A resected case of pancreatic head cancer developing 40 years after lateral pancreaticojejunostomy for chronic pancreatitis.

A 72-year-old male patient presented to our department complaining of with upper abdominal pain and jaundice. He had a history of a side-to-side pancreaticojejunostomy performed 40 years previously for chronic pancreatitis. A diagnostic workup revealed a tumor 3 cm in size in the pancreatic head as the etiology of the jaundice. Subsequently, the patient was diagnosed with resectable pancreatic cancer. Following two cycles of neoadjuvant chemotherapy, an extended pancreatoduodenectomy was performed because of tumor invasion at the previous pancreaticojejunostomy site. Concurrent portal vein resection and reconstruction were performed. Pathological examination confirmed invasive ductal carcinoma (T2N1M0, Stage IIB). This case highlights the clinical challenges in pancreatic head carcinoma following a side-to-side pancreaticojejunostomy. Although pancreaticojejunostomy is believed to reduce the risk of pancreatic cancer in patients with chronic pancreatitis, clinicians should be aware that, even after this surgery, there is still a chance of developing pancreatic cancer during long-term follow-up.

Prognostic and recurrent significance of SII in patients with pancreatic head cancer undergoing pancreaticoduodenectomy.

Background: To investigate the clinical significance of preoperative inflammatory status in patients with pancreatic head carcinoma (PHC), we performed a single-center study to assess it. Method: We studied a total of 164 patients with PHC undergoing PD surgery (with or without allogeneic venous replacement) from January 2018 to April 2022. Systemic immune-inflammation index (SII) was the most important peripheral immune index in predicting the prognosis according to XGBoost analysis. The optimal cutoff value of SII for OS was calculated according to Youden index based on the receiver operating characteristic (ROC) curve and the cohort was divided into Low SII group and High SII group. Demographic, clinical data, laboratory data, follow-up data variables were obtained and compared between the two groups. Kaplan-Meier curves, univariable and multivariable Cox regression models were used to determine the association between preoperative inflammation index, nutritional index and TNM staging system with OS and DFS respectively. Results: The median follow-up time was 16 months (IQR 23), and 41.4% of recurrences occurred within 1 year. The cutoff value of SII was 563, with a sensitivity of 70.3%, and a specificity of 60.7%. Peripheral immune status was different between the two groups. Patients in High SII group had higher PAR, NLR than those in Low SII group (P <0.01, <0.01, respectively), and lower PNI (P <0.01). Kaplan-Meier analysis showed significantly poorer OS and DFS (P < 0.001, <0.001, respectively) in patients with high SII. By using the multivariable Cox regression model, high SII (HR, 2.056; 95% CI, 1.082-3.905, P=0.028) was significant predictor of OS. Of these 68 high-risk patients who recurrence within one year, patients with widespread metastasis had lower SII and worse prognosis (P <0.01). Conclusion: High SII was significantly associated with poor prognosis in patients with PHC. However, in patients who recurrence within one year, SII was lower in patients at TNM stage III. Thus, care needs to be taken to differentiate those high-risk patients.

Prediction scores of postoperative liver metastasis and long-term survival of pancreatic head cancer based on the distance between the mesenteric vessels and tumor, preoperative serum carbohydrate antigen 19-9 level, and lymph node metastasis rate.

BACKGROUND: The shortest distance between the superior mesenteric artery (SMA) or superior mesenteric vein (SMV) and the tumor margin was combined with preoperative serum carbohydrate antigen (CA) 19-9 and lymph node ratio (LNR) to evaluate joint effects on long-term survival and liver metastasis in patients with pancreatic head cancer after radical surgery. METHODS: This retrospective study included 149 patients who underwent pancreaticoduodenectomy for pancreatic head cancer at Harbin Medical University Tumor Hospital from May 2011 to March 2021. The preoperative serum CA 19-9 level and LNR were combined with the SMA or SMV distance. The joint association between long-term survival and postoperative liver metastasis was evaluated. RESULTS: Based on the receiver operating characteristic curve of postoperative liver metastasis or long-term survival, the optimal cut-off values of SMV distance were 3.1 and 0.7 mm, respectively, whereas the optimal cut-off value of SMA distance was 10.25 mm. The univariate model identified the liver metastasis score (p < 0.001) as a negative factor for postoperative liver metastasis of pancreatic head carcinoma. The SMV distance (p = 0.003), SMA distance (p < 0.001), LNR score (p < 0.001), and survival score (p < 0.001) were negatively correlated with long-term survival after pancreatic head cancer. The multivariate model highlighted SMA distance (p < 0.001), survival score (p = 0.001), and LNR score (p < 0.001) as independent risk factors for long-term survival in pancreatic head cancer. CONCLUSION: Liver metastasis score may be an independent predictor of postoperative liver metastasis in patients with pancreatic head cancer. Survival and LNR scores may be independent predictors of long-term postoperative survival in patients with pancreatic head cancer. However, the LNR score appears to improve long-term survival.

