Pancreaticoduodenectomy (PD) and lateral pancreatojejunostomy are established surgical techniques for treating chronic pancreatitis (CP), but their combination has not been studied. We performed PD combined with lateral pancreatojejunostomy in 15 patients with morphological changes consistent with CP. Preoperative imaging revealed features of CP confined to the head of the pancreas (HOP) and main pancreatic duct (MPD) dilation with strictures and stones in all but one patient. Surgical procedures were completed successfully in all the patients. One patient (6.6%) developed major complications that required reoperation. There was no 90-day mortality. At follow-up (median, 66 months), pain, quality of life, and exocrine function had improved, whereas endocrine function worsened in 4 of the 7 non-insulin-dependent diabetic patients, requiring insulin therapy. This hybrid approach provided durable pain relief, improved quality of life, and stabilized exocrine function. Endocrine deterioration in some cases highlights the challenges of managing pre-existing pancreatic insufficiency.

Backgrounds/Aims:The benefits of nasogastric intubation after pancreaticoduodenectomy are not well understood, and it remains unclear which patients may need nasogastric intubation in the immediate postoperative period. This study evaluated the effectiveness of nasogastric intubation following pancreaticoduodenectomy and identified factors influencing the reintubation rate. Methods:We conducted a retrospective case-control cohort study involving adult patients who underwent pancreaticoduodenectomy for either benign or malignant periampullary disease, with a 90-day follow-up. Patients were divided into two groups: the nasogastric tube (NGT) was removed at the end of the procedure (NGT-removed group, n = 110; case group) or retained during the postoperative recovery (NGT-retained group, n = 100; control group). Results:The overall postoperative complication rate (grades I-IVb) was 40.4%. The only significant difference between the groups was a higher incidence of nausea and vomiting in the NGT-removed group (p = 0.02). Additionally, 14.8% of patients required NGT reinsertion postoperatively. No preoperative or intraoperative factors were found to influence the NGT reinsertion rate. Although patients requiring reinsertion experienced a higher rate of postoperative complications, no factor remained significant in the multivariate analysis. Conclusions:There were no significant differences in clinical outcomes, reinsertion rates, or postoperative complications between the two groups, indicating that the removal of the NGT after pancreaticoduodenectomy is safe. However, univariate analysis revealed that postoperative complications significantly affected the need for NGT reinsertion, suggesting that nasogastric decompression may be crucial for patients at high risk for complications.

INTRODUCTION:The influence of baseline health-related quality of life (HRQoL) on peri-operative outcomes in pancreatobiliary (PB) patients is not well established. This study investigated the impact of baseline HRQoL on peri-operative outcomes and the effect of surgery on HRQoL. METHODS:A secondary post-hoc analysis of a multicenter trial (2011-2016) assessed PB patients undergoing pancreatectomy. Pre-operative and 30-day post-operative FACT-G surveys were analyzed. Logistic regressions determined associations between baseline HRQoL scores and 60-day major complications. Subgroup analysis evaluated change in HRQoL (pre-operative to 30-day scores). RESULTS:Among 391 patients, higher baseline HRQoL (FACT-G overall OR 0.54,p ​= ​0.04) was associated with decreased likelihood of developing major complications. Surgery resulted in improvement in HRQoL for patients with chronic pancreatitis (10.2 points) compared to other pathologies (-7 to 3.9 points). CONCLUSION:Baseline HRQoL was associated with post-operative complications and HRQoL significantly improved for patients with chronic pancreatitis, highlighting the importance of HRQoL on patient-centered outcomes.

Roux-en-Y hepaticojejunostomy enables tension-free bile-duct reconstruction and minimizes reflux. However, factors like a short mesentery or severe peri-hilar inflammation may prevent the jejunal loop from reaching the hepatic hilum, making safe anastomosis unfeasible. We have developed a novel surgical technique that overcomes these challenges. In this case report, we describe our triple bypass technique, in which a vascularized gastric tube graft is anastomosed to the common bile duct, and we present short-term outcomes from the use of this technique in a patient with chronic pancreatitis; overall, this patient recovered well, with a viable graft and no leakage. This novel technique expands surgical options for complex extrahepatic bile-duct reconstruction.

