Preservation of Pancreatic Function Should Not Be Disregarded When Performing Pancreatectomies for Pancreatoblastoma in Children.

Complete surgical resection in the context of a multimodal approach has been associated with excellent long-term survival in children diagnosed with pancreatoblastoma (PB). Traditionally, curative intent surgery for PB implies standard pancreatic resections such as pancreaticoduodenectomies and distal pancreatectomies with splenectomies, surgical procedures that may lead to significant long-term pancreatic functional deficiencies. Postoperative pancreatic functional deficiencies are particularly interesting to children because they may interfere with their development, considering their long life expectancy and the significant role of pancreatic functions in their nutritional status and growth. Thus, organ-sparing pancreatectomies, such as spleen-preserving distal pancreatectomies and central pancreatectomies, are emerging in specific tumoral pathologies in children. However, data about organ-sparing pancreatectomies' potential role in curative-intent PB surgery in children are scarce. Based on the literature data, the current review aims to present the early and late outcomes of pancreatectomies in children (including long-term deficiencies and their potential impact on the development and quality of life), particularly for PB, and further explore the potential role of organ-sparing pancreatectomies for PB. Organ-sparing pancreatectomies are associated with better long-term pancreatic functional outcomes, particularly central pancreatectomies, and have a reduced impact on children's development and quality of life without jeopardizing their oncological safety. The long-term preservation of pancreatic functions should not be disregarded when performing pancreatectomies for PB in children. A subset of patients with PB might benefit from organ-sparing pancreatectomies, particularly from central pancreatectomies, with the same oncological results as standard pancreatectomies but with significantly less impact on long-term functional outcomes.

A Glimpse into the Role and Effectiveness of Splenectomy for Isolated Metachronous Spleen Metastasis of Colorectal Cancer Origin: Long-Term Survivals Can Be Achieved.

Background: Many papers exploring the role of resectioning metastases in colorectal cancer (CRC) have focused mainly on liver and lung sites, showing improved survival compared with non-resectional therapies. However, data about exceptional metastatic sites such as splenic metastases (SMs) are scarce. This paper aims to assess the role and effectiveness of splenectomy in the case of isolated metachronous SM of CRC origin. Methods: The patients' data were extracted after a comprehensive literature search through public databases for articles reporting patients with splenectomies for isolated metachronous SM of CRC origin. Potential predictors of survival were explored, along with demographic, diagnostic, pathology, and treatment data for each patient. Results: A total of 83 patients with splenectomies for isolated metachronous SM of CRC origin were identified. The primary CRC was at an advanced stage (Duke's C-70.3%) and on the left colon (45.5%) for most patients, while the median interval between CRC resection and SM was 24 months. The median overall survival after splenectomy was 84 months, and patients younger than 62 years presented statistically significantly worse overall survival rates than those ≥62 years old (p = 0.011). There was no significant impact on the long-term outcomes for factors including primary tumor location or adjuvant chemotherapy (p values ≥ 0.070, ns). Laparoscopic splenectomy was increasingly used in the last 20 years from 2002 (33.3% vs. 0%, p < 0.001). Conclusions: Splenectomy is the optimal treatment for patients with isolated metachronous SM of CRC, with the laparoscopic approach being increasingly used and having the potential to become a standard of care. Encouraging long-term survival rates were reported in the context of a multidisciplinary approach. Younger ages are associated with worse survival. Perioperative chemotherapy in the context of a patient diagnosed with SM of CRC origin appears to be a reasonable option, although the present study failed to show any significant impact on long-term survival.

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.

Pancreaticoduodenectomies with Concurrent Colectomies: Indications, Technical Issues, Complications, and Oncological Outcomes.