Percutaneous transhepatic cholangial drainage combined with intra-tumoral iodine-125 seeds implantation and chemotherapy for locally progressive pancreatic head cancer with obstructive jaundice.

Purpose: To investigate the clinical efficacy of percutaneous transhepatic cholangial drainage (PTCD) combined with intra-tumoral iodine-125 (125I) particle implantation and chemotherapy in the treatment of locally advanced pancreatic head cancer (LAPHC) with obstructive jaundice. Material and methods: Twenty-one patients with LAPHC with obstructive jaundice were selected, and routine examination before surgery to determine location of obstruction and degree of bile duct dilatation was performed. All 21 patients underwent PTCD first, and usual examinations, including liver and kidney function, were re-examined after operation. When the liver function recovered significantly, patients were treated with seed implantation and systemic chemotherapy after surgery. Clinical efficacy and complications of 21 patients were observed, and changes in survival time and serum level of tumor markers were analyzed. Results: After combined treatment, there were 3 cases of complete response (CR), 12 cases of partial response (PR), 3 cases of stable disease (SD), and 3 cases of progressive disease (PD) in 21 patients. The overall effective rate was 71.43%, and the local control rate was 85.71%. The pain relief was statistically significant one month after treatment, compared with that before treatment (VAS scores: 6.76 ±2.25 vs. 3.25 ±1.92, p < 0.001), and the rate of pain relief was 71.43% (15/21). In all patients, jaundice, abdominal pain, and abdominal distension improved to different degrees after surgery, and the skin pruritus disappeared. Bilirubin and transaminase improved to varying degrees 3 days, 1 week, and 4 weeks after treatment (p < 0.05). Cancer antigen 199 (CA-199), carcinoembryonic antigen (CEA), and cancer antigen 125 (CA-125) after combination therapy, achieved statistically significant differences (t = 9.525, 10.378, 3.262, respectively, p < 0.05). The overall survival time of 21 patients was 11.6 months, ranging from 3.9 to 22.6 months. Conclusions: For LAPHC patients with obstructive jaundice, PTCD combined with particle implantation and chemotherapy is clinically effective in improving the quality of life and prolonging survival.

Clinical value of extended lymphadenectomy in radical surgery for pancreatic head carcinoma at different T stages.

BACKGROUND: As the lymph-node metastasis rate and sites vary among pancreatic head carcinomas (PHCs) of different T stages, selective extended lymphadenectomy (ELD) performance may improve the prognosis of patients with PHC. AIM: To investigate the effect of ELD on the long-term prognosis of patients with PHC of different T stages. METHODS: We analyzed data from 216 patients with PHC who underwent surgery at our hospital between January 2011 and December 2021. The patients were divided into extended and standard lymphadenectomy (SLD) groups according to extent of lymphadenectomy and into T1, T2, and T3 groups according to the 8th edition of the American Joint Committee on Cancer's staging system. Perioperative data and prognoses were compared among groups. Risk factors associated with prognoses were identified through univariate and multivariate analyses. RESULTS: The 1-, 2- and 3-year overall survival (OS) rates in the extended and SLD groups were 69.0%, 39.5%, and 26.8% and 55.1%, 32.6%, and 22.1%, respectively (P = 0.073). The 1-, 2- and 3-year disease-free survival rates in the extended and SLD groups of patients with stage-T3 PHC were 50.3%, 25.1%, and 15.1% and 22.1%, 1.7%, and 0%, respectively (P = 0.025); the corresponding OS rates were 65.3%, 38.1%, and 21.8% and 36.1%, 7.5%, and 0%, respectively (P = 0.073). Multivariate analysis indicated that portal vein invasion and lymphadenectomy extent were risk factors for prognosis in patients with stage-T3 PHC. CONCLUSION: ELD may improve the prognosis of patients with stage-T3 PHC and may be of benefit if performed selectively.