Background: Introduction: Enhanced recovery after surgery (ERAS) protocols have decreased length of stay (LOS), reduced hospital costs, and improved care following pancreaticoduodenectomy (PD). However, patients at high risk for complications may not be appropriate candidates for early discharge. The Fistula Risk Score (FRS) accurately predicts subsequent clinically relevant postoperative pancreatic fistula (CR-POPF). We hypothesized that low FRS would be associated with success to discharge by post-operative day (POD) 3.

BACKGROUND Pancreatobiliary (PB) disorders, especially cancer, negatively impact patients' health-related quality of life (HRQoL). However, the influence of baseline, pre-intervention HRQoL on peri-operative and oncologic outcomes has not been well-defined. We hypothesized that low baseline HRQoL is associated with worse peri-operative and long-term survival outcomes for PB surgical patients. STUDY DESIGN Pre-treatment FACT-Hep survey results and clinical data from PB patients (2008-2016) from a single center's prospective database were analyzed. Survey responses were aggregated into composite scores and divided into quintiles. Patients in the highest quintile of HRQoL were compared to patients in the bottom four quintiles combined. Overall (OS) and disease-free (DFS) were analyzed using the Kaplan-Meier method. Logistic and cox regressions were used to determine associations between quintiles of HRQoL scores and 30-day complications and long-term survival, respectively. RESULTS Of 162 patients evaluated, 99 had malignancy, and 63 had benign disease. Median follow-up was 31 months. Baseline HRQoL scores were similar for benign and malignant disease (p=0.42) and were not associated with the development of any (p=0.08) or major complications (p=0.64). Patients with highest quintile HRQoL scores had longer 3-year OS (84.6 vs 61.7%, p = 0.03) compared to patients in the lowest four quintiles of HRQoL. Among cancer patients only, those with highest quintile scores had longer 3-year OS (81.6 vs 47.4%, p = 0.02). On multivariable analysis, highest quintile HRQoL scores were associated with longer OS and DFS for patients with malignancy. CONCLUSIONS Pre-treatment HRQoL was associated with both OS and DFS among PB patients and might have prognostic utility. Future studies are necessary to determine whether patients with poorer HRQoL may benefit from targeted psycho-social interventions.

Adenocarcinoma with enteroblastic differentiation is an extremely rare tumor with poor prognosis and unique pathologic features. The tumor appears to be relatively more common in stomach, with rare cases reported in esophagus, colon, rectum and ampulla. Underrecognition by pathologists may be a contributing factor towards underreporting of this tumor. Combination of carcinosarcoma and enteroblastic differentiation has not been reported so far. We report a unique case of ampullary carcinosarcoma with enteroblastic differentiation in a 59-year-old female, diagnosed in the pancreatoduodenectomy specimen. The carcinomatous component showed features of enteroblastic differentiation characterized by tubular architecture with clear cytoplasm, solid component with trabecular architecture and immunohistochemical expression of SALL4 and AFP. The patient was treated with adjuvant Folfirinox chemotherapy and is disease free at 17 months follow up.

Objective: Early drain removal when POD1 drain fluid amylase (DFA) was ≤5000 IU/L reduced complications in a previous randomized controlled trial. We hypothesized that most surgeons continue to remove drains late and that this is associated with inferior outcomes. Methods: We assessed the practice of pancreas surgeons in a prospectively maintained pancreas surgery consortium database to determine the association between timing of drain removal with demographics, co-morbidities, and all complications including clinically relevant post-operative pancreatic fistula (CR-POPF). We excluded patients without drains or POD1 DFA >5000, and if POD1 DFA values or timing of drain removal was unknown. Early drain removal was defined as ≤POD5. Early and late removal groups were compared using Chi square. Results: 213 patients met all inclusion criteria. Only 74 (35%) had drains removed early. There was no difference between groups in demographics or co-morbidities. EBL was greater in the late group (early 146 mL, late 325 mL; p=0.008). All other intra-operative characteristics were similar. Complications were significantly increased in the late group (Table 1). There were no CR-POPF or major complications in patients with early removal. When subset analysis was performed for type of resection, complications remained significant for distal pancreatectomy (early (4/29 (14%) vs late 24/35 (69%), p <0.0001). Conclusion: Despite level 1 data suggesting improved outcomes with early removal when POD1 DFA is ≤5000, experienced pancreas surgeons more frequently removed drains late. This practice was not explained by known risk factors (except EBL) and may be associated with inferior outcomes suggesting potential for improvement, particularly in distal pancreatectomy.Table 1Comparison of Early and Late Drain Removal GroupsEarly (n=74)Late (n=139)p-valuePatients with any complication21 (28%)114 (82%)<0.0001Patients with major complications(Accordion grade ≥3)016 (11%)0.04Pancreatic fistula (Grade B/C)010 (7%)0.03 Open table in a new tab

