Background: Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular tumor with an incidence of one per million worldwide. Little consensus exists for optimal multimodality treatment paradigms including surgical, locoregional, and systemic therapies. The purpose of this observational study involving one of the largest single-center experiences with HEHE is to highlight stage-dependent outcomes following various treatment modalities. Methods: This single-institution study included all patients with a histopathologic diagnosis of HEHE from 2000-23. Patient demographics, staging, treatment, and survival data were gathered from electronic medical records. Results: The study cohort included 18 patients with HEHE; 55.6% female; 88.9% Caucasian, 5.6% African American, and 5.6% unknown race or ethnicity. The median age at diagnosis was 58 years (range, 24-86). According to AJCC staging, 7 patients were stage IB, and 6 were stage IV. Local therapy included liver resection (N=7), stereotactic external beam radiation therapy (N=1), and selective arterial-based liver directed radiation (y90) therapy (N=1). No patient received a liver transplant. Ten patients received systemic therapy with the most common agent being sirolimus (N=5). Two patients declined treatment. The median follow-up was 20 months (range, 1-68). Patients with stage IV HEHE had a median overall survival (OS) of 25.6 months, while patients without systemic metastases had a 5-year OS of 64%. Kaplan-Meier curves are shown in Figure 1. Conclusions: The natural history and treatment outcomes for HEHE are not well established. This single-institution observational study suggests improved outcomes after liver resection for HEHE without extrahepatic metastases. Larger multi-institutional studies and meta-analyses are needed.

Background: Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common complication after pancreatoduodenectomy and is associated with significant mortality. The Fistula Risk Score (FRS), incorporating pancreatic duct size, parenchymal texture, blood loss, and at-risk pathology, is a validated tool for predicting CR-POPF. Postoperative pancreatitis (POP), reflecting parenchymal injury or ischemia, has been described in up to 40% of patients after pancreatoduodenectomy, but its association with POPF remains unclear. The aim of this study was to examine the relationships between POP, FRS, and CR-POPF.

Background: Approximately 5-10% of patients with pancreatic adenocarcinoma (PDAC) carry germline mutations that contributed to the development of their cancer. Recently, the National Comprehensive Cancer Network (NCCN) began recommending that all pancreatic cancer patients and first-degree relatives undergo genetic testing. For patients who were previously unaware of their germline mutation, such findings may have significant impact on the patient’s family and family planning. The aim of this study was to investigate the frequency of new diagnoses of germline mutations in pancreatic cancer and characterize their oncologic outcomes.

Background: Rates of opioid usage during necrotizing pancreatitis (NP) disease course are unknown. We hypothesized that a significant number of NP patients were prescribed opioid analgesics chronically. Methods: Single institution IRB-approved retrospective study of 230 NP patients treated between 2015 and 2019. Results: Data were available for 198/230 (86%) patients. 166/198 (84%) were discharged from their index hospitalization with a prescription for an opioid. At the first clinic visit following hospitalization, 110/182 (60%) were using opioids. Six months after disease onset, 72/163 (44%) continued to require opioids. At disease resolution, 38/144 (26%) patients remained on opioid medications. The rate of active opioid prescriptions at six months after disease onset declined throughout the period studied from 68% in 2015 to 39% in 2019. Conclusions: Opioid prescriptions are common in NP. Despite decline over time, 1 in 4 patients remain on opioids at disease resolution. These data identify an opportunity to adjust analgesic prescription practice in NP patients.

Background: Delayed gastric emptying (DGE) after pancreatoduodenectomy (PD) presents both an economic and functional burden on affected patients. Patients with DGE often require nutritional supplementation as they experience prolonged periods of inadequate oral intake. Some patients are not able to tolerate enteral nutrition and receive parenteral nutrition only. In this study we aim to evaluate if supplementation by parenteral nutrition only adversely affects outcomes in patients with DGE.

Background: An understanding of the incidence and treatment of biliary stricture after major hepatectomy (MH) with bile duct resection (BDR) is limited by small-volume series and/or lack of long-term follow-up. The aim of this study was to evaluate the incidence, risk factors, and treatment strategy of biliary stricture after MH with BDR. We hypothesized that biliary stricture after MH with BDR is more common than previously appreciated and is successfully managed with percutaneous interventions.

