Riccardo Ariotti

Relaparotomy for a pancreatic fistula after a pancreaticoduodenectomy: a comparison of different surgical strategies

INTRODUCTION A relaparotomy for a pancreatic fistula (PF) after a pancreaticoduodenectomy (PD) is a formidable operation, and the appropriate treatment of anastomotic leakage is under debate. The objective of this study was to compare the outcomes of different strategies in managing the pancreatic remnant during a relaparotomy for PF after a PD. METHODS In this retrospective study on prospectively collected data, 669 PD were performed between 2004 and 2011. The study group comprised 31 patients requiring a relaparotomy, because of delayed haemorrhage (n = 19) or sepsis (n = 12). The pancreatic stump was treated either using pancreas-preserving techniques (simple drainage or duct occlusion) or completion of a pancreatectomy (CP). In 2008, autologous islet transplantation (AIT) was introduced for endocrine tissue rescue of CP. RESULTS The mortality rate, blood loss and transfusion requirement were similar for all techniques. Patients undergoing a CP required a further relaparotomy less frequently than patients with pancreas preservation (7% versus 59%, P < 0.01), and the intensive care unit (ICU) stay was reduced after CP (P = 0.058). PF persisted at discharge in 66% of patients after pancreas-preserving techniques. AIT was associated with CP in 7 patients, of whom one died post-operatively. Long-term graft function was maintained in four out of six surviving patients, with one insulin-independent patient at 36 months after transplantation. CONCLUSIONS When a PF requires a relaparotomy, CP has become our favoured technique. AIT can reduce the metabolic impact of the procedure.

Combined laparoscopic spleen-preserving distal pancreatectomy and islet autotransplantation for benign pancreatic neoplasm

AIM To evaluate the safety and feasibility of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with autologous islet transplantation (AIT) for benign tumors of the pancreatic body-neck. METHODS Three non-diabetic, female patients (age 37, 44 and 35 years, respectively) were declared candidates for surgery, between May and September 2011, because of pancreatic body/neck cystic lesions. The planned operation was an LSPDP associated with AIT from the normal pancreas distal to the neoplasm. Islets isolation was performed on the residual pancreatic parenchyma after frozen section examination of the margin. Purified autologous islets were infused into the portal vein by a percutaneous transhepatic approach the day after surgery. RESULTS The procedure was performed successfully in all the three cases, and the spleen was preserved along with its vessels. Mean operation time was 283 ± 52 min and average blood loss was 133 ± 57 mL. Residual pancreas weights were 33, 22 and 30 g, and 105.200, 40.390 and 94.790 islet equivalents were isolated, respectively. Surgical complications occurred in one patient (grade A pancreatic fistula). Postoperative stays were 6, 6 and 7 d, respectively. Histopathological evaluation revealed mucinous cystic neoplasm in cases 1 and 3, and serous cystic neoplasm in patient 2. No postoperative insulin administration was required. One patient developed a transient partial portal thrombosis 2 mo after islet infusion. Patients are insulin independent at a mean follow up of 8 ± 2 mo. CONCLUSION Combination of LSPDP and AIT is feasible and could be effective to minimize the surgical impact for benign neoplasm of pancreatic body-neck.

Enhanced recovery after surgery in pancreatic surgery: Preliminary data on safety and adherence for new pathways

gene copy number was determined by means of a TaqMan real-time PCR assay. Results: Significantly higher frequencies of the AA genotype of G-20A and the AA genotype of G-52A were observed among the patients with severe acute pancreatitis as compared with the healthy controls (38% vs 20%, and 41% vs 18% respectively). The GG protective genotype of C-44G SNP was much less frequent (1%) among the patients than among the controls (9%). A higher frequency of a lower (<4) copy number of the DEFB4 gene was observed in the patients with severe acute pancreatitis than in the healthy controls (62% vs 24% respectively). Conclusions: The genetic variations in the genes encoding the human b-defensin 1 and that of human b-defensin 2 may be associated with the risk of severe acute pancreatitis.

A new minimally invasive technique for benign neoplasm of the pancreatic body: Laparoscopic spleen-preserving distal pancreatectomy with autologous islet transplantation (AIT)

gene copy number was determined by means of a TaqMan real-time PCR assay. Results: Significantly higher frequencies of the AA genotype of G-20A and the AA genotype of G-52A were observed among the patients with severe acute pancreatitis as compared with the healthy controls (38% vs 20%, and 41% vs 18% respectively). The GG protective genotype of C-44G SNP was much less frequent (1%) among the patients than among the controls (9%). A higher frequency of a lower (<4) copy number of the DEFB4 gene was observed in the patients with severe acute pancreatitis than in the healthy controls (62% vs 24% respectively). Conclusions: The genetic variations in the genes encoding the human b-defensin 1 and that of human b-defensin 2 may be associated with the risk of severe acute pancreatitis.

