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Background: Limited data comparing recovery of health-related quality of life (HRQoL) after laparoscopic (LDP) versus open distal pancreatectomy (ODP) are available. The aim of this study was to assess the impact of laparoscopy on postoperative HRQOL after DP using the Patient-Reported Outcomes Measurement Information System (PROMIS). Methods: Data from consecutive patients who underwent DP (2020–2022) enrolled in a prospective clinical trial were reviewed. Patients completed PROMIS-29 plus 2 profile preoperatively, at postoperative day (POD) 15, 30, 90, and 180. Linear regression analysis adjusting for confounders including preoperative PROMIS scores, age, gender, ASA score, diagnosis, and multivisceral resection was used to estimate mean between-group differences (MD) in postoperative PROMIS domains T scores. Results: Overall, 202 patients (118 laparoscopic, 86 open) underwent DP (median age 66 years, pancreatic cancer 41%, multivisceral resection 10%, median LOS 6 days). At POD15, LDP was associated with higher physical function (MD 5.6) and participation in social roles and activities scores (MD 3.8), reduced fatigue (MD − 2.7) and sleep disturbance (MD − 3.8) compared to ODP. At POD30, LDP patients had higher physical function (MD 5.2) and participation in social roles and activities scores (MD 6.0), reduced fatigue (MD − 3.5), and anxiety (MD − 4.0) compared to ODP. No between-group differences were found in HRQoL domains at POD90 and 180. Six months after surgery, the proportions of patients who had not recovered to preoperative physical function, participation in social roles and activities, fatigue, pain interference, sleep disturbance, cognitive function, depression, and anxiety were 31%, 31%, 28%, 20%, 15%, 14%, 8%, and 7%, respectively. Conclusions: According to PROMIS, LDP resulted in improved physical and social functioning and reduced anxiety and fatigue up to 30 days after surgery compared to ODP. At 6 months after surgery, recovery of physical domains is still incomplete in up to 30% of patients. Graphical abstract:

Background: Distal pancreatectomy is burdened by a high rate of clinically relevant postoperative pancreatic fistula (CR-POPF). The presence of a fistula-related abdominal collection often requires additional treatment such as antibiotics, percutaneous drainage, and endoscopic drainage thus prolonging patient recovery. Aim of this study was to describe the management of abdominal collections related to CR-POPF and identify variables associated with the need for invasive procedures. Methods: A retrospective review of clinical data for patients who underwent distal pancreatectomy between 2015 and 2020 was conducted. All postoperative CT-scan imaging performed for clinical signs related to POPF was reviewed. The main outcome of the study was the need for procedural management (percutaneous or endoscopic) of CR-POPF-related fluid collections at 90 days after surgery. A multivariate regression analysis was adopted to analyze factors influencing procedural management of the collection. Results: Five hundred sixteen patients were included in the study. Laparoscopic resection was performed in 290 patients (56%). At 90 days after surgery, CR-POPF occurred in 207 (40.1%) patients. A symptomatic collection related to fistula was observed in 130 patients (25.2%). Factors associated with fluid collections were increased body mass index (BMI) (25.5 versus 24, p= 0.001) and intraoperative blood loss (median of 250 versus 200 ml, p< 0.001). Procedural management was required in 70 patients (13.6%); 52 patients required interventional radiology and 18 endoscopic drainage. At multivariate analysis, risk factors for invasive procedures were the following CT-scan parameters: fluid collection diameter greater than 5 cm (OR 6.366, 95%CI 2.29–17.66, p= 0.001), presence of blood in the fluid collection (OR 10.618, 95%CI 1.94–58.09, p= 0.006), and enhancement of its walls (OR 4.073, 95%CI 1.22–13.57, p= 0.022). Conclusion: CR-POPF-related fluid collections affect about a quarter of patients undergoing distal pancreatectomy. CT-scan provides important information which can guide the management of the collection in a “step-up” fashion.

Due to its robustness and cost-effectiveness, the three-phase induction motor (TIM) has become the most widespread electric machine today. However, like any other equipment, it is vulnerable to a fault, and about 52% of these are related to bearings. This work presents the detection of flaws in the outer bearing’s raceway from the measurement of motor dynamic strain signals collected from sensors based on fiber Bragg grating (FBG). Three different degrees of severity were considered for faults in the outer bearing’s raceway. The tests were carried out on the motor operating under no-load conditions, with 47 different power supply frequencies. This work proposes a support vector machine (SVM) classifier to identify fault severity levels. Feature extraction was performed using two techniques: selecting the four highest peaks in the frequency spectrum and principal component analysis (PCA). The supervised SVM classifiers show that the dataset formed from the PCA presented a higher hit rate than the dataset constituted by the four highest peaks, with 99.82% and 92.73%, respectively. Based on the methodology presented in this work, it was possible to validate the use of FBG to detect bearing faults. Regardless of the degree of severity of the fault analyzed, the sensor detected its characteristic frequency. Based on the methodology presented in this work, it was possible to validate the use of FBG to detect bearing faults. Regardless of the degree of severity of the flaw analyzed, the sensor detected its characteristic frequency.