Introduction: The refined 8th edition of the AJCC TNM classification for pancreatic cancer sought to improve staging with a better distribution among T stages. The emphasis shifted from extrapancreatic invasion to tumor size and lymph node number. We hypothesized that the updated classification may result in undertreatment of patients. Methods: From January 2016 to November 2020, 476 consecutive patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma at a single academic center were included. Survival analysis was performed. Results: Of the patients who met the inclusion criteria, 53% died over the study period, after a median of 14 months. The 7th AJCC TNM classification categorized 81% as pT3, whereas T stages were more evenly distributed in the 8th edition (T1:22.5%; T2:55.5%; T3:19.7%). T and N staging in either edition failed to predict survival in Cox regression. The newer classification resulted in 14.5% downstaging from stage III to stage I, with 40.5% of down-staged patients not receiving neoadjuvant treatment. Interestingly, however, it yielded the type of pancreatectomy (p=0.038), neoadjuvant chemotherapy (p=0.003), pathological response (p=0.017), grade (p=0.003), and extra-pancreatic invasion (p=0.008) as independent predictors of longer survival. Conclusion: The 8th edition of the AJCC TNM staging for pancreatic cancer is easier to use and more reproducible. However, the emphasis on size results in down-staging of some patients and a corresponding decrease in neoadjuvant treatment. A more comprehensive system including extra-pancreatic invasion and grade to reflect tumor biology as in other cancers such as breast, may better impact prognostic accuracy and therapeutic decision making.

Introduction: Drain amylase is often relied on to determine the timing of drain removal after pancreatectomy. Although early drain removal is becoming more common, other predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) when drain amylase is low in the early postoperative period have yet to be established. Methods: Patients who underwent distal pancreatectomy (DP) or pancreatoduodenectomy (PD) between 2013-2020 were queried from a prospectively maintained NSQIP database at a single, high-volume institution. Those whose drain amylase on postoperative day 1 (POD1) was less than three times the laboratory upper limit for normal were selected. CR-POPF was defined as grade B or C fistulas according to the 2016 International Study Group on Pancreatic Surgery guidelines. Results: 499 of 1549 (32.2%) of DPs and PDs demonstrated low drain amylase on POD1. Of these, 17 (3.4%) developed CR-POPF (11 grade B, 6 grade C). Surgery type (DP vs. PD) was not associated with CR-POPF (3.6% vs 3.5%, p=0.95). Age, BMI, and other historical medical conditions including diabetes, ascites, and dialysis dependence also showed no association. Patients who were male (5.7% vs. 0.8%, RR=7.1, p<0.01), had disseminated cancer (13.3% vs 3.1%, RR=4.3, p=0.03), and soft pancreas gland texture (7.6% vs. 1.6% intermediate vs. 1.8% hard, p=0.014) were more likely to develop CR-POPF. Blood transfusion also correlated with CR-POPF (6.3% vs. 2.4%, RR=2.6, p=0.04). Conclusions: Patient and perioperative factors other than drain amylase, such as blood transfusion, may be predictive of CR-POPF in the early postoperative period and should be considered in postsurgical care.

Necrotizing pancreatitis (NP) is caused by hypertriglyceridemia (HTG) in up to 10% of patients. Clinical experience suggests that HTG-NP is associated with increased clinical severity; objective evidence is limited and has not been specifically studied in NP. The aim of this study was to critically evaluate outcomes in HTG-NP. We hypothesized that patients with HTG-NP had significantly increased severity, morbidity, and mortality compared to patients with NP from other etiologies. A case–control study of all NP patients treated at a single institution between 2005 and 2018 was performed. Diagnostic criteria of HTG-NP included a serum triglyceride level > 1000 mg/dL and the absence of another specific pancreatitis etiology. To control for differences in age, sex, and comorbidities, non-HTG and HTG patients were matched at a 4:1 ratio using propensity scores. Outcomes were compared between non-HTG and HTG patients. A total of 676 NP patients were treated during the study period. The incidence of HTG-NP was 5.8% (n = 39). The mean peak triglyceride level at diagnosis was 2923 mg/dL (SEM, 417 mg/dL). After propensity matching, no differences were found between non-HTG and HTG patients in CT severity index, degree of glandular necrosis, organ failure, infected necrosis, necrosis intervention, index admission LOS, readmission, total hospital LOS, or disease duration (P = NS). Mortality was similar in non-HTG-NP (7.1%) and HTG-NP (7.7%), P = 1.0. In this large, single-institution series, necrotizing pancreatitis caused by hypertriglyceridemia had similar disease severity, morbidity, and mortality as necrotizing pancreatitis caused by other etiologies.