Total mesopancreas excision is the better staging tool of the mesopancreas in pancreatic head carcinoma.

Preoperative imaging staging based on tumor, node, metastasis classification cannot be effective to avoid R1 resection because only further improvements in imaging technologies will allow the precise assessment of perineural and lymphatic invasion and the occurrence of microscopic tumour deposits in the mesopancreas. However, waiting for further improvements in imaging technologies, total mesopancreas excision remains the only tool able to precisely assess mesopancreatic resection margin status, maximize the guarantee of radicality in cases of negative (R0) mesopancreatic resection margins, and stage the mesopancreas.

Application and progress of medical imaging in total mesopancreas excision for pancreatic head carcinoma.

Pancreatic head carcinoma (PHC) is one of the common gastrointestinal malignancies with a high morbidity and poor prognosis. At present, radical surgery is still the curative treatment for PHC. However, in clinical practice, the actual R0 resection rate, the local recurrence rate, and the prognosis of PHC are unsatisfactory. Therefore, the concept of total mesopancreas excision (TMpE) is proposed to achieve R0 resection. Although there have various controversies and discussions on the definition, the range of excision, and clinical prognosis of TMpE, the concept of TMpE can effectively increase the R0 resection rate, reduce the local recurrence rate, and improve the prognosis of PHC. Imaging is of importance in preoperative examination for PHC; however, traditional imaging assessment of PHC does not focus on mesopancreas. This review discusses the application of medical imaging in TMpE for PHC, to provide more accurate preoperative evaluation, range of excision, and more valuable postoperative follow-up evaluation for TMpE through imaging. It is believed that with further extensive research and exploratory application of TMpE for PHC, large-sample and multicenter studies will be realized, thus providing reliable evidence for imaging evaluation.

[Preoperative diagnostics in periampullary adenocarcinomas]. / Präoperative Diagnostik bei periampullären Adenokarzinomen.

BACKGROUND: Approximately 30-40% of pancreatoduodenectomies for adenocarcinomas result in nonpancreatic periampullary adenocarcinoma as the final diagnosis. Depending on the origin, a distinction is made between four different carcinomas with histomorphological subtypes. OBJECTIVE: Carcinoma location and subtype are of prognostic and therapeutic relevance; however, the preoperative differentiation is often incorrect despite modern diagnostics. MATERIAL AND METHODS: Overview of the current literature on the classification and preoperative diagnostics of periampullary adenocarcinomas. RESULTS: A precise knowledge of the papillary anatomy is necessary for the correct classification of diagnostic findings. Current studies demonstrate diagnostically valuable information from the anamnesis, imaging and endoscopy. CONCLUSION: In ca. 70-80% of cases a correct diagnosis of the type of periampullary adenocarcinoma is possible on the basis of interdisciplinary diagnostics. This potentially enables a correspondingly individualized treatment planning in the preoperative phase.

CA19-9 Level to Serum γ-Glutamyltransferase as a Potential Prognostic Biomarker in Patients with Pancreatic Head Carcinoma.

