Bleeding is still one of the most feared intraoperative and postoperative complications that can lead to an increase in morbidity, mortality, length of hospital stay and costs. Nowadays, in addition to accurate surgical techniques, several local haemostatic agents are available and can be used in case of oozing bleeding. Herein, we report our experience with a ready-to-use polysaccharide powder in two patients undergoing distal splenopancreatectomy. Bleeding control was achieved in both cases. No patient showed postoperative bleeding, and no other complications were reported.

Introduction: Infections caused by multidrug-resistant bacteria (MDR) occur more frequently after pancreaticoduodenectomy (PD) compared to other abdominal surgeries, and infective complications represent a major determinant of postoperative morbidity following PD. Preoperative biliary stent (PBS) placement often leads to biliary contamination, which plays a significant role in postoperative infections. The aim of this study is to evaluate the impact of MDR contamination on short-term postoperative outcomes in patients undergoing PD and to evaluate the relationship between MDR bacteria, PBS, and bile contamination. Methods: This is a retrospective study based on a prospectively maintained database including 825 consecutive patients who underwent pancreaticoduodenectomies (PDs). All procedures were performed by experienced pancreatic surgeons at a high-volume center and the patients were managed according to the same perioperative enhanced recovery protocol. Results: MDR bacteria were present in 17.5% of bile cultures, exclusively within the stented group. At the multivariate analysis, the development of major postoperative complications (MPC) was correlated with the presence of MDR bacteria in the bile (OR 1.66, 95% CI: 1.1–2.52; p = 0.02). MDR bacteria were detected early in the surgical drainage in 144 out of 825 patients (12.1%), with 72.2% having a previous biliary stent placement and 27.8% without stents (p < 0.001). Moreover, the development of an MPC was associated with the presence of MDR bacteria in the drainage (OR = 1.81, 95% CI: 1.21–2.73, p = 0.0042). Conclusions: We demonstrated that MDR contamination worsens the short-term outcomes of patients undergoing PDs. Specifically, when MDR bacteria are present in both the bile and drainage, there is a statistically significant increase in the incidence of major postoperative complications (MPC). Our data suggest that the majority of MDR surgical site infections stem from biliary contamination resulting from the placement of a preoperative biliary stent (PBS).

Background. Survival after surgery for pancreatic ductal adenocarcinoma (PDAC) remains poor, due to early recurrence (ER) of the disease. A global definition of ER is lacking and different cut-off values (6, 8, and 12 months) have been adopted. The aims of this study were to define the optimal cut-off for the definition of ER and predictive factors for ER. Methods. Recurrence was recorded for all consecutive patients undergoing upfront surgery for PDAC at our institute between 2010 and 2017. Receiver operating characteristic (ROC) curves were utilized, to estimate the optimal cut-off for the definition of ER as a predictive factor for poor post-progression survival (PPS). To identify predictive factors of ER, univariable and multivariable logistic regression models were used. Results. Three hundred and fifty one cases were retrospectively evaluated. The recurrence rate was 76.9%. ER rates were 29.0%, 37.6%, and 47.6%, when adopting 6, 8, and 12 months as cut-offs, respectively. A significant difference in median PPS was only shown between ER and late recurrence using 12 months as cut-off (p = 0.005). In the multivariate analysis, a pre-operative value of CA 19-9 > 70.5 UI/L (OR 3.10 (1.41–6.81); p = 0.005) and the omission of adjuvant treatment (OR 0.18 (0.08–0.41); p < 0.001) were significant predictive factors of ER. Conclusions. A twelve-months cut-off should be adopted for the definition of ER. Almost 50% of upfront-resected patients presented ER, and it significantly affected the prognosis. A high preoperative value of CA 19-9 and the omission of adjuvant treatment were the only predictive factors for ER.

Background: Pancreatoblastoma (PB) is a rare malignant epithelial tumor of the pancreas, mainly occurring in pediatric population. Pancreatoblastoma of the adult is extremely rare and usually shows a more aggressive biological behavior and a worse prognosis. Case Presentation: The patient was a 54-year-old man admitted for abdominal pain and weight loss. A computed tomography (CT) scan showed a 12 cm heterogeneous hypoattenuating mass in the pancreatic head. An endoscopic ultrasound-guided biopsy suggested the diagnosis of pancreatoblastoma (PB). The patient underwent a pancreaticoduodenectomy (PD) combined with limited liver resections for intraoperative finding of multiple liver metastasis. Pathological findings confirmed the diagnosis of PB metastatic to the liver. The tumor recurred in the liver 5 months after surgery and the patient succumbed due to tumor dissemination 8 months after initial diagnosis. Conclusion: Adult pancreatoblastoma is a rare pancreatic neoplasm with malignant behavior. The aim of this manuscript is to report our experience with pancreatoblastoma in the adult and to contribute improving knowledge about the clinical behavior of this rare and aggressive malignancy.

