R. Valente

Pancreatectomy with arterial resection is superior to palliation in patients with borderline resectable or locally advanced pancreatic cancer

BACKGROUND Few studies have investigated the outcome of pancreatectomy associated with artery resection (PAR). METHODS Retrospective analysis of a cohort of operated borderline or locally advanced pancreatic cancer patients with surgically confirmed arterial involvement. Short and long-term outcome were analyzed and compared in patients who underwent PAR (Group 1) and palliative surgery (Group 2). RESULTS Of 73 patients who underwent surgical exploration with intent of resection, 34 underwent PAR (±venous resection) (Group 1) and 39 underwent palliation (Group 2). 23 patients (67.7%) in Group 1 underwent combined artery-vein resection (AVR). Operation time was longer and blood loss higher in group 1 compared to group 2. There were no differences in post-operative mortality (2.9% vs 2.6%, p = 0.9) and post-operative surgical complications (38.2% vs 25.6%, p = 0.2). The 1, 3 and 5 years survival in Group 1 was superior to Group 2 (63.7%, 23.4% and Q3 23.4% vs 41.7%, 3.2% and 0, p = 0.003). CONCLUSION PAR seems to be safe and feasible in well selected patients and associated with an advantage of survival compared to palliation, in patients affected by locally advanced pancreatic cancer.

Minimally Invasive Pancreaticoduodenectomy for the Treatment of Pancreatic-Head and Periampullary Tumors

The outcome of minimally invasive pancreaticoduodenectomy for the treatment of pancreas-head and periampullary cancers is still a matter of debate. If on one hand some studies suggested a potential advantage of applying minimally invasive procedures for the treatment of such tumors,1 on the other hand, other studies reported overall higher rates of morbidity when compared with traditional open surgery.2 It is also noteworthy that, despite a lack of well-designed prospective randomized trials supporting the advantages of minimally invasive procedures over traditional ones, the overall number of the former has been rising over time on a worldwide scale. As underlined by Adam and colleagues,3 in the United States, the percentage of such procedures has increased more than 400% from 2000 to 2012. A possible explanation for such a trend can be understood by looking closely into the details of the balance between supply and demand for such procedures in the general economy. If it is true that there is a rising demand from patients to gain access to minimally invasive pancreaticoduodenectomy, it is also true that surgeons have provided a progressive parallel increase in offering the procedure, possibly also reflecting interinstitutional competitions for patient allocation. In our opinion, it is also noteworthy that these procedures are heterogeneously distributed among different hospitals and, more interestingly, they are unequally distributed among hospitals with different surgical volumes. In fact, according to the authors, 57% of procedures were performed in centers with a volume of fewer than 10 cases per year and 20% in centers with an average volume of 1 case per year. Considering this general overview, it becomes clear that minimally invasive pancreaticoduodenectomy is likely seldom performed in high-volume centers, with most cases being reserved to low-volume hospitals. In our view, the explanation for such a phenomenon cannot be found just in the centralization process that concentrates more difficult cases to high-volume centers. Indeed, and in contrast to the authors, we believe that this distribution might also mirror a better and more accurate baseline selection of patients, possibly suitable for minimally invasive pancreaticoduodenectomy, in high-volume centers compared with low-volume ones. Interestingly, the authors suggested 22 cases per year to be the best threshold for hospital procedural volume. Nevertheless, as the authors correctly remarked in the Discussion section, to have a more consistent overview about the balance between risks and benefits, this number should be weighed against the total number of pancreaticoduodenectomies performed by a center per year, including the total amount of open-surgery procedures. If 22 minimally invasive pancreaticoduodenectomies are enough to obtain acceptable short-term results, in our opinion, the choice of the correct indication, the possibility to apply multimodality treatments, the ability to overwhelm possible complications, and the evaluation of long-term results are all factors that should be taken into consideration when analyzing the overall final outcome of these procedures. It is well demonstrated that hospital volume is inversely correlated with perioperative mortality.4 Particularly in pancreatic surgery, the surgical volume plays an important role in impacting survival.5 Laparoscopy and robotic techniques should be tools in the hands of pancreatic surgeons, and skills in minimally invasive approaches cannot compensate for the lack of experience in pancreatic surgery and in pancreatology. Independently from the surgical procedure applied, we believe that for major pancreatic surgery, surgical volume, instead of the application itself of minimally invasive approaches, might play the major role in determining postoperative and long-term survival outcomes. Future prospective randomized trials, hopefully by highvolume centers, are strongly needed to compare shortand longterm outcomes of minimally invasive and open pancreaticoduodenectomy to balance risks and benefits and to definitively assess its possible role in the future of pancreatic surgery.

Oncological Treatment of Cystic Tumors of the Pancreas

During the last decades, the technical improvement in clinical, abdominal radiological, and endoscopic imaging techniques leads to an increased detection and finest characterization of previously mostly underdiagnosed/misdiagnosed pathological entities such as pancreatic cystic neoplasms. This kind of lesions displays an overall prevalence up to 20 % and a biological spectrum that nuances from benign to malignant behavior.