Background: It is unclear whether routine postoperative admission to the intensive care unit (ICU) can improve outcomes for patients undergoing elective pancreatic surgery. Aim of the study was to determine preoperative and intraoperative predictors of unplanned ICU access in patients undergoing pancreatectomy treated within an established enhanced recovery pathway (ERP) and compare outcomes between direct and late ICU admission. Methods: A retrospective observational study was conducted on adult patients who underwent pancreatic resection (2015–2019) within an ERP. Patients with preoperatively planned ICU admission were excluded from the study. Multiple multivariate logistic regression models were constructed to verify the association of preoperative and intraoperative variables with study outcomes. Results: The study included 1486 consecutive patients (cancer diagnosis 60%, pancreaticoduodenectomy 60%; laparoscopic approach 20%; vascular resection 9%). Sixty-six (4.4%) patients had an unplanned ICU admission. Direct admission occurred in 22 (33%) patients and late ICU admission in 44 (67%) patients. Mortality was significantly lower in direct admission group (n= 3, 14%) compared to late admission (n= 25, 57%; p> 0.001). A comprehensive model including preoperative and intraoperative variables identified ASA score ≥ 3 (OR 5.59, pvalue < 0.001), history of hypertension (OR 2.29, p= 0.029), chronic obstructive pulmonary disease (OR 3.05, p= 0.026), proximal pancreatic resection (OR 2.79, pvalue 0.046), multivisceral resection (OR 8.86, pvalue < 0.001), high intraoperative blood loss (OR 1.01 per ml, p< 0.001), and increased serum lactate at the end of surgery (OR 1.25, p= 0.017) as independent factors associated with ICU admission. Area under the ROC curve was 0.891. Conclusion: Patient comorbidities, surgical complexity, and lactic acidosis at the end of surgery were associated with unplanned postoperative ICU admission. Late ICU admission had very high mortality rates compared to direct admission. Our findings suggest that patients with a combination of preoperative and intraoperative risk factors could benefit from upfront postoperative ICU admission to potentially improve postoperative outcomes.

Background: Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP. Methods: Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien–Dindo grade ≥ 3) were performed. Results: At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p< 0.001), followed by serum amylase on POD 1 (0.651, p< 0.001), serum CRP on POD3 (0.644, p< 0.001), and CRP change between POD 2 and POD 3 (0.644, p< 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36–3.86; p= 0.002), DFA ≥ 1500 U/L on POD2 (OR 4.63, 95% CI 2.72–7.89; p< 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01–2.93; p= 0.046), and CRP increase by at least 25 mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11–3.21; p= 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714–0.816, p< 0.001). Conclusions: Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management.

Background: A recent RCT showed similar postoperative outcomes and a reduced time to functional recovery in patients undergoing minimally invasive distal pancreatectomy (DP) compared to open approach. However, it reported very-high post-discharge readmission rates, calling for further investigation. The aim of our study was to evaluate the extent to which minimally invasive surgery impacts on postoperative readmissions following DP. Methods: Clinical data for patients undergoing DP between 2011 and 2018 were reviewed. Primary outcome was hospital readmission at 90 days after surgery. Secondary outcomes included post-discharge emergency department (ED) visits and time to functional recovery. Regression analyses were performed to evaluate the impact of the laparoscopic approach and other perioperative factors. Results: Overall, 376 consecutive patients underwent DP during the study period. Laparoscopy was successfully performed in 219 (58%) patients. Overall, 62 patients (16.5%) returned to the ED after discharge, 41 (18.7%) of laparoscopically operated patients, and 21 (13.4%) of those undergoing open surgery (p= 0.162). Forty-six (12.2%) of them required readmission, 31 (14.2%) after laparoscopic, and 15 (9.6%) after open procedures (p= 0.179). At multivariate regression, a low preoperative physical status (OR 2.3, 95% CI 1.2–4.7; p= 0.017), occurrence of pancreatic fistula (OR 6.8, 95% CI 2.9–15.9; p< 0.001), and post-pancreatectomy hemorrhage (OR 3.9, 95% CI 1.2–13.1; p= 0.025) were significantly associated with 90-day readmission, while laparoscopy had no impact. Median time to reach functional recovery was 5 (IQR 4–6) days. At multivariate analysis, laparoscopy reduced time to functional recovery by 13% (95% CI − 19 to − 6%; p< 0.001), time to adequate oral intake by 19% (95% CI − 27 to − 10%; p< 0.001), and time to adequate pain control by 12% (95% CI − 18 to − 5%; p< 0.001). Conclusion: Hospital readmissions and ED visits following DP were not influenced by the surgical approach. A low preoperative physical status, occurrence of postoperative pancreatic fistula and hemorrhage were significantly associated with post-discharge readmission within 90 days. Laparoscopy reduced time to functional recovery.