Multi-visceral resections for colon and pancreatic cancer (PDAC) are feasible, safe, and justified for early and late outcomes. However, the use of pancreaticoduodenectomy (PD) with concurrent colectomies is highly debatable in terms of morbidity and oncological benefits. Based on current literature data, this review assesses the early and long-term outcomes of PD with colectomies. The association represents a challenging but feasible option for a few patients with PDAC or locally advanced right colon cancer when negative resection margins are anticipated because long-term survival can be achieved. Concurrent colectomies during PD should be cautiously approached because they may significantly increase complication rates, including severe ones. Thus, patients should be fit enough to overcome potential severe complications. Patients with PD and colectomies can be classified as borderline resectable, considering the high risk of developing postoperative complications. Carefully selecting patients suitable for PD with concurrent colectomies is paramount to mitigate the potentially severe complications of the two surgical procedures and maximize the oncological benefits. These procedures should be performed at high-volume centers with extensive experience in pancreatectomies and colectomies, and each patient situation should be assessed using a multimodal approach, including high-quality imaging and neoadjuvant therapies, in a multidisciplinary team discussion.

Outcomes of Duct-to-Mucosa vs. Invagination Pancreatojejunostomy: Toward a Personalized Approach for Distal Pancreatic Stump Anastomosis in Central Pancreatectomy?

(1) Background: The jejunum is primarily used for distal pancreatic stump anastomoses after central pancreatectomy (CP). The study aimed to compare duct-to-mucosa (WJ) and distal pancreatic invagination into jejunum anastomoses (PJ) after CP. (2) Methods: All patients with CP and jejunal anastomoses (between 1 January 2002 and 31 December 2022) were retrospectively assessed and compared. (3) Results: 29 CP were analyzed: WJ-12 patients (41.4%) and PJ-17 patients (58.6%). The operative time was significantly higher in the WJ vs. PJ group of patients (195 min vs. 140 min, p = 0.012). Statistically higher rates of patients within the high-risk fistula group were observed in the PJ vs. WJ group (52.9% vs. 0%, p = 0.003). However, no differences were observed between the groups regarding the overall, severe, and specific postpancreatectomy morbidity rates (p values ≥ 0.170). (4) Conclusions: The WJ and PJ anastomoses after CP were comparable in terms of morbidity rates. However, a PJ anastomosis appeared to fit better for patients with high-risk fistula scores. Thus, a personalized, patient-adapted technique for the distal pancreatic stump anastomosis with the jejunum after CP should be considered. At the same time, future research should explore gastric anastomoses' emerging role.

Pancreatico-Duodenectomy for Pancreatic Ductal Adenocarcinoma: from Artery-First Approaches toTRIANGLE Operation.

Pancreatico-duodenectomy (PD) is the single hope for long-term survival in a patient with pancreatic head ductal adenocarcinoma (PDAC). Unfortunately, even after curative intent PD, the long-term survival of patients with PDAC remains under expectations, with high recurrence rates, including the loco-regional ones. Positive resection margins after resection of PDAC are frequent, and they have a detrimental effect on both recurrence and long-term survival rates, particularly the R1 (direct) ones, toward the mesopancreas. In the last years, there were made increased efforts by surgeons to introduce in clinical practice several technical refinements to the standard technique of PD better to resect the tumor, including an accurate lymph node dissection, hoping to increase the rate of negative resection margins, to decrease local recurrence rates and to improve prognosis. Furthermore, to extend the number of patients with resectable disease, a few surgical techniques were also intended to convert to resectability the patients with the regional disease (i.e., anatomical borderline resectable and locally advanced PDAC) in the context of multimodal therapies, particularly neoadjuvant therapies. With this, we briefly discuss a few technical refinements addressing the resection time of PD, like the artery-first approaches and the Triangle operation. Both surgical techniques aim for better clearance of the retroperitoneal space for nerves, lymphatic nodes, and vessels, including total mesopancreas excision.

Using Molecular Subtyping of Pancreatic Ductal Adenocarcinoma for Multimodal Treatment Selection in Resectable Disease.