Background: We hypothesized that the development and implementation of an ERAS pathway targeting next day discharge following distal pancreatectomy (DP) would reduce length of stay (LOS) without affecting post-operative morbidity or mortality. Methods: The ERAS pathway was carried out by one surgeon over a 23-month period starting in March 2016 (ERAS group). Outcomes in this group were compared to patients operated on by other surgeons not following the pathway during the same time period (contemporary group) and to a retrospective cohort (retrospective group) of patients operated on by the same single surgeon, between December 2013 to February 2016. A prospectively maintained database with documentation of 60-day complications and 90-day mortality was retrospectively reviewed and analyzed. Analysis was performed using chi-squared for categorical variables and Mann Whitney testing for continuous variables. Results: Among 120 patients included in the study; 42 were in the ERAS group, 42 in the retrospective group, and 36 in the contemporary group. No significant differences in patient demographics, co-morbidities, or fistula risk scores existed between groups. Implementation of the pathway reduced median LOS by 43% in the ERAS group compared to the retrospective group (2 vs 3.5 days, P < 0.001) and by 50% compared to the contemporary group (2 vs 4 days, P < 0.001). Within the ERAS group, post-operative pancreatic fistulas were reduced compared to both the retrospective group (9.5% vs 26.2%, P = 0.0031) and the contemporary group (9.5% vs 36.1%, P = 0.006), however, no difference in clinically relevant fistulas was present. Urinary retention occurred more frequently among patients in the ERAS group at 14.3% (contemporary: 0%, P = 0.024; retrospective: 2.4%, P = 0.052). There were no other differences in post-operative complications, rates of re-operation, re-admission, or 90-day mortality. Conclusion: Utilization of an ERAS pathway targeting next day discharge following distal pancreatectomy significantly reduced LOS without affecting morbidity or mortality.

BACKGROUND:Early drain removal when postoperative day (POD) one drain fluid amylase (DFA) was ≤5000 U/L reduced complications in a previous randomized controlled trial. We hypothesized that most surgeons continue to remove drains late and this is associated with inferior outcomes. METHODS:We assessed the practice of surgeons in a prospectively maintained pancreas surgery registry to determine the association between timing of drain removal with demographics, comorbidities, and complications. We selected patients with POD1 DFA ≤5000 U/L and excluded those without drains, and subjects without data on POD1 DFA or timing of drain removal. Early drain removal was defined as ≤ POD5. RESULTS:Two hundred and forty four patients met inclusion criteria. Only 90 (37%) had drains removed early. Estimated blood loss was greater in the late removal group (190 mL versus 100 mL, P = 0.005) and pathological findings associated with soft gland texture were more frequent (97 [63%] versus 35 [39%], P < 0.0001). Patients in the late drain removal group had more complications (84 [55%] versus 30 [33%], P = 0.001) including pancreatic fistula (55 [36%] versus 4 [4%], P < 0.0001), delayed gastric emptying (27 [18%] versus 3 [3%], P = 0.002), and longer length of stay (7 d versus 5 d, P < 0.0001). In subset analysis for procedure type, complications and pancreatic fistula remained significant for both pancreatoduodenectomy and distal pancreatectomy. CONCLUSIONS:Despite level one data suggesting improved outcomes with early removal when POD1 DFA is ≤ 5000 U/L, experienced pancreas surgeons more frequently removed drains late. This practice was associated with known risk factors (estimated blood loss, soft pancreas) and may be associated with inferior outcomes suggesting potential for improvement.

