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Celiac artery compression can complicate the performance of pancreaticoduodenectomy or total pancreatectomy due to the need for ligation of the gastroduodenal artery. Median arcuate ligament release restores normal arterial flow to the liver, spleen, and stomach and may avoid complications related to poor perfusion of the foregut. All patients who underwent median arcuate ligament release for celiac artery compression at the time of pancreatectomy between 2009 and 2023 were reviewed. Pre- and postoperative computed tomography was used to categorize celiac artery compression by the extent of compression (types A [<50%], B [50%–80%], and C [>80%]). Of 695 patients who underwent pancreatectomy, 22 (3%) had celiac artery compression, and a majority (17) were identified on preoperative imaging. Median celiac artery compression was 52% (interquartile range = 18); 8 (36%) patients had type A and 14 (64%) had type B compression with a median celiac artery compression of 39% (interquartile range = 18) and 59% (interquartile range = 14), respectively (P <.001). Postoperative imaging was available for 20 (90%) patients, and a reduction in the median celiac artery compression occurred in all patients: type A, 14%, and type B, 31%. Complications included 1 (5%) death after hospital discharge, 1 (5%) pancreatic fistula, 1 (5%) delayed gastric emptying, and 4 (18%) readmissions. No patient had evidence of a biliary leak or liver dysfunction. Preoperative computed tomography allows accurate identification of celiac artery compression. Ligation of the gastroduodenal artery during pancreaticoduodenectomy or total pancreatectomy in the setting of celiac artery compression requires median arcuate ligament release to restore normal arterial flow to the foregut and avoid preventable complications. [ABSTRACT FROM AUTHOR]

Long term continuous intravenous inotrope infusion therapy (LTInT) has improved the quality of life for patients with refractory heart failure with reduced ejection fraction. However, its utility in symptomatic, refractory heart failure with preserved ejection fraction >40% (HFpEF) remains less well-described. We describe the characteristics and outcomes of such patients at our center. We conducted a retrospective review of consecutively enrolled patients with HFpEF who received LTInT from 2016-2022, for 19378 cumulative person-days of follow-up (∼646 person-months). Of the 65 participants (mean age 74±11 years), 23 were female and 42 were male. Dobutamine was used for 23 participants whereas 42 received milrinone. LTInT was used palliatively for 46 patients. A total of 150 hospitalizations occurred in the pre-inotrope year, with a median (quartile 1-3) of 2(1-4) hospitalizations per patient per year. While receiving LTInT, fewer cardiovascular hospitalizations were observed, totaling 96 hospitalizations with a median of 1(0-4) hospitalizations per patient per year, p=0.005. All-cause hospitalizations were numerically lower but the difference was not statistically significant (median 1[0-4], p=0.3, Total=142). 25 deaths (38%) occurred in the cohort. On an average, deaths occurred 7 months after initiating LTInT. Dobutamine recipients had a higher mortality rate than milrinone recipients (65% vs 24%, p=0.001) (Table). However, this was confounded by the observation that patients on dobutamine had a significantly worse NYHA class functional statuses and had higher N-terminal-pro-Brain Natriuretic Peptide (BNP) levels