BACKGROUND: The aim of this study was to reduce the influence of biliary obstruction on carbohydrate antigen 19-9 level (CA19-9) by introducing the CA19-9 level to serum γ-glutamyltransferase (GGT) ratio as an indicator, and ultimately to reveal the correlation between CA19-9/GGT and the prognosis of patients with pancreatic head carcinoma (PHC). METHODS: A total of 339 enrolled patients who underwent pancreatoduodenectomy for PHC in Beijing ChaoYang Hospital from January 2010 to December 2019 were analyzed retrospectively. The optimal cut-off value, according to which patients were divided into a low-ratio group (Group 1, n=179) and a high-ratio group (Group 2, n=160), was determined by the ROC curve obtained from preoperative CA19-9/GGT and 1-year survival. Through univariate and multivariate analyses, risk factors for postoperative tumor recurrence and long-term survival were screened out among PHC patients. RESULTS: The best cut-off value of CA19-9/GGT was 2.07 (area under the curve=0.567, 95% CI 0.498-0.636). Compared with Group 2, Group 1 had lower CA19-9, and higher GGT, total bilirubin (TB) and lymph-node metastasis rate (P<0.05). The 1-, 2- and 3-year disease-free survival rates of patients in Groups 1 and 2 were 68.2%, 42.5% and 28.2%, and 42.2%, 19.3% and 18.3%, respectively (P=0.000), and the 1-, 2- and 3-year overall survival rates were 79.1%, 50.7% and 29.1%, and 56.7%, 22.2% and 17.2%, respectively (P=0.000). Multivariate analysis showed that CA19-9/GGT, portal system invasion and lymph-node metastasis were independent risk factors for postoperative tumor recurrence and long-term survival among patients with PHC. CONCLUSION: Compared with CA19-9 level alone, CA19-9/GGT plays a more precise role in the evaluation of postoperative tumor recurrence and the long-term prognosis of PHC patients. The lower the ratio, the better the long-term prognosis. The CA19-9/GGT ratio may prove to be a useful biomarker for identifying PHC patients at high risk of early recurrence and unfavorable prognosis.

Ratio of CA19-9 level to total bilirubin as a novel prognostic indicator in patients with pancreatic head carcinoma following curative resection.

BACKGROUND: Ratio of carbohydrate antigen 19-9 level to total bilirubin (CA19-9/TB) is used to reduce the influence of obstructive jaundice on the concentration of CA19-9, thereby determining the correlation between CA19-9/TB and tumor recurrence or long-term prognosis of patients with pancreatic head cancer (PHC). METHODS: In this study, a total of 339 patients were enrolled. The optimal cut-off value of CA19-9/TB was determined by ROC curve based on preoperative CA19-9/TB and 1-year survival, and the patients were divided into low-ratio group (Group 1) and high-ratio group (Group 2) accordingly. Univariate and multivariate analyses were performed to screen out the risk factors affecting postoperative recurrence and long-term prognosis of PHC. RESULTS: The best cut-off value of CA19-9/TB was 7.7. [area under curve (AUC), 0.599, 95% CI: 0.533-0.666] Compared with Group 1, Group 2 had lower CA19-9, higher TB and lymph node metastasis rate (P<0.05). The 1-, 2- and 3-year disease-free survival (DFS) rates of patients in Group 1 and Group 2 were 70.1%, 44.3% and 30.8%, 39.9%, 17.1% and 13.6%, respectively (P=0.000), and the 1-, 2- and 3-year overall survival (OS) rates were 81.5%, 52.1% and 31.5%, 53.7%, 20.5% and 14.2%, respectively (P=0.000). Multivariate analysis showed that CA19-9/TB, portal vein invasion and lymph node metastasis were independent risk factors for postoperative tumor recurrence and long-term survival of PHC. CONCLUSIONS: Compared with CA19-9 alone, CA19-9/TB is more valuable in judging postoperative tumor recurrence and long-term survival of PHC. The lower the ratio, the better the long-term prognosis.

Pancreatic ductal adenocarcinoma and distal cholangiocarcinoma: a proposal of preoperative diagnostic score for differential diagnosis.

PURPOSE: The differential diagnosis between primary adenocarcinoma of the pancreas head and distal cholangiocarcinoma remains a clinical challenge. Recent studies have shown important differences in terms of survival between these tumors. Therefore, different treatments should be considered, but the preoperative histological diagnosis is still difficult. Aim of this study is to create a preoperative diagnostic score for differential diagnosis between primary pancreatic adenocarcinoma and primary distal cholangiocarcinoma. METHODS: One hundred eighty consecutive patients who underwent pancreaticoduodenectomy at Sapienza University of Rome from January 2010 to December 2019 were retrospectively analyzed. Inclusion criteria were pancreatic or biliary histologic origin obtained by definitive postoperative histological examination. Exclusion criteria were diagnosis of ampullary carcinoma, non-ampullary duodenal adenocarcinoma, pancreatic metastasis, and benign disease. One hundred one patients were considered eligible for the retrospective study. Preoperative biological, clinical, and radiological parameters were considered. RESULTS: CRP > 10 mg/dL (p = 0.001), modified Glasgow Prognostic Score 2 (p = 0.002), albumin < 35 g/L (p = 0.05), CA 19-9 > 230 U/mL (p = 0.001), and Wirsung diameter > 3 mm (p < 0.001) were significant at univariate logistic analysis. Multivariate logistic analysis has shown that parameters independently associated with primary pancreatic adenocarcinoma were CRP > 10 mg/dL (p = 0.012), CA 19-9 > 230 U/mL (p = 0.043), and diameter of the Wirsung > 3 mm (p = 0.005). Through these parameters, a diagnostic score has been developed to predict a primary pancreatic adenocarcinoma when > 1 and a primary distal cholangiocarcinoma when < 1. CONCLUSION: This feasible and low-cost diagnostic score could have a potential impact to differentiate pancreatic cancer histologic origin and to improve target therapeutic strategy.