Presenter: Sean McGuire MD | Indiana University Background: The inflammatory insult of necrotizing pancreatitis (NP) increases rates of venous thromboembolism, including splanchnic venous thrombosis (SVT). The natural history of SVT in NP is incompletely understood. We hypothesized that NP patients with SVT would have more severe pancreatic necrosis and higher rates of NP-associated morbidity. Methods: Single institution retrospective review of 745 NP patients treated between 2005-2019. We compared the comorbidity profile, necrotizing pancreatitis severity and disease course, and short-term outcomes between patients with and without SVT. Statistical significance was determined using t-test, chi-square, or ANOVA; P-values less than 0.05 were accepted as significant. Results: The overall incidence of SVT was 43% (322/745 NP patients). Isolated splenic venous thrombosis (SplVT) was the most common anatomic distribution (49%), followed by combined superior mesenteric venous thrombosis (SMVT) and SplVT (14%), isolated portal vein thrombosis (PVT) (10%), combined PVT, SMVT, and SplVT (9%), combined PVT and SplVT (7%), isolated SMVT (6%), and combined PVT and SMVT (5%). SVT was diagnosed an average of 97 ± 14 days after NP diagnosis. Patients with SVT were more likely to be male (71% versus 60%, p = 0.002). No differences in pre-existing comorbidities or NP etiology were seen between patients with and without SVT. Patients with SVT had more severe pancreatic necrosis: the average CTSI in patients with SVT was 7.1 ± 0.4 compared to 6.3 ± 0.1 in patients without SVT (p50% necrosis compared to 19% of patients without SVT (p<0.001). Patients with SVT were more likely to have infected necrosis (61% vs 48%, p<0.001). Disease duration was longer in patients with SVT (228 ± 12.6 days) compared to patients without SVT (171 ± 6.2 days) (p <0.001). The location of pancreatic necrosis correlated with the location of venous thrombosis (Figure). Significant heterogeneity in disease course and outcomes was observed relative to the location of venous thrombus. Patients with PVT, SMVT, or multi-vein involvement had significantly greater rates of infected necrosis, organ failure, and mortality than those with isolated SplVT (Figure). Conclusion: Splanchnic venous thrombosis is very common in necrotizing pancreatitis. More severe necrosis is associated with an increased likelihood of SVT development. SVT is associated with prolonged disease course; however, NP disease course and mortality rates vary depending on venous thrombus location, suggesting that SVT is a heterogenous problem requiring an individualized approach to management.

positivity was the strongest predictors of recurrence.The patterns of initial recurrence appear to differ between primary tumor site.These differences likely reflect underlying differences in anatomy and disease biology.While these data need to be corroborated in a larger cohort, they could help inform future studies involving novel neoadjuvant/ adjuvant therapies, as well as timing and anatomic focus for surveillance imaging.

This study aimed to determine the incidence of new onset hepatic steatosis after neoadjuvant chemotherapy for pancreatic cancer and its impact on outcomes after pancreatoduodenectomy. Retrospective review identified patients who received neoadjuvant chemotherapy for pancreatic adenocarcinoma and underwent pancreatoduodenectomy from 2013 to 2018. Preoperative computed tomography scans were evaluated for the development of hepatic steatosis after neoadjuvant chemotherapy. Hypoattenuation included liver attenuation greater than or equal to 10 Hounsfield units less than tissue density of spleen on noncontrast computed tomography and greater than or equal to 20 Hounsfield units less on contrast-enhanced computed tomography. One hundred forty-nine patients received neoadjuvant chemotherapy for a median of 5 cycles (interquartile range (IQR), 4–6). FOLFIRINOX was the regimen in 78% of patients. Hepatic steatosis developed in 36 (24%) patients. The median time from neoadjuvant chemotherapy completion to pancreatoduodenectomy was 40 days (IQR, 29–51). Preoperative biliary stenting was performed in 126 (86%) patients. Neoadjuvant radiotherapy was delivered to 23 (15%) patients. Female gender, obesity, and prolonged exposure to chemotherapy were identified as risk factors for chemotherapy-associated hepatic steatosis. Compared with control patients without neoadjuvant chemotherapy-associated hepatic steatosis, patients developing steatosis had similar rates of postoperative pancreatic fistula (8% (control) vs. 4%, p = 0.3), delayed gastric emptying (8% vs. 14%, p = 0.4), and major morbidity (11% vs. 15%, p = 0.6). Ninety-day mortality was similar between groups (8% vs. 2%, p = 0.08). Hepatic steatosis developed in 24% of patients who received neoadjuvant chemotherapy but was not associated with increased morbidity or mortality after pancreatoduodenectomy.