This record contains data related to article “Invasive IPMN relapse later and more often in lungs in comparison to pancreatic ductal adenocarcinoma” Background: The different oncological outcomes of invasive intraductal papillary mucinous neoplasm (I-IPMN) and pancreatic ductal adenocarcinoma (PDAC) are debated. This study aimed to compare disease recurrence patterns and histopathological characteristics in patients with resected I-IPMN and PDAC. Methods: Consecutive patients undergoing surgical resection for stage I-III I-IPMN or PDAC between 2010 and 2016 were retrospectively analyzed. Patients treated with neoadjuvant therapy or resected for Tis neoplasia were excluded. All surgical specimens were re-staged according to AJCC-8th-edition. Results: A total of 330 patients were included, of whom 43 had I-IPMN and 287 had PDAC. Median follow-up time was 26.7 (1.3-92.3) months and estimated median disease-free survival (DFS) was 60.3 months (47.2-73.4) for I-IPMN and 23.8 (19.3-28.2) months for PDAC (p < 0.001). During follow-up, 32.6% of I-IPMN and 67.9% of PDAC patients experienced recurrence (p < 0.001). The sites of first recurrence were the lungs (38.5% vs 13.1%, p = 0.027), liver (28.6% vs 45.0%, p = 0.180) and local (15.4% vs 36.6%, p = 0.101) for I-IPMN and PDAC, respectively. At multivariate analysis, I-IPMN histology remained an independent predictive factor for longer DFS (OR 0.528, CI 95% 0.278-1.000, p = 0.050), regardless of stage or adjuvant chemotherapy. I-IPMN and PDAC differed in rates of neuroinvasion (51.2% vs 97.2%) and positive lymph node status (N+) (46.5% vs 82.7%), especially in patients with lower T status. Conclusion: I-IPMN showed a different recurrence pattern compared to PDAC, with a higher lung tropism, and longer DFS. This different biological behavior is associated with lower rates of neuroinvasion and nodal involvement, especially in early-stage disease.

Postoperative pancreatic fistula (POPF) remains a major complication after distal pancreatectomy (DP) with a significant impact on patients’ quality of life. There is limited evidence that preservation of the spleen reduces the risk of POPF. Therefore, we aimed to investigate the impact of splenectomy on perioperative outcome.Data from patients who underwent DP for malignant and benign disease at our institution between 2004 and 2021 were reviewed. Patients were grouped according to spleen preservation (SP-DP) and splenectomy (DPS). Intraoperative parameters and postoperative outcomes were compared between groups. Univariable and multivariable analyses were used to investigate factors that influence the occurrence of clinically relevant (cr)POPF.A total of 199 patients were included, of whom 61 (30.7%) patients underwent SP-DP. Patients who underwent SP-DP had a significantly lower rate of crPOPF (p = 0.022), shorter hospital stay (p = 0.003), and less readmissions (p = 0.012). On multivariate analysis, obesity (OR 2.88, p = 0.021), benign lesions (OR 2.35, p = 0.018), postoperative acute pancreatitis (OR 2.53, p = 0.028), and splenectomy (OR 2.83, p = 0.011) were independent risk factors associated with the onset of crPOPF.Preservation of the spleen reduces the risk of crPOPF in patients undergoing distal pancreatectomy for benign and malignant disease.

Nuclear receptor coactivator 5 (NCOA5) is known to modulate ERα-mediated transcription and has been found to be involved in the progression of several malignancies. However, the potential correlation between NCOA5 and clinical outcome in patients with luminal breast cancer remains unknown. In the present study, we demonstrated that NCOA5 was significantly up-regulated in luminal breast cancer tissues compared with adjacent non-cancerous tissues both in validated cohort and TCGA cohort. Moreover, Kaplan-Meier analysis indicated that patients with high NOCA5 expression had significantly lower overall survival (P = 0.021). Cox regression analysis indicated that the high NOCA5 expression was independent high risk factor as well as old age (>60) and HER-2 expression (P = 0.039; P = 0.003; P = 0.005; respectively). This study provides new insights and evidences that NOCA5 over-expression was significantly correlated with progression and prognosis in luminal breast cancer. However, the precise cellular mechanisms for NOCA5 in luminal breast cancer need to be further explored.