Pancreatic ductal adenocarcinoma (PDAC) is characterized by high heterogeneity; thus, even after a curative intent surgery, there is significant variability in the survival of patients, reflecting different biological behaviors. The selection of proper, personalized therapy for each patient with resectable PDAC, in multimodal therapy, by an experienced multidisciplinary team is of utmost importance to get maximal clinical benefit avoiding potentially harmful treatments. Identifications of patients with resectable PDAC that would benefit from surgical resections in the context of multimodal therapy remain a topic of interest for clinical practice. To improve PDAC patient outcomes, a significant step forward would be the integration of the molecular sub-types in the clinical decision-making between upfront surgery versus neoadjuvant treatment. Successful integration of the preoperative knowledge of the subtype of PDAC can properly guide this treatment selection to further improve patient outcomes. In this review, we present an overview of the current knowledge on the role of molecular subtyping in surgical decisions for PDAC patients.

The Optimal Management of Distal Pancreatic Stump After Pancreatico-Duodenectomy: Different Indications for Gastric and Jejunal Anastomoses.

BACKGROUND/AIM: The optimal management of distal pancreatic stump after pancreaticoduodenectomies (PD) remains unclear. The study aims to assess the early outcomes after anastomoses with jejunum vs. stomach of the distal pancreatic stump in a relatively large series of patients with PD. Patients and Methods: All patients with PD performed between Oct 1, 2016, and Oct 1, 2021, were retrospectively assessed: anastomoses with the jejunum (PJ group) vs. with the stomach (PG group). Results: A number of 360 PD: PJ group 293 patients (81.4%) and PG group 67 patients (18.6%). No statistically significant differences were observed between the groups regarding the early outcomes (p values 0.065), except for the clinically relevant delayed gastric emptying higher rates in the PG group (38.8% vs. 25.9%, p = 0.049). In the PG group there were statistically significant higher rates of pylorus-preservation (19.4% vs. 8.2%, p = 0.012), soft pancreas texture (76.1% vs. 34.4%, p 0.001), small Wirsung ducts (4 mm (0-25) vs. 3 mm (1-10), p 0.001) and intermediate and high-risk fistula scores (83.6% vs. 52.6%, p 0.001). Conclusions: No particular anastomotic technique can avoid postoperative complications. In patients with hard pancreas texture and dilated Wirsung duct, a duct-to-mucosa PJ anastomosis should be the first option, while for patients with small Wirsung duct and soft pancreas texture, an invagination PG anastomosis should be preferred.

Technical Aspects of a Posterior Pancreatic Head Enucleation - An Organ-Sparing Alternative to Pancreatico-Duodenectomy for Benign and Low-Grade Malignant Pancreatic Tumors.

From a technical point of view, enucleation can be challenging for a few locations with hard access, such as the posterior pancreatic head, particularly for deeply-located lesions, in close relationship with the main pancreatic duct (MPD). The risk of MPD injuries with secondary pancreatic fistula is high in these specific situations. Hereby we describe a technique of posterior pancreatic head enucleation in a 48-year-old male patient diagnosed with a deeply-located branch duct type intraductal papillary mucinous neoplasm (BD-IPMN). A posterior pancreatic head enucleation of the BD-IPMN was performed along with segmental resection of the MPD and end-to-end anastomosis, with protection by a plastic stent passing both through the MPD anastomosis and major duodenal papilla. No protective pancreatico-jejunostomy was necessary. A grade B pancreatic fistula complicated the postoperative course, and a grade A delayed gastric emptying, both conservatively managed. Enucleation of deeply-located tumors at the dorsal pancreatic head is challenging but feasible and safe. Segmental resection of the MPD with end-to-end anastomosis protected by a transpapillary plastic stent for injuries during enucleation can be safely performed. Thus, the operative time during enucleation is reduced, and the potential morbidity of a pancreaticojejunostomy is eliminated.

Pancreatic Fistula after D1+/D2 Radical Gastrectomy according to the Updated International Study Group of Pancreatic Surgery Criteria: Risk Factors and Clinical Consequences. Experience of Surgeons with High Caseloads in a Single Surgical Center in Eastern Europe.