Background: Although current guidelines recommend multimodal therapy for all patients with pancreatic ductal adenocarcinoma, it is unclear the extent to which clinical stage I patients are accurately staged and how this may affect management. Methods: In this retrospective cohort study of 4,404 patients aged 18-79 years with clinical stage 1 (ie, T1N0 or T2N0) pancreatic ductal adenocarcinoma treated with upfront resection in the National Cancer Database (2004-2014), understaging was ascertained by comparing pretreatment clinical stage with pathologic stage. The association between adjuvant treatment and overall risk of death among true stage I and understaged patients was evaluated using multivariable Cox regression. Results: Upstaging was identified in 72.6% of patients (62.8% T3/4, 53.9% N1) of whom 69.7% received adjuvant therapy compared with 47.0% with true stage I disease. Overall survival at 5 years among those with true stage I disease was significantly higher than those who had been clinically understaged (42.9% vs 16.6%; log-rank, p < 0.001). For true stage I patients, adjuvant therapy was not associated with risk of death (hazard ratio: 1.07, 95% confidence interval: 0.89-1.29). For understaged patients, adjuvant therapy significantly decreased risk of death (hazard ratio: 0.64, 95% confidence interval: 0.55-0.74). Conclusion: The majority of clinical stage I pancreatic ductal adenocarcinoma patients actually have higher-stage disease and benefit from multimodal therapy; however, one third of understaged patients do not receive any adjuvant treatment. Clinicians should discuss all potential treatment strategies with patients (in the context of the acknowledged risks and benefits), including the utilization of neoadjuvant approaches in those presenting with potentially resectable disease. Published by Elsevier Inc.

Introduction: Nasogastric decompression (NGD) has been routinely used after major gastrointestinal surgery. The purpose of this randomized controlled trial (RCT) is to evaluate the benefit of NGD in the early postoperative period as compared to routine intra-operative oro-gastric tube (OGT) decompression, in patient undergoing pancreaticoduodenectomy (PD). Methods: Over 4-year period, a total of 120 patients undergoing PD were enrolled in this prospective RCT. There were 57 patients in group 1 (OGT) and 63 patient in group II (NGT). Postoperative variables evaluated, were time to starting oral diet, Incidence of postoperative nausea and vomiting, Postoperative ileus, delayed gastric emptying (DGE), NGT re-insertion rate, anastomotic leak, pulmonary complication, length of hospital stay (LOS), and mortality. Results: There were no significant difference between both groups in regard to the preoperative and intra-operative variables. However, time to oral diet was significantly shorter in group I compared to group II (1.5 ± 0.5 vs 3.0 ± 2.4; P < 0.05, respectively). On average, NGT was maintained for 1.4 ± 1 days after surgery in group II. The re-insertion rate of NGT was similar in both group I and II (11.3 % vs 10.2%, respectively, P value = 0.3). Nasogastric decompression did not significantly reduce the incidence of nausea in group II compared to group I (12% vs 17%, P value = 0.5). The incidence of anastomotic leakage, DGE, postoperative ileus, and morbidity and mortality were similar in both groups. Similarly, there was no difference in the LOS in either group. Conclusion: Routine postoperative NGT decompression is not necessary after pancreaticoduodenectomy.