Metastatic Site in Pancreatic Adenocarcinoma Correlates with Prognosis

Context Pancreatic adenocarcinoma (PA) is mostly metastatic at time of diagnosis with a poor survival. Objective We decided to explore whether metastatic site correlates with prognosis. Methods Patients with pathologic diagnosis of metastatic PA, treated at our Institution with upfront combination chemotherapy between April 1997 and August 2010 were eligible for this analysis. Baseline tumor assessment consisted of contrast enhanced computed tomography scan of the abdomen and the thorax. Results Two-hundreds and sixty-five patients with metastatic PA, median age 60 years; median PS 90; median CA 19-9 1,048 were eligible; 19 (7.2%) had prior pancreatic surgery. Metastases were located: in a single organ (n=150; 56.6%); liver (n=227; 85.3%); peritoneum (n=32; 12.1%); lung (n=53; 19.9%). Lung was the only metastatic site in 15 cases (5.6%). Median and 1-year overall survival (OS) was 9.0 months and 32.2%. Prior surgery correlated with better OS (11.7 and 51.0% versus 8.9 and 30.8%; P=0.006); liver metastases with worse OS (median and 1-year OS: 8.8 months and 29.7% versus 11.1 and 47.4%; P=0.005); while no difference in OS was observed based on number of metastatic sites (P=0.37); peritoneal (P=0.50) or lung metastases (P=0.10). Patients with lung as isolated metastatic site lived longer (17.3 months and 66.7%) with respect to the whole population (9.0 months and 30.1%; P=0.01) and to patients with lung metastases associated to other metastatic sites (8.8 months and 34.2%; P=0.07). Conclusions Prior surgery and metastatic site correlate with prognosis and should be used as a stratification criterion in prospective trials. Patients with lung as isolated metastatic site has a particularly good prognosis.

Post-Pancreatectomy Hemorrhage: Management, Outcome and Predicting Factors of a Life-Threatening Complication

Context Hemorrhagic complications are life-threatening complications occurring after pancreatectomy. Objectives 1. To analyze incidence, management, and clinical outcome of post-pancreatectomy hemorrhage (PPH). 2. To identify factors associated with its occurrence. Methods Retrospective study on prospectively collected data about 981 consecutive patients undergoing a standard pancreatic resection (pancreaticoduodenectomy or left pancreatectomy) between 2004 and 2011. PPH was defined as postoperative clinical or radiological evidence of bleeding, requiring transfusion of packed red blood cells. PPH was stratified based on: time of onset (early: within 24 hr after surgery; late >24 hr); site (intraluminal: in the GI tract; or extraluminal); severity (mild: self-limiting with no need for radiologic or surgical intervention; severe: requiring intervention). Results A total of 65 patients (6.6%) experienced PPH. It was early in 17 (26%) and late in 48 (74%) patients. In 9 cases (14%) PPH was intraluminal, in 56 (86%) extraluminal. In 14 patients (21%) PPH was mild; angiography (with embolization or stenting) was used in 9 patients (14%), and it was successful in 5 patients; the remaining 4 patients needed further radiological or surgical treatment. Relaparotomy for PPH was necessary in overall 49 patients (75%). Mean volume of postoperative transfusion was 1,847±1,997 mL. Re-bleeding after radiological or surgical intervention occurred in 10 patients (15%). Overall mortality in patients with PPH was 45%. Factors predicting PPH were type of surgery (pancreaticoduodenectomy), soft pancreatic stump, and postoperative pancreatic fistula. Conclusion PPH can be a dramatic complication, frequently leading to relaparotomy, and carries a high risk of mortality.

Laparoscopic Versus Open Left Pancreatectomy: Short Term Outcome and Cost-Benefit Analysis

Context An increasing number of surgeons are today performing laparoscopic left pancreatectomy (LLP), since available nonrandomized studies demonstrated its feasibility, safety and oncologic adequacy. However, most existing data come from small single-institution reports or from heterogeneously composed multicenter comparisons. Moreover, there is very limited information about economic implications of minimally invasive pancreatic surgery. Objective This study reports our experience in laparoscopic left pancreatectomy compared with open technique (OLP), assessing perioperative outcomes and financial impact of this procedure in a high volume surgical setting. Methods Between February 2009 and June 2011 we performed 112 left pancreatectomies, 53 of which (47%) were LLP. Excluding the initial learning curve, the remaining 43 patients were matched with a control group selected from our perspective electronic database. Match criteria were gender, age, ASA score, BMI, lesion site, malignant or benign disease. Results Mean operative time was similar (LLP 216±61 min; OLP 214±7 min; P=0.885), blood loss was reduced in LLP (388±371 mL vs. 571±599 mL, P=0.092), especially in cancer patients (514±350 mL vs . 946±787 mL, P=0.072); intraoperative transfusion and unplanned splenectomy rates were similar. Larger lesions were associated with increased unplanned splenectomy rate. Conversion rate (CR) was 18%; higher BMI (>30 kg/m 2 ) and pancreatic body site were associated with increased CR. There were no differences in positive margin rates, number of nodes examined and number of N1 patients. There was no mortality in both groups. Overall morbidity was equable (63% in LLP, 60% in OLP; P=0.958), as well as major complication rate (7% in LLP, 3% in OLP; P=0.604). Clinically significant pancreatic fistula rate was 14% in LLP and 9% in OLP (P=0.728). No grade C fistulas were observed. An equal proportion of patients in each group was discharged before removing surgical drain. Delayed gastric empting, wound and urinary tract infection were more frequent in OLP. Mean LOS was 8.37 days in LLP vs . 8.81 days in OLP (P=0.481); LOS in non complicated patients was 6.96 days in LLP vs . 7.50 days in OLP (P=0.220). Mean number of diagnostic test, transfusion rate, antibiotic administration and readmission rate were similar. Each patient of LLP group saved €168.47 because of shorter LOS and slightly fewer complication cost, generating however an extra cost of €767,01 due to more expensive surgical instruments. Conclusion This study confirms safety and oncologic adequacy of this technique, identifying probable risk factors for conversion and demonstrating economic sustainability of LLP. Final balance still have to be realized considering indirect costs as shorter home convalescence, quality of life and better cosmetic result.