PURPOSE: Incidence, risk factors, and clinical consequences of pancreatic fistula (POPF) after D1+/D2 radical gastrectomy have not been well investigated in Western patients, particularly those from Eastern Europe. MATERIALS AND METHODS: A total of 358 D1+/D2 radical gastrectomies were performed by surgeons with high caseloads in a single surgical center from 2002 to 2017. A retrospective analysis of data that were prospectively gathered in an electronic database was performed. POPF was defined and graded according to the International Study Group for Pancreatic Surgery (ISGPS) criteria. Uni- and multivariate analyses were performed to identify potential predictors of POPF. Additionally, the impact of POPF on early complications and long-term outcomes were investigated. RESULTS: POPF was observed in 20 patients (5.6%), according to the updated ISGPS grading system. Cardiovascular comorbidities emerged as the single independent predictor of POPF formation (risk ratio, 3.051; 95% confidence interval, 1.161-8.019; P=0.024). POPF occurrence was associated with statistically significant increased rates of postoperative hemorrhage requiring re-laparotomy (P=0.029), anastomotic leak (P=0.002), 90-day mortality (P=0.036), and prolonged hospital stay (P<0.001). The long-term survival of patients with gastric adenocarcinoma was not affected by POPF (P=0.661). CONCLUSIONS: In this large series of Eastern European patients, the clinically relevant rate of POPF after D1+/D2 radical gastrectomy was low. The presence of co-existing cardiovascular disease favored the occurrence of POPF and was associated with an increased risk of postoperative bleeding, anastomotic leak, 90-day mortality, and prolonged hospital stay. POPF was not found to affect the long-term survival of patients with gastric adenocarcinoma.

A Morphological and Immunohistochemical Study of the Tumoral and Inflammatory Cells in Pancreatic Ductal Adenocarcinoma.

This study is aimed at investigating tumoral and inflammatory cells and the significance of the prognostic factors of pancreatic ductal adenocarcinoma (PDAC); it is also aimed at determining the role of immunohistochemistry in the diagnosis and prognosis of this neoplasm. Materials and Methods. 230 cases of pancreatic ductal adenocarcinoma were included in the study group; these cases were selected from the archives of the Department of Pathology of the Fundeni Clinical Institute over a ten-year period. Immunohistochemistry was performed using the following antibodies: MUC 1, CD 34, Factor VIII, CD 68, MMP-7, CEA, p21, p53, and Ki 67. Results. There were 133 male (57.8%) and 97 female (42.2%) patients included in this study, with ages between 20 and 81 years old (mean age: 58.2 years) and with tumors located in the pancreatic head (n = 196; 85.2%), pancreatic body (n = 12; 5.2%), and pancreatic tail (n = 20, 8.7%), as well as panpancreatic tumors (n = 2; 0.9%). Patients presented with early stages (IA and IB), with low pathologic grade (G1), with small size tumors (less than 1-1.5 cm), with tumors located in the head of the pancreas, (p53: negative; p21: positive; and CD 68: positive in peritumoral tissue), with low nuclear index (Ki 67 < 10%), without metastases at the time of surgery (had a better prognosis), and with a survival rate of about 7 months. Conclusions. Immunohistochemistry is useful for an accurate diagnosis, differential diagnosis, and establishment of additional factors that might have a prognostic importance. It is recommended to study peritumoral tissue from the quantitative and qualitative points of view to increase the number of prognostic factors. This study represents a multidisciplinary approach, and it is a result of teamwork; it presents histopathological methods of examination of this severe illness and describes only a part of the scientific effort to determine the main pathological mechanisms of this neoplasm.

Central pancreatectomy: a comprehensive, up-to-date meta-analysis.

BACKGROUND: Central pancreatectomy (CP) is the alternative to distal pancreatectomy (DP) for specific pathologies of the mid-pancreas. However, the benefits of CP over DP remain controversial. This study aims to compare the two procedures by conducting a meta-analysis of all published papers. METHODS: A systematic search of original studies comparing CP vs. DP was performed using PubMed, Scopus, and Cochrane Library databases up to June 2018. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was followed. RESULTS: Twenty-one studies were included (596 patients with CP and 1070 patients with DP). Compared to DP, CP was associated with significantly higher rates of overall and severe morbidity (p < 0.0001), overall and clinically relevant pancreatic fistula (p < 0.0001), postoperative hemorrhage (p = 0.02), but with significantly lower incidences of new-onset (p < 0.0001) and worsening diabetes mellitus (p = 0.004). Furthermore, significantly longer length of hospital stay (p < 0.0001) was observed for CP patients. CONCLUSIONS: CP is superior to DP regarding the preservation of pancreatic functions, but at the expense of significantly higher complication rates and longer hospital stay. Proper selection of patients is of utmost importance to maximize the benefits and mitigate the risks of CP.

