Tailoring the Use of Central Pancreatectomy Through Prediction Models for Major Morbidity and Postoperative Diabetes: International Retrospective Multicenter Study.

OBJECTIVE: To develop a prediction model for major morbidity and endocrine dysfunction after CP which could help in tailoring the use of this procedure. SUMMARY BACKGROUND DATA: Central pancreatectomy (CP) is a parenchyma-sparing alternative to distal pancreatectomy for symptomatic benign and pre-malignant tumors in body and neck of the pancreas CP lowers the risk of new-onset diabetes and exocrine pancreatic insufficiency compared to distal pancreatectomy but it is thought to increase the risk of short-term complications including postoperative pancreatic fistula (POPF). METHODS: International multicenter retrospective cohort study including patients from 51 centers in 19 countries (2010-2021). Primary endpoint was major morbidity. Secondary endpoints included POPF grade B/C, endocrine dysfunction, and the use of pancreatic enzymes. Two risk model were designed for major morbidity and endocrine dysfunction utilizing multivariable logistic regression and internal and external validation. RESULTS: 838 patients after CP were included (301 (36%) minimally invasive) and major morbidity occurred in 248 (30%) patients, POPF B/C in 365 (44%), and 30-day mortality in 4 (1%). Endocrine dysfunction in 91 patients (11%) and use of pancreatic enzymes in 108 (12%). The risk model for major morbidity included male sex, age, BMI, and ASA score≥3. The model performed acceptable with an area under curve (AUC) of 0.72(CI:0.68-0.76). The risk model for endocrine dysfunction included higher BMI and male sex and performed well (AUC:0.83 (CI:0.77-0.89)). CONCLUSIONS: The proposed risk models help in tailoring the use of CP in patients with symptomatic benign and premalignant lesions in the body and neck of the pancreas and are readily available via www.pancreascalculator.com.

Parenchymal-sparing hepatectomy with hepatic vein resection and reconstruction.

BACKGROUND: Hepatectomy remains the most important treatment modality for most malignant liver tumors. Vascular involvement stays a reason for unresectability or major parenchymal resection. A possible way to avoid this is parenchymal-sparing hepatectomy (PSHX) with vascular resection and reconstruction (HVRR). In this article, we aim to demonstrate the specific role of this technique in avoiding post-hepatectomy liver failure (PHLF). METHODS: A retrospective analysis of 10 patients who underwent HVRR was conducted. 99mTechnetium-mebrofenin hepatobiliary scintigraphy (HBS) was used to predict the future liver remnant function (FLRF). Calculations were made for each patient to compare HVRR and major hepatectomy (with or without portal vein embolization). RESULTS: In our cohort, there was no perioperative mortality. Two patients suffered a Clavien-Dindo grade 3a complication and none had clinically significant PHLF. Estimated FLRF was significantly higher in HVRR compared to major hepatectomy after portal vein embolization (p < .005). CONCLUSIONS: Instead of focusing on inducing liver remnant hypertrophy, preserving parenchyma through HVRR can be an interesting treatment strategy. It can be performed with an acceptable operative risk. Calculations of FLRF (using HBS) suggest that this approach is able to reduce the risk for PHLF and related morbidity or mortality.

Atriobronchial Fistula Complicated by Septic Cerebral Air Emboli After Pulmonary Vein Ablation.

OBJECTIVE: To describe a case of an infected atriobronchial fistula as a late complication after pulmonary vein ablation, leading to septic air emboli and requiring urgent cardiac surgery. DATA SOURCES: Clinical observation. STUDY SELECTION: Case report. DATA EXTRACTION: Relevant clinical information. PubMed was searched for relevant literature. DATA SYNTHESIS: Given its high success and low complication rate, pulmonary vein isolation is expected to be increasingly performed worldwide. Despite its success, some of its rare complications are potentially devastating and are difficult to diagnose early. In this report, we present the case of a 32-year-old woman, who was readmitted to hospital 2 months after pulmonary vein ablation. The clinical picture resembled meningococcemia with spreading petechiae on legs and arms raising concern for Waterhouse-Friderichsen syndrome. Further echocardiographic investigation led to the discovery of massive amounts of intracardiac air which demanded urgent lung isolation and sternotomy. Intraoperatively a small infected left atrial perforation was oversewn and a fistula to the right main bronchus was closed by means of an autologous pericardial patch. One month later, still revalidating, she could be discharged home with only minor neurologic sequelae. CONCLUSIONS: Clinicians should be aware of the dramatic complications of invasive antiarrhythmic procedures and their atypical and late presentations. Better preprocedural appreciation of cardiac wall thickness, early echocardiographic diagnosis, and swift referral for cardiac surgery might impact outcome dramatically.