Stefano Partelli , Sara Massironi , Alessandro Zerbi, Patricia Niccoli, Wooil Kwon , Luca Landoni, Francesco Panzuto, Ales Tomazic, Alberto Bongiovanni, Gregory Kaltsas, Alain Sauvanet, Emilio Bertani, Vincenzo Mazzaferro , Martyn Caplin, Thomas Armstrong, Martin O. Weickert, John Ramage, Eva Segelov , Giovanni Butturini, Stefan Staettner, Mauro Cives, Andrea Frilling, Carol Anne Moulton, Jin He , Florian Boesch, Andreas Selberheer, Orit Twito, Antonio Castaldi , Claudio G. De Angelis, Sebastien Gaujoux , Katharina Holzer, Colin H. Wilson, Hussein Almeamar, Emanuel Vigia, Francesca Muffatti, Martina Lucà, Andrea Lania, Jacques Ewald, Hongbeom Kim , Roberto Salvia, Maria Rinzivillo, Alojz Smid, Andrea Gardini, Marina Tsoli, Olivia Hentic, Samuele Colombo, Davide Citterio, Christos Toumpanakis, Emma Ramsey, Harpal S. Randeva, Ray Srirajaskanthan, Daniel Croagh, Paolo Regi, Silvia Gasteiger, Pietro Invernizzi, Cristina Ridolfi, Marc Giovannini, Jin-Young Jang, Claudio Bassi and Massimo Falconi*

Background: It is unclear whether invasive intraductal papillary mucinous neoplasm (IPMN) has different clinical and prognostic characteristics, beyond histological factors, when compared to pancreatic ductal adenocarcinoma (PDAC).Aims: compare prognostic features of resected PDAC and invasive IPMNMethods: A retrospective study of patients resected for PDAC or invasive IPMN realized at Humanitas Cancer Center's Pancreatic Surgery Unit, Milan, Italy, between 2010 and 2016. Data recorded included patient demographics, onset symptoms, preoperative health status, tumor features, histology and surgical characteristics. Overall survival was estimated using Kaplan-Meier and prognostic factors for survival were assessed by multivariate Cox regression.Results: A total of 332 patients were included (PDAC, n = 289; invasive IPMN, n = 43). Patients with invasive IPMN had better overall survival than PDAC patients (median: 76.6 versus 25.6 months; 5-year OS rate: 65.4% vs. 14.2%; p < 0.001). PDAC histology was associated with a significantly higher risk of death than IPMN (hazard ratio 1.815, 95% CI: 1.02, 3.24; p = 0.044). Survival was also worse with PDAC in early-stage disease (IA-IB-IIA, N0). In multivariate analysis, independent predictors of worse survival included perineural invasion, preoperative ASA physical status >= 3 and pain at diagnosis.Conclusions: Patients with IPMN had a better prognosis than PDAC patients, regardless of disease stage. (c) 2021 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Purpose: Minimally Invasive Pancreatoduodenectomy(MIPD) is a complex procedure where abnormal vascular anatomy(AVA), compared to normal vascular anatomy(NVA), can add to the surgical difficulty and risks. In particular, right or common hepatic artery (RHA and CHA, respectively) anomalies can be a source of serious problems. Hence preoperative planning and intraoperative care are paramount. Herein we present a video showing MIPD in case of AVA, discuss our protocol and surgical techniques, and compare results in patients with AVA involving the HA versus NVA. Method: Data of patients undergoing MIPD(2015-2020) were analysed. Preoperative CT-angiography was performed in all patients. A superior mesenteric artery(SMA)-first approach was performed in all patients with AVA while a hybrid left/anterior/posterior approach was adopted in NVA. The bile duct was divided at last in NVA patients, while biliary division was performed earlier in patients with AVA or with tumours adherent to the SMV/PV, thus allowing a cranio-caudal and caudo-cranial dissection. Results: Among 83 patients, 25 showed AVA: 10 had a LHA from the LGA and 15(18%) had a replaced RHA(n=11)/CHA(n=4). These latter were compared with 68 with NVA. Operative time, blood loos and conversion rates were similar in both groups. Postoperative outcomes were similar, except for significantly lower rates of PPH in AVA patients. Moreover there was no difference in the rates of positive resection margins and number of harvested nodes (table 1). Conclusion: Preoperative identification of AVA, SMA-first approach, early biliary division, and cranio-caudal-cranial approach can mitigate the added anatomical challenge, thus ensuring a safe and sound oncological MIPD.