The correct diagnosis of a patient presenting with a solid pancreatic mass requires a careful diagnostic work-up, since many differential diagnoses are possible that completely alter the following treatments. In our chapter, we have discussed the clinical approach to the problem in a sort of diagnostic flow-chart. Firstly, we analysed the different potential presentations of a solid pancreatic mass, which can be both asymptomatic or symptomatic, and the differential diagnosis based on the symptoms of presentation. Then we focused on the various imaging techniques commonly used in the diagnostic work-up, stressing on the different presentations according to the type of disease, and the operative procedures that can supplement this part. Lastly, we discussed the best diagnostic work up that should be followed to fully understand the characteristics of each disease, which is of paramount importance to choose the adequate treatment plan, with special attention to pancreatic adenocarcinoma and its many treatment strategies such as chemotherapy, surgery, or medical therapy. In patients presenting with a solid pancreatic mass it is crucial to reach a definitive diagnosis using a well determined diagnostic work-up to better characterize the lesion, since the best treatment varies widely according not only to the type of disease but also to its features.In this issueEditorial: Pancreatic cancer is still waiting for the big leap forwardS. Gaujoux et al. (France)Epidemiology and burden of pancreatic cancerP. Maisonneuve (Italy)Diagnostic strategy with a solid pancreatic massG. Guarneri et al. (Italy)Pancreatic cancer surgical managementF. Jeune et al. (France)Pancreatic cancer: ChemotherapyC. Springfeld et al. (United Kingdom, Germany)Pancreatic cancer: Best supportive careA.L. Védie et al. (France)Pancreatic cancer: What’ nextR. Salvia et al. (Italy)

Predictors of response to neoadjuvant chemotherapy are not available for gastric and oesophago-gastric junction carcinoma. HER-2 over-expression in breast cancer correlates with poor prognosis and high incidence of recurrence. First aim of this study was to evaluate if the HER-2 expression/amplification is predictive of response to neoadjuvant chemotherapy in terms of pathologic regression. Secondary aim was to evaluate if HER-2 expression varies after neoadjuvant treatment. Thirty-five patients with locally advanced gastric or oesophago-gastric junction carcinoma underwent preoperative chemotherapy and surgical resection at San Raffaele Scientific Institute and Spedali Civili of Brescia. HER-2 expression/amplification was evaluated on every biopsy at diagnosis time and on every surgical sample after neoadjuvant chemotherapy. Pathologic response to chemotherapy was evaluated according to TNM classification (ypT status and ypN status) and Mandard’s tumour regression grade classification. In our series 10 patients (28.6%) showed a reduction in HER-2 overexpression and in 6 of them (17.1%) HER-2 expression completely disappeared. Only three of the six patients with HER-2 disappearance had a complete pathological response to neoadjuvant chemotherapy. There was a strong correlation between HER-2 negativity on biopsy and absence of lymph node metastasis in surgical samples after neoadjuvant chemotherapy, irrespective of nodal status before chemotherapy. A direct correlation between HER-2 reduction after neoadjuvant chemotherapy and pathologic regression (primary tumour and lymph nodes) in surgical samples was found. HER-2 negativity may represent a predictor of pathologic response to neoadjuvant chemotherapy for gastric and oesophago-gastric junction adenocarcinoma. Neoadjuvant treatment can reduce HER-2 overexpression.

Several publications have focused on the cardiotoxicity of specific classes of haematological therapeutic agents such as antracyclines and cyclofosfamide. Cardiotoxicity of cancer chemotherapeutics is a problem for patients of all ages, but it increases with age. Toxicity can also be developed months after the last chemotherapy dose, and late reactions can be seen years later when they present new-onset cardiomyopathy. No data are available about the cardiotoxicity of non-chemotherapy agents currently used as preferred therapy for haematological malignancy in elderly. In this review we have provided a summary of the cardiovascular toxic effects produced by different drugs and therapeutic agents. Early identification of patients who are at risk for cardiotoxicity should be a primary goal for haematologists in the development of personalised antineoplastic therapeutic strategies or interventions. Thus, the discovery of new biomarkers to identify patients at a high risk for the development of these complications is a high priority. Although targeted therapies such as imatinib and anti-CD20 antibody, such as rituximab, are considered less toxic and better tolerated by patients compared with classic chemotherapy drugs, certain cardiological complications can be very serious as these agents have been in use for a limited period of time.