Caudate Lobectomy for Perihilar Cholangiocarcinoma - Current Evidence.

At the moment, surgery is considered the only therapeutic approach offering a chance of long-term survival in patients diagnosed with perihilar cholangiocarcinoma (PHC). Curative intent surgery for PHC has experienced significant technical improvements over the years, from simple bile duct resection to complex surgical procedures including lymph nodes dissection, major hepatectomies and, sometimes, vascular resections. The modern surgical approach of PHC is associated with significantly improved survival rates, albeit with increased postoperative morbidity. The initial Western experience with major hepatectomies for PHC was not encouraging, as it was associated with unacceptably high mortality rates. Currently the mortality rates after surgery for PHC have significantly decreased, but it appears that the mortality rates in Western centres still remain higher, compared with the East Asian centres. The differences of outcomes between East Asian and Western centres are explained not only by the management of PHC but also by patient characteristics. En bloc caudate lobectomy as part of radical resections for PHC has been reported in clinical practice nearly three decades ago. The rationale of en bloc caudate lobectomy is based on the pattern of tumour spread in PHC, taking in consideration the fact that caudate lobe invasion appears to be a frequent event in patients resected for PHC. While en bloc caudate lobectomy in the context of curative intent surgery for PHC has been discussed in a host of publications so far, the currently available literature reached conflicting results regarding its overall impact on the patient. Therefore, the aim of this paper is to review the current relevant literature pertaining to the impact of en bloc caudate lobectomy in the context of curative intent surgery for PHC.

Technical Issues and Early Outcomes of Restorative Proctocolectomy for Familial Adenomatous Polyposis and Ulcerative Colitis: The Largest Romanian Single-Team Experience.

Background/ Aim: Restorative proctocolectomy (RPC) is a complex surgical procedure used to treat patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The present study aims to assess the technical issues and early outcomes of RPC for FAP and UC, in a relatively large single-team series of patients. Patients and Methods: The data of all patients with RPC performed by a single surgical team between 1991 and 2018 were retrospectively assessed from a prospectively maintained electronic database. Results: The study group included 77 patients with RPC, and 70.1% have had FAP. The average number of RPC per year was 3.3 for the surgical team and 4.3 for the institution. A J pouch was performed in 93.5% of the patients. A hand-sewn reservoir was made in 76.6% of the patients. A hand-sewn ileal pouch-anal anastomosis was performed in 81.8% of the patients. A diverting ileostomy was performed in 92.2% of the patients. Mucosectomy was performed in 84.4% of the patients. The early morbidity rate was 36.4%, with severe complications rate of 13%. The main complications were pouch-related septic complications (18.2%), wound infections (9.1%), small-bowel obstruction (6.5%) and hemorrhage (6.5%). Conclusions: Although a RPC remains an uncommon surgical procedure in Romania, however, the early outcomes of the present series are comparable to those reported in high volume centers. Good outcomes after RPC can be obtained if such complex surgical procedures are performed by dedicated surgical teams, with high case-load.

Retrohepatic Gallbladder Masquerading as Hydatid Cyst in a Patient with Right Liver Agenesis.

Agenesis of the right liver is a rare congenital anomaly which can be associated with an ectopic gallbladder. Hereby, it is presented the case of a 39-year-old man investigated for right upper quadrant abdominal pain and diagnosed at computed tomography with a cystic liver mass initially considered as hydatid cyst. At laparotomy, it was discovered agenesis of the right liver and the presumed hydatid cyst was a retrohepatic gallbladder with lithiasis. Cholecystectomy was performed with an uneventful outcome. Reassessment of the computed tomography images by an experienced radiologist confirmed the intraoperative diagnosis. Although agenesis of the right liver with retrohepatic gallbladder is an exceptional appearance, surgeons should be aware of this anomaly because it can raise challenging issues of diagnosis and surgical planning during cholecystectomy.

