM were studied. RESULTS Of the 461 PDs performed at our institution, 45 (10%) had no PM; of these cases, 35 (78%) were performed for a clinical suspicion of malignancy. The final pathologic review showed chronic pancreatitis (CP) in 23 (66%) patients, biliary tract disease in 10 (28%) patients, duodenal ulcer in 1 (3%) patient, and distal common bile duct stricture with localized pancreatic fibrosis in 1 (3%) patient. CONCLUSION Most patients undergoing PD have evidence of a PM. A subset of patients may have lesions that mimic a PM. In these patients, when PM cannot be ruled out, if possible, they should be offered PD.

Important region in the β-spectrin C-terminus for spectrin tetramer formation

Abstract: Many hereditary hemolytic anemias are due to spectrin mutations at the C‐terminal region of β‐spectrin (the βC region) that destabilize spectrin tetramer formation. However, little is known about the βC region of spectrin. We have prepared four recombinant β‐peptides of different lengths from human erythrocyte spectrin, all starting at position 1898 of the C‐terminal region, but terminating at position 2070, 2071, 2072 or 2073. Native polyacrylamide gel electrophoresis showed that the two peptides terminating at positions 2070 and 2071 did not associate with an N‐terminal region α‐peptide (Spα1–156) in the micromolar range. However, the peptides that terminated at positions 2072 and 2073 associated with the α‐peptide. Circular dichroism results showed that the unassociated helices in both α‐ and β‐peptides became associated, presumably to form a helical bundle, for those β‐peptides that formed an αβ complex, but not for those β‐peptides that did not form an αβ complex. In addition, upon association, an increase in the α‐helical content was observed. These results showed that the β‐peptides ending prior to residue 2072 (Thr) would not associate with α‐peptide, and that no helical bundling of the partial domains was observed. Thus, we suggest that the C‐terminal segment of β‐spectrin, starting from residue 2073 (Thr), is not critical to spectrin tetramer formation. However, the C‐terminal region ending with residue 2072 is important for its association with α‐spectrin in forming tetramers.

Preoperative liver function tests and hemoglobin will predict complications following pancreaticoduodenectomy.

IntroductionPrevious studies identified an association between dilated pancreatic and biliary ducts and lower rates of pancreatic leak after pancreaticoduodenectomy, but it remains unclear whether elevated liver function tests are also associated with lower rates of complications. The purpose of this study was to determine if preoperative liver function tests are associated with postoperative complications.Materials and MethodsWe identified 452 patients who received a pancreaticoduodenectomy from 1990–2007. Clinicopathological data was collected for each patient, and regression analyses were performed to identify predictors of postoperative complications.ResultsOf the patients studied, 289(64%) experienced no postoperative complications. In univariate analysis, patients with a low or normal preoperative aspartate aminotransferase (p = 0.03) or alkaline phosphatase(p = 0.03), had higher rates of complications. Multivariate analysis confirmed an elevated alkaline phosphatase was associated with a lower incidence of complications (OR = 0.56, p = 0.02), while preoperative anemia was found to be a predictor of complications following pancreaticoduodenectomy(OR = 2.01, p = 0.02).ConclusionAnemic patients and those with normal liver function tests were more likely to experience complications after pancreaticoduodenectomy. This may represent extent of disease and tumors not causing biliary or pancreatic dilatation, respectively. Precautions, such as intraoperative ductal stents, should be considered when operating on this group of patients to minimize complications.

Support for a postresection prognostic score for pancreatic endocrine tumors

BACKGROUND Prognostic scores predicting long-term survival of patients with pancreatic neuroendocrine tumors (PNETs) have been created. The purpose of this study was to validate a prognostic scoring scheme at a single institution. METHODS We reviewed all resections for PNETs from 1996 to 2004. Prognostic scores based on patient age, tumor grade, and distant metastasis were calculated. Survival was compared with an established postresection prognostic score for PNETs. RESULTS A total of 34 PNETs were identified. Predicted 5-year survival for prognostic scores of 1, 2, and 3 were 76.7%, 50.9%, and 35.7%, respectively. Final prognostic scores of 1, 2, and 3 were observed in 13 (38%), 18 (53%), and 3 (9%) patients, with observed actual 5-year survivals of 92.3%, 72.2%, and 66.7%, respectively. CONCLUSIONS PNET prognostic scores were found to be inversely related to survival. PNET postresection prognostic score categories may be useful tools in predicting long-term survival.

Su1656 Endoscopic and Surgical Alternatives to Pancreaticoduodenectomy and Distal Pancreatectomy

Purpose: While standard resections such as pancreaticoduodenectomy and distal pancreatectomy are necessary for malignant disease, low grade tumors and benign lesions of the pancreas and duodenum present a unique surgical dilemma. Select patients may benefit from non-standard resections (NSR) which preserve parenchyma and function, and thus may avoid the potential complications inherently related to more traditional resections. Here, we describe our experience with NSR of various pancreatic and duodenal lesions. Methods: A retrospective review of a prospectively collected database of 777 patients who underwent resections of pancreatic and duodenal lesions between 1999 and 2012 was conducted. Of these, 45 patients underwent NSR, defined as pancreatic or duodenal resections excluding standard pancreaticoduodenectomy or distal pancreatectomy. Clinicopathologic features and outcomes were assessed. Results: In sum, 26 males and 19 females were evaluated; median age 64 years (range 30-87) and median follow-up 4.4 years (range 0.3-13.3 years). Preoperatively, 32 patients underwent EGD, 33 EUS, and 39 CT scans. The median lesion size was 2.3 cm (range 0.7-9 cm). The various types of NSR included: 16 pancreas-sparing duodenectomies, 9 central pancreatectomies, 9 enucleations, 6 ampullectomies, 4 transduodenal polypectomies, and 1 endoscopic polypectomy. The final pathologic diagnoses included: 12 villous adenomas, 7 neuroendocrine tumors, 5 mucinous cystadenomas, 5 stromal tumors, 4 duodenal carcinomas, 3 serous cystadenomas, 3 tubular adenomas, 2 lymphoepithelial cysts, 2 IPMNs, and 2 other pathologies. EUS was 100% accurate in predicting depth of mucosal invasion, while EGD and CT were 100% accurate in identifying the lesion location. Furthermore, the overall accuracy of pre-operative imaging in selecting appropriate patients amenable to NSR was 100%. Overall, five patients developed postprocedure complications (10.9%). Of the central pancreatectomies (n=9), three developed pancreatic fistulas (33%), although no patients developed diabetes or steatorrhea. One patient had a subsequent episode of pancreatitis following ampullectomy, and one developed a pancreatic pseudocyst requiring endoscopic drainage following enucleation. There were no peri-operative mortalities. Of the four patients with duodenal carcinomas, all underwent pancreas-sparing duodenectomy, and the overall survival was 50% at the time of analysis (deaths occurred at 1.7 and 4 years; follow-up for two survivors was 4.1 and 11.7 years). Conclusion: Based on our findings, EGD, CT, and EUS were 100% accurate in selecting appropriate patients for NSR. Therefore, proper selection of patients using certain imaging modalities may allow some patients to achieve adequate resection, while avoiding more complicated and morbid procedures, such as pancreaticoduodenectomy or distal pancreatectomy.