Survival outcomes of pancreaticoduodenectomy versus extended pancreaticoduodenectomy procedure for pancreatic head carcinoma: a propensity score matching study.

BACKGROUND: It is unclear if the modified extended pancreaticoduodenectomy (PD) has better outcome superior the conventional PD for patients with pancreatic head carcinoma (PHC). The objective of this study is to compare the survival outcomes of the classic PD procedure and the modified extended PD procedure for PHC. METHODS: A total of 7,084 resected PHC patients with PD and extended PD procedure from the SEER database from 2004 to 2014 were stratified. With the utilization of propensity score matching (PSM), patient baseline characteristics were balanced to decrease the bias. Overall survival (OS) and cancer-specific survival (CSS) were analyzed in both groups. RESULTS: Of the 7,084 patients, 6,541 (92.3%) and 543 (7.7%) patients received PD and extended PD surgical procedures, respectively. After 2:1 ratio of PSM, 543 patients with extended PD procedure and 1,084 patients with PD procedure were completely matched. The median CSS and OS for PD and extended PD group were 20.0 and 19.0 months, and 19.0 and 18.0 months, respectively. The 5-year CSS and OS rates for PD and extended PD group were 17.5% and 16.1%, and 13.9% and 13.1%, respectively. CONCLUSIONS: There is no distinct difference in survival outcomes between PD and extended PD procedure in patients with PHC.

Comparison Between Dunking (Invagination) Pancreaticojejunoanastomosis and Double Layer Duct to Mucosa Anastomosis After Cephalic Duodenopancreatectomy-Whipple Procedure for Pancreatic Cephalic Carcinoma.

INTRODUCTION: Pancreatic cancer is malignancy with poor prognosis for quality of life and overall survival. The incidence is variant, 7.7/100,000 in Europe, 7.6/100,000 in the USA, 2.2/100.000 in Africa. The only real benefit for cure is surgery, duodenopancreatectomy. The key points for this procedure are radicality, low morbidity and low mortality, the follow up and the expected overall survival. The benchmark of the procedure is the pancreaticojejunoanastomosis, with its main pitfall, postoperative pancreatic fistula B or C. Subsequently, the manner of creation of pancreaticojejunoanastomosis defines the safety, thus the postoperative morbidity and mortality. Finally, this issue remarkably depends on the surgeon and the surgical technique creating the anastomosis. We used 2 techniques with interrupted sutures, dunking anastomosis and duct-to-mucosa double layer technique. The objective of the study was to compare these 2 suturing techniques we applied, and the aim was to reveal the risk benefit rationale for dunking either duct to mucosa anastomosis. MATERIAL AND METHOD: In our last series of 25 patients suffering pancreatic head carcinoma we performed a standard dodenopancreatectomy. After the preoperative diagnosis and staging with US, CICT, tumor markers, they underwent surgery. Invagination-dunking anastomosis was performed in 15, whereas, duct-to-mucosa, double layer anastomosis was performed in 10. In the first group with dunking anastomosis, we had 6 patients with soft pancreas and 8 with narrow main pancreatic duct, less than 3 mm. In the duct-to-mucosa group there were 5 patients with soft pancreas and 4 with narrow main pancreatic duct. All other stages of surgery were unified, so the only difference in the procedure remained on the pancreatojejunoanastomosis. The onset of the postoperative pancreatic fistula was estimated with revelation of 3 fold serum level of alfa amylases from the third postoperative day in the drain liquid. RESULTS: In the duct to mucosa group there wasn't a clinically relevant postoperative pancreatic fistula, while in the dunking anastomosis group we had 4 postoperative pancreatic fistula B, 26 %. One of these 4 patients experienced intraabdominal collection - abscess, conservatively managed with lavation through the drain. Comparing the groups, there was no significant difference between the groups concerning the appearance of postoperative pancreatic fistula: p>0.05, p=0.125. From all 25 patients, in 21 patients biliary stent was installed preoperatively to resolve the preoperative jaundice. All 21 suffered preoperative and postoperative reflux cholangitis, extending the intra-hospital stay. CONCLUSION: So far, there have been many trials referring to opposite results while comparing these 2 techniques in creation of the pancreticojejunoanastomosis. In our study, the duct to mucosa anastomosis prevailed as a technique, proving its risk benefit rationale. However, further large randomized clinical studies have to be conducted to clarify which of these procedures would be the prime objective in the choice of the surgeon while creating pancreatojejunoanastomosis.