Background: Pancreatic Ductal Adenocarcinoma (PDAC) and invasive Intraductal Papillary Mucinous Tumor (IPMN) show a different prognosis. The prognosis of invasive IPMNs is generally believed to be more favorable than PDAC because IPMN-associated carcinomas are frequently diagnosed at an earlier stage. We evaluated a surgical cohort of patients resected for PDAC's and invasive IPMN's early stages and compare these 2 groups. Material & Methods: We prospectively collected clinical, surgical, postoperative, and histologic data of 76 patients undergone radical pancreatic resection for PDAC's and invasive IPMN's early stages (node negative) at Humanitas Cancer Center Pancreatic Surgery Unit from January 2010 to December 2016. Surgery specimens were re-staged according to American Joint Committee on Cancer (AJCC) 8th edition. Data were illustrated as frequencies, percentages, median and range. Four years overall survival (OS) was estimated using the Kaplan-Meier method. Results: We identified 50 PDACs and 26 invasive IPMNs, 46 (60.5%) men and 30 (39.5%) women. No differences in postoperative course were noted between the 2 groups and 89.5% of patients had Clavien-Dindo score≤2. 54% of PDAC patients had tumor grade≥3 versus 4% of IPMN ones (p=0.001). With a median time of follow-up of 47 months, 84.8% invasive IPMN patients reached 4ys overall survival, while 41.6% PDACs (p=0.008). Univariable model found tumor grade≥3 (p=0.001), presence of perineural invasion (p<0.001) and positive resection margin, R1, (p=0.002) to have an adverse prognostic effect on OS. Besides PDAC histological type had 3.6 times higher risk of death (95%CI: 1.37;9.44, p=0.001) than IPMN one. Multivariable model confirmed the negative prognostic role of perineural invasion (HRyes vs no: 6.0, 95%CI: 1.8;20.3, p=0.004) and of R1 (HRR1vs R0: 2.7, 95%CI: 1.25;6, p=0.012). Conclusion: We confirmed that prognosis of early stages of IPMN patients are better than that of patients with node-negative PDAC.

Background: The Fistula Risk Score (FRS) for pancreaticoduodenectomy represent a validated tool to predict the onset of this treacherous complication. Although there is no agreement on the management of this peculiar subpopulation, total pancreatectomy is an option to be considered. Material & Methods: We considered 738 patients scheduled for a pancreaticoduodenectomy in our center between January 2010 and December 2018. Data were collected prospectively. 62 patients present a FRS ≥7. Major complication were considered as Clavien-Dindo ≥3. Continuous data are presented as median [IQR]. Islet autotrasplant after completion pancreatectomy is available in our institution as part of clinical studies for patients with preoperative normal glycemic control. Result(s): Of the 62 patients 35 where managed with pancreatico-jejunal anastomosis (GroupA); 18 with total pancreatectomy (GroupB1); 9 with total and islet autotransplant(GroupB2). In GroupB 70.4% underwent a spleen preserving procedure. 5.7% patients in GroupA,38.8% in GroupB1 were diabetic (p=0.038). Median age was 64.4[24.2] years GroupA; 73.1[10.1] GrupB1,67.5[12.2] GroupB2 (p=0,050). BMI was 24.85[6.6] GroupA 26.95[3.7] GroupB1 30.86[6.6] GroupB2 (p=0.014). 17,6% had an ASA score ≥3 in GroupA, 50% GroupB1, 33.3%, GroupB2 (p=0.079). 2 patients died 1 in GroupA an 1 in GroupB both to septic shock the second arising from a urinary tract infection. Major complication were 42.9% GroupA, 27.8% GroupB1, 22.2% GroupB2 (p=0.466). Reoperation rate was 17.1% GroupA, 11.1% GropB (p=0.090). Postoeprative length of stay was 15[9] GroupA 12[11] GroupB1 10[7] GroupB2 (p=0.501). Length of stay among total pancreatectomies was shorter in the spleen preserving 11[10] vs 14[9].In Group A Biochemical leak was 22.8%, pancreatic fistula B 40% C 8.5%. Readmission were observed only in Group A 25.7% (p:0.001). Conclusion(s): Completion pancreatectomy should be considered in high FRS patients, short term outcomes are good and islet autotrasplant offer promising scenarios for the long term. Patient's characteristic and technical specific approaches had to be considered.

Background The inability to comply with enhanced recovery protocols (ERp) after pancreaticoduodenectomy (PD) is a real but understated issue. Our goal is to report our experience and a potential tool to predict ERp failure in order to better characterize this problem. Methods From January 1, 2014, to January 31, 2016, 205 consecutive patients underwent PD in our center and were managed according to an ERp. Failure to comply with postoperative protocol items was defined as any of: no active ambulation on postoperative day 1 (POD1); less than 4 h out of bed on POD2; removal of nasogastric tube and bladder catheter after POD1 and POD3, respectively; reintroduction of oral feeding after POD4; and continuation of intravenous infusions after POD4. Data were collected in a prospective database. Results Taking in consideration the number of failed items and the length of stay, we defined failure of the ERp as no compliance to two or more items. A total of 116 patients (56.6%) met this definition of failure. We created a predictive model consisting of age, BMI, operative time, and pancreatic stump consistency. These variables were independent predictors of failure (OR 1.03 [1.001–1.06] p = 0.01; OR 1.11 [1.01–1.22] p = 0.03; OR 1.004 [1.001–1.009] p = 0.02 and OR 2.89 [1.48–5.67] p = 0.002, respectively). Patient final score predicted the failure of the ERp with an area under the ROC curve of 0.747. Conclusions It seems to be possible to predict ERp failure after PD. Patients at high risk of failure may benefit more from a specific ERp.