Many pancreatic surgeons continue to use intraperitoneal drains, but others have limited or avoided their use, believing this improves outcomes. We conducted a systematic review and meta-analysis of the literature assessing outcomes in pancreatectomy without drains, selective drainage, and early drain removal. We searched PubMed, Embase, and the Cochrane Library databases and conducted a systematic review of randomized and nonrandomized studies comparing routine intra-abdominal drainage versus no drainage, selective drain use, and early versus late drain removal after pancreatectomy, with major complications as the primary outcome. A meta-analysis of the literature assessing routine use of drains was conducted using the random-effects model. A total of 461 articles met search criteria from PubMed (168 articles), Embase (263 articles), and the Cochrane Library (30 articles). After case reports and articles without primary data on complications were excluded, 14 studies were identified for systematic review. Definitive evidence-based recommendations cannot be made regarding the management of drains following pancreatectomy because of limitations in the available literature. Based on available evidence, the most conservative approach, pending further data, is routine placement of a drain and early removal unless the patient's clinical course or drain fluid amylase concentration suggests a developing fistula.

Background: Resection of pancreatic cystic lesions can prevent pancreas cancer but aggressive resection of benign cysts may cause harm. More conservative guidelines for cyst management have been proposed. We hypothesized that if conservative guidelines were applied to our patient population, pancreas resections for benign cystic lesions would decrease without failure to resect malignant lesions.

Pancreatic cancer is an aggressive malignancy with a poor prognosis. The disease and its treatment can cause significant nutritional impairments that often adversely impact patient quality of life (QOL). The pancreas has both exocrine and endocrine functions and, in the setting of cancer, both systems may be affected. Pancreatic exocrine insufficiency (PEI) manifests as weight loss and steatorrhea, while endocrine insufficiency may result in diabetes mellitus. Surgical resection, a central component of pancreatic cancer treatment, may induce or exacerbate these dysfunctions. Nutritional and metabolic dysfunctions in patients with pancreatic cancer lack characterization, and few guidelines exist for nutritional support in patients after surgical resection. We reviewed publications from the past two decades (1995–2016) addressing the nutritional and metabolic status of patients with pancreatic cancer, grouping them into status at the time of diagnosis, status at the time of resection, and status of nutritional support throughout the diagnosis and treatment of pancreatic cancer. Here, we summarize the results of these investigations and evaluate the effectiveness of various types of nutritional support in patients after pancreatectomy for pancreatic adenocarcinoma (PDAC). We outline the following conservative perioperative strategies to optimize patient outcomes and guide the care of these patients: (1) patients with albumin < 2.5 mg/dL or weight loss > 10% should postpone surgery and begin aggressive nutrition supplementation; (2) patients with albumin < 3 mg/dL or weight loss between 5% and 10% should have nutrition supplementation prior to surgery; (3) enteral nutrition (EN) should be preferred as a nutritional intervention over total parenteral nutrition (TPN) postoperatively; and, (4) a multidisciplinary approach should be used to allow for early detection of symptoms of endocrine and exocrine pancreatic insufficiency alongside implementation of appropriate treatment to improve the patient’s quality of life.

Objective: The objective of this study was to test the hypothesis that distal pancreatectomy (DP) without intraperitoneal drainage does not affect the frequency of grade 2 or higher grade complications. Background: The use of routine intraperitoneal drains during DP is controversial. Prior to this study, no prospective trial focusing on DP without intraperitoneal drainage has been reported. Methods: Patients undergoing DP for all causes at 14 high-volume pancreas centers were preoperatively randomized to placement of a drain or no drain. Complications and their severity were tracked for 60 days and mortality for 90 days. The study was powered to detect a 15% positive or negative difference in the rate of grade 2 or higher grade complications. All data were collected prospectively and source documents were reviewed at the coordinating center to confirm completeness and accuracy. Results: A total of 344 patients underwent DP with (N = 174) and without (N = 170) the use of intraperitoneal drainage. There were no differences between cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, or operative technique. There was no difference in the rate of grade 2 or higher grade complications (44% vs. 42%, P = 0.80). There was no difference in clinically relevant postoperative pancreatic fistula (18% vs 12%, P = 0.11) or mortality (0% vs 1%, P = 0.24). DP without routine intraperitoneal drainage was associated with a higher incidence of intra-abdominal fluid collection (9% vs 22%, P = 0.0004). There was no difference in the frequency of postoperative imaging, percutaneous drain placement, reoperation, readmission, or quality of life scores. Conclusions: This prospective randomized multicenter trial provides evidence that clinical outcomes are comparable in DP with or without intraperitoneal drainage.