Complete duodenal obstruction induced by groove pancreatitis: A case report.

BACKGROUND: Groove pancreatitis (GP) is a type of chronic pancreatitis occurring in an anatomic area between the duodenum, head of the pancreas, and common bile duct. Duodenal obstruction is always caused by malignant pancreatic diseases, such as pancreatic head carcinoma, while is rarely induced by benign pancreatic diseases, such as pancreatitis. CASE SUMMARY: A 39-year-old man presented with a 1-mo history of upper abdominal discomfort. His concomitant symptoms were abdominal distension, postprandial nausea, and vomiting. Contrast-enhanced computed tomography of the abdomen showed thickening of the intestinal wall with enhancement of the descending segment of the duodenum, which could not be clearly differentiated from the head of the pancreas. Upper gastrointestinal radiographs and gastrointestinal endoscopy showed a complete obstruction of the descending duodenum. An operation found that a 3-cm mass was located in the "groove part" of the pancreas and oppressing the descending duodenum. Pancreaticoduodenectomy was performed to relieve the obstruction and thoroughly remove the pancreatic lesions. The pathologic diagnosis was pancreatitis. The patient had an uneventful recovery with no complications. CONCLUSION: Because of the special location and the contracture induced by long-term chronic inflammation, our case reminds surgeons that some benign pancreatic diseases, such as GP, can also present with symptoms similar to those of pancreatic cancer. This knowledge can help to avoid an unnecessary radical operation.

Tongue coating microbiome data distinguish patients with pancreatic head cancer from healthy controls.

Background: The microbiota plays a critical role in the process of human carcinogenesis. Pancreatic head carcinoma (PHC)-associated tongue coating microbiome dysbiosis has not yet been clearly defined.Objective: Our aim is to reveal the bacterial composition shifts in the microbiota of the tongue coat of PHC patients.Design: The tongue coating microbiota was analyzed in 30 PHC patients and 25 healthy controls using 16S rRNA gene sequencing technology.Results: The microbiome diversity of the tongue coat in PHC patients was significantly increased, as shown by the Shannon, Simpson, inverse Simpson, Obs and incidence-based coverage estimators. Principal component analysis revealed that PHC patients were colonized by remarkably different tongue coating microbiota than healthy controls and liver cancer patients. Linear discriminant analysis effect size revealed that Leptotrichia, Fusobacterium,Rothia, Actinomyces, Corynebacterium, Atopobium, Peptostreptococcus, Catonella, Oribacterium, Filifactor, Campylobacter, Moraxella and Tannerella were overrepresented in the tongue coating of PHC patients, and Haemophilus, Porphyromonas and Paraprevotella were enriched in the tongue coating microbiota of healthy controls. Strikingly, Haemophilus, Porphyromonas, Leptotrichia and Fusobacterium could distinguish PHC patients from healthy subjects, and Streptococcus and SR1 could distinguish PHC patients from liver cancer patients. Conclusions: These findings identified the microbiota dysbiosis of the tongue coat in PHC patients, and provide insight into the association between the human microbiome and pancreatic cancer.

Biliary leakage following pancreaticoduodenectomy: Prevalence, risk factors and management.