Male gender and increased body mass index independently predicts clinically relevant morbidity after spleen-preserving distal pancreatectomy.

AIM: To identify risk factors for clinically relevant complications after spleen-preserving distal pancreatectomy (SPDP). No previous studies explored potential predictors of morbidity after SPDP. METHODS: The data of 41 patients who underwent a SPDP in a single surgical center between 2000 and 2015 were retrospectively reviewed from a prospectively maintained electronic database established in our Department of Surgery. The database included demographic, clinical, bioumoral, pathological, intraoperative and postoperative parameters. Uni- and multivariate analyses were performed to assess potential predictors of clinically relevant morbidity. Postoperative morbidity was defined as in-hospital complications and mortality was assessed at 90 d. Clinically relevant morbidity was defined as complication ≥ grade 2 Dindo. RESULTS: Overall morbidity rate was 34.1% (14 patients): grade I (6 patients, 14.6%), grade II (2 patients, 4.8%), grade IIIa (1 patient, 2.4%), and grade IIIb (5 patients, 12.2%). A number of 5 patients (12.2%) required re-laparotomy for postoperative complications. There was no postoperative mortality. Thus, at least one clinically relevant complication occurred in 8 patients (19.5%). Univariate analysis identified male gender (P = 0.034), increased body mass index (P = 0.002) and neuroendocrine pathology (P = 0.013) as statistically significant risk factors. Multivariate analysis identified male gender [odds ratio (OR): 1.29, 95%CI: 1.07-1.55, P = 0.005] and increased body mass index (OR: 23.18, 95%CI: 1.72-310.96, P = 0.018) as the only independent risk factors of clinically relevant morbidity after SPDP. CONCLUSION: Male gender and increased body mass index are independently associated with increased risk of clinically relevant morbidity after SPDP. These findings may assist a surgeon in clinical decision-making to better select patients suitable for SPDP.

Pattern of the First Recurrence Has No Impact on Long-Term Survival after Curative Intent Surgery for Perihilar Cholangiocarcinomas.

AIM: To explore the pattern of the first recurrence and impact on long-term survival after curative intent surgery for perihilar cholangiocarcinomas (PHC). MATERIALS AND METHODS: Patients with curative intent surgery for PHC between 1996 and 2017 were analyzed. Survival times were estimated using the Kaplan-Meier method. Comparisons were made with the log-rank test. RESULTS: A number of 139 patients were included. The median overall survival was 26 months. A recurrence was observed in 86 patients (61.9%), during a median follow-up time of 89 months. The median disease-free survival was 21 months with 1-, 3-, 5-, and 10-year estimated recurrence rates of 38%, 60%, 69%, and 77%, respectively. A number of 57 patients (41%) developed distant only recurrence, while 26 patients (18.7%) presented local and distant recurrences. An isolated local recurrence was observed in 3 patients (2.2%). The median overall survival was 15 months for patients with local recurrence, 15 months for patients with liver metastases, and 17 months for patients with peritoneal carcinomatosis (p = 0.903) as the first recurrence. CONCLUSION: Curative intent surgery for PHC is associated with high recurrence rates. Most patients will develop distant metastases, while an isolated local recurrence is uncommon. The pattern of recurrence does not appear to have a significant impact on survivals.

Is Hepatitis B Virus a Player in Pancreatic Cancer?