Objective: The literature comparing minimally invasive distal pancreatectomy (DP) to open DP is mostly limited to one or two minimally invasive surgical (MIS) techniques. Previous studies have addressed outcomes between robotic, laparoscopic, and open DP but have not included hand-assisted laparoscopic surgery. We evaluated outcomes of these four DP techniques in a multi-center study. Methods: Data was collected from a prospectively maintained pancreas surgery consortium database at three high-volume pancreatic centers. We analyzed pre-operative, oncologic, and post-operative outcomes including complications, pancreatic fistula of any grade, and clinically relevant fistula in each DP procedure type. Results: 261 patients underwent DP. 36% underwent open, 25% laparoscopic, 14% hand-assisted, and 25% robotic DP. The most common diagnosis was cystic lesion (39%) followed by pancreatic adenocarcinoma (PDAC) (27%). Open DP was more common in patients with PDAC (p=0.001) and with greater co-morbidities, particularly HTN (p=0.02) and smoking history (p=0.02). EBL and transfusions were greater with open DP. Length of procedure was greater with MIS. Soft gland texture was more common in the MIS groups (Table 1). There was no difference in post-operative complications except for increased fistula of any grade with MIS (p=0.02). However, there was no difference in clinically relevant fistula (p=0.4). There was no difference in LOS, R0 resection, or lymph node yield. Conclusion: There is no difference in post-operative complications and oncologic outcomes between open and various MIS modalities for DP. The increased use of open DP for PDAC patients is likely a result of selection bias.Table 1ResultsOpenLapHALRoboticp-valueBaseline characteristicsHTN56 (61%)25 (44%)21 (60%)23 (38%)0.02Smoking history53 (58%)30 (47%)13 (35%)19 (28%)0.02Initial diagnosis PDAC43 (45%)7 (11%)10 (27%)9 (14%)0.001Perioperative characteristicsEBL (mL)43823960225<0.0005Transfusion10 (11%)2 (3%)02 (3%)0.009Soft gland texture69 (75%)49 (83%)32 (91%)58 (98%)0.001Post-operative complicationsFistula any grade21 (23%)25 (48%)12 (39%)17 (33%)0.02CR-POPF (ISGPS Grade B/C)9 (10%)10 (19%)3 (10%)7 (14%)0.4Patients with any complications44 (42%)33 (28%)15 (41%)23 (36%)0.3Patients with Accordion ≥ grade 3 complications20 (21%)13 (20%)5 (14%)11 (20%)0.8 Open table in a new tab

Delayed gastric emptying (DGE) is a common complication of pancreaticoduodenectomy. We determined the efficiency of a new reconstruction technique, designed to preserve motilin-secreting cells and maximize the utility of their receptors, in reducing the incidence of DGE after pancreaticoduodenectomy. From April 2005 to September 2014, 217 consecutive patients underwent pancreaticoduodenectomy at our institution. Nine patients who underwent total pancreatectomy were excluded. We compared outcomes between patients who underwent pancreaticoduodenectomy with resection of the pyloric ring followed by proximal Roux-en-y gastrojejunal anastomosis (group I, n = 90) and patients who underwent standard pancreaticoduodenectomy with the orthotopic reconstruction technique (group II, n = 118). Overall and clinically relevant rates of DGE were significantly lower in group I than in group II (10 and 2.2 % vs. 57 and 24 %, respectively; p < 0.05). Length of hospital stay as a result of DGE was shorter in group I than in group II. In univariate analysis, older age, comorbidities, ASA grade 4, operative time, preoperative diabetes, standard reconstruction technique, and postoperative complications were significant risk factors for DGE. In multivariate analysis, older age, standard technique, and postoperative complications were independent risk factors for DGE. Our new reconstruction technique reduces the occurrence of DGE after pancreaticoduodenectomy.

We examined whether 2-octyl cyanoacrylate (Dermabond) topically applied to the pancreaticojejunostomy (PJ) anastomotic site after pancreaticoduodenectomy (PD) reduces the rate of postoperative pancreatic fistula (POPF).