BACKGROUND: Few studies investigated biliary leakage after pancreaticoduodenectomy (PD) especially when compared to postoperative pancreatic fistula (POPF). This study was to determine the incidence of biliary leakage after PD, predisposing factors of biliary leakage, and its management. METHODS: We retrospectively studied all patients who underwent PD from January 2008 to December 2017 at Gastrointestinal Surgery Center, Mansoura University, Egypt. According to occurrence of postoperative biliary leakage, patients were divided into two groups. Group (1) included patients who developed biliary leakage and group (2) included patients without identified biliary leakage. The preoperative data, operative details, and postoperative morbidity and mortality were analyzed. RESULTS: The study included 555 patients. Forty-four patients (7.9%) developed biliary leakage. Ten patients (1.8%) had concomitant POPF. Multivariate analysis identified obesity and time needed for hepaticojejunostomy reconstruction as independent risk factors of biliary leakage, and no history of preoperative endoscopic retrograde cholangiopancreatiography (ERCP) as protective factor. Biliary leakage from hepaticojejunostomy after PD leads to a significant increase in development of delayed gastric emptying, and wound infection. The median hospital stay and time to resume oral intake were significantly greater in the biliary leakage group. Non-surgical management was needed in 40 patients (90.9%). Only 4 patients (9.1%) required re-exploration due to biliary peritonitis and associated POPF. The mortality rate in the biliary leakage group was significantly higher than that of the non-biliary leakage group (6.8% vs 3.9%, P = 0.05). CONCLUSIONS: Obesity and time needed for hepaticojejunostomy reconstruction are independent risk factors of biliary leakage, and no history of preoperative ERCP is protective factor. Biliary leakage increases the risk of morbidity and mortality especially if concomitant with POPF. However, biliary leakage can be conservatively managed in majority of cases.

Application of three-dimensional visualization technique in total mesopancreas excision(TMp E) for pancreatic head carcinoma / 中国实用外科杂志

OBJECTIVE: To evaluate the application of three-dimensional visualization technique in total mesopancreas excision(TMpE) for pancreatic head carcinoma. METHODS: From January 2013 to June 2017, 105 TMpE for pancreatic head carcinoma were performed in our institution, and clinical data of these cases were analyzed retrospectively. In order to evaluate the feasibility of operation, three-dimensional visualization techniques were applied to observe the site and size of the pancreatic head tumors, and the relationship between the tumors and peripancreatic vessels before the operation. RESULTS: The median operation time was 239 minutes, and the median blood loss was 409 mL. 29 cases with postoperative complications and no perioperative deaths. 74 patients were considered as R0 resection in final threedimensional pathologic examination, and the rate of R0 resection is 70.5%. CONCLUSION: Preoperative application of three-dimensional visualization technique in TMpE can improve preoperative assessment accuracy and increase the rate of R0 resection, in addition to reduce postoperative complications.

Predictors of long-term survival after pancreaticoduodenectomy for peri-ampullary adenocarcinoma: A retrospective study of 5-year survivors.

BACKGROUND: Pancreaticoduodenectomy (PD) is the standard curative treatment for periampullary tumors. The aim of this study is to report the incidence and predictors of long-term survival (≥ 5 years) after PD. METHODS: This study included patients who underwent PD for pathologically proven periampullary adenocarcinomas. Patients were divided into 2 groups: group (I) patients who survived less than 5 years and group (II) patients who survived ≥ 5 years. RESULTS: There were 47 (20.6%) long-term survivors (≥ 5 years) among 228 patients underwent PD for periampullary adenocarcinoma. Patients with ampullary adenocarcinoma represented 31 (66.0%) of the long-term survivors. Primary analysis showed that favourable factors for long-term survival include age < 60 years old, serum CEA < 5 ng/mL, serum CA 19-9 < 37 U/mL, non-cirrhotic liver, tumor size < 2 cm, site of primary tumor, postoperative pancreatic fistula, R0 resection, postoperative chemotherapy, and no recurrence. Multivariate analysis demonstrated that CA 19-9 < 37 U/mL [OR (95% CI) = 1.712 (1.248-2.348), P = 0.001], smaller tumor size [OR (95% CI )= 1.335 (1.032-1.726), P = 0.028] and Ro resection [OR (95% CI) = 3.098 (2.095-4.582), P < 0.001] were independent factors for survival ≥ 5 years. The prognosis was best for ampullary adenocarcinoma, for which the median survival was 54 months and 5-year survival rate was 39.0%, and the poorest was pancreatic head adenocarcinoma, for which the median survival was 27 months and 5-year survival rate was 7%. CONCLUSIONS: The majority of long-term survivors after PD for periampullary adenocarcinoma are patients with ampullary tumor. CA 19-9 < 37 U/mL, smaller tumor size, and R0 resection were found to be independent factors for long-term survival ≥ 5 years.