Pancreatic cancer (i.e., pancreatic ductal adenocarcinoma, PDAC) is an important healthcare issue and a highly lethal disease. Thus, almost 80% of patients with PDAC will die within one year after diagnosis. Several factors including smoking, obesity, advanced age, diabetes mellitus and chronic pancreatitis have been associated with increased risk of PDAC. Hepatitis B virus (HBV) infection is also considered as a risk factor for PDAC development in some studies. However, the role of HBV infection in PDAC is poorly explored. The present paper reviews the current relevant literature exploring the impact of HBV infection in PDAC. Assessment of HBV infection impact in PDAC is challenging because its effects could be easily underestimated. Indeed, the role played by occult B infection (OBI) and intrinsic difficulties to detect HBV antigens or DNA in pancreatic tissue remains major limitations to further progress. To date a significant proportion of available literature suggests the potential oncogenic role of HBV in PDAC but experimental evidences remain scarce. Remarkably, it appears that HBV infection might influence some clinical and pathological features of patients with PDAC. Future researches to better define the role of HBV infection in developing PDAC are urgently needed.

One Hundred Pancreatectomies with Venous Resection for Pancreatic Adenocarcinoma.

Introduction: Invasion of portal vein (PV)/ superior mesenteric vein (SMV) in pancreatic ductal adenocarcinoma (PDAC) is no longer a contraindication for resection when reconstruction is technically feasible. However, the literature data reached conflicting conclusions regarding the early and long-term outcomes of patients with venous resection and pancreatectomies for PDAC. The study aims to present the outcomes in a large series of patients with pancreatectomies and associated PV/ SMV resection for PDAC, in a single center experience. Patients Methods: The data of 100 patients with pancreatectomies and PV and/ or SMV resection performed between 2002 and 2016 (February, 1st) were retrospectively analyzed from a prospectively maintained electronic database, which included 474 pancreatectomies for PDAC. Only patients with a final pathological diagnosis of PDAC were included in the present study. Results: Overall, 21.1% of patients with pancreatectomies for PDAC required a venous resection (100 patients out of 474 patients). Segmental resection was performed in 77 patients (out of 100 patients with pancreatectomies and venous resection - 77%), while 23 patients (23%) have had tangential venous resection. In the group of patients with segmental venous resection, reconstruction was made by end-to-end anastomosis in 53 patients (out of 77 patients - 68.8%), while in 24 patients (out of 77 patients - 31.2%) a graft interposition was necessary. Negative resections margins were obtained in 63 patients (63%). Histological tumor invasion of the resected vein was confirmed in 64 patients (64%). Postoperative complications occurred in 47 patients (47%), with severe complications (i.e., Dindo-Clavien grade III-V) in 19 patients (19%). Postoperative pancreatic fistulae, delayed gastric emptying and post-pancreatectomy hemorrhage rates were 9%, 20% and 15%, respectively. PV/ SMV thrombosis occurred in 5 patients (5%). The 90-day mortality rate in the group of patients with venous only resection, without any associated procedures, was 8%. Adjuvant treatment was performed in 63 patients (63%), while only 2 patients (2%) underwent neoadjuvant chemotherapy. Median follow-up time was 105 months (range, 3 - 186 months), with a median overall survival time of 13 months (range, 3 - 186 months). In the group of patients with negative resection margins, the median overall survival time was 16 months (range, 3 - 186 months). Conclusions: PV/ SMV resection during pancreatectomies for PDAC is technically feasible, and grafts are rarely required for venous reconstruction. However, venous resection is associated with high postoperative complications rates, and the mortality rate is not neglectable. The main goal of such complex procedure is to obtain negative resection margins, a situation associated with encouraging survival rates.

What is the Value of Total Mesopancreas Excision in Pancreatic Ductal Adenocarcinoma? Current Evidence of the Literature.

Pancreatic ductal adenocarcinoma (PDAC) is a disease with a grim prognosis. Pancreatectomy represents the single hope for long-term survival in a patient with PDAC. Recurrence is a common event after curative-intent surgery for PDAC, mainly related to incomplete removal at the site of resection margins; medial/ superior mesenteric margins are the most often positive. The concept of total mesopancreas excision (TMpE) in PDAC was proposed in analogy to the concept of total mesorectal excision for rectal cancer, to better control loco-regional recurrence. This paper aims to discuss the current evidence for the value of TMpE in PDAC.