Multi-modality imaging features distinguish pancreatic carcinoma from mass-forming chronic pancreatitis of the pancreatic head.

The present study retrospectively analyzed computerized tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography-computerized tomography (PET/CT) data to identify features that may distinguish pancreatic carcinoma (PC) from mass-forming chronic pancreatitis (MFCP) of the pancreatic head. The mean diameter of the lesions was larger in the MFCP patients (n=24) than in the PC patients (n=30; 5.44±27 vs. 3.34±1.23 cm; P<0.001). PC lesions showed increased lobulation when compared with the MFCP cases (83.33 vs. 12.5%; P<0.001). Lesions in the MFCP patients exhibited diffuse and marginally distributed calcification. MFCP patients showed increased exudation around the lesion (83.33 vs. 13.33%), pseudocyst formation (58.33 vs. 10%) and thickening of the right renal fascia (83.33 vs. 13.33%) than in the PC patients. MFCP patients also exhibited visible remnants of normal pancreatic tissue within the lesions. MFCP and PC patients could be distinguished by a cutoff value of 4.40 cm for lesion size [area under the curve (AUC): 0.894; 95% confidence interval (CI): 0.810-0.978)], 21.85 Hu for net-increased value in the arterial phase (AUC, 0.799; 95% CI, 0.670-0.928), 37.70 Hu for net-increased value in the portal phase (AUC, 0.798; 95% CI, 0.919-0.677), 4.85 for early standardized uptake value (SUV) of 18F-deoxyglucose (18F-FDG; AUC, 0.934; 95% CI, 0.850-1.018) and 4.90 for delayed SUV of 18F-FDG (AUC, 0.958; 95% CI, 0.878-1.038). These findings demonstrated that the integration of data from dynamic contrast-enhanced CT, MRI and PET/CT imaging may distinguish MFCP from PC.

Comparison of prognostic prediction between nomogram based on lymph node ratio and AJCC 8th staging system for patients with resected pancreatic head carcinoma: a SEER analysis.

BACKGROUND: The prognosis of pancreatic carcinoma (PC) remains poor and the American Joint Committee on Cancer (AJCC) 8th staging system for survival prediction in PC patients after curative resection is still limited. Thus, the aim of this study is to refine a valuable prognostic model and novel staging system for PC with curative resection. METHODS: The data of 3,458 patients used in this study were retrieved from the Surveillance, Epidemiology, and End Results database registry of National Cancer Institute. The prognostic value of lymph node ratio (LNR) was analyzed in the primary cohort and prognostic nomogram based on the LNR was established to create a novel staging system. Then, analyses were conducted to evaluate the application of the formulated nomogram staging system and the AJCC 8th staging system. The predictive performance of model was further validated in the internal validation cohort. RESULTS: Significant positive correlations were found between LNR and all factors except for surgical procedures. The results of univariate and multivariate analyses showed that LNR was identified as an independent prognostic indicator for overall survival (OS) in both primary and validation cohorts (all P < 0.001). A prognostic nomogram based on the LNR was formulated to obtain superior discriminatory abilities. Compared with the AJCC 8th staging system, the formulated nomogram staging system showed higher hazard ratios of stage II, III, and IV disease (reference to stage I disease) that were 1.637, 2.300, and 3.521, respectively, by univariate analyses in the primary cohort and the distinction between stage I, II, and III disease at the beginning or end of the survival curves was more apparent. All these results were further verified in the validation cohort. CONCLUSION: LNR can be considered as a useful independent prognostic indicator for PC patients after curative resection regardless of the surgical procedures. Compared with the AJCC 8th staging system, the formulated nomogram showed superior predictive accuracy for OS and its novel staging system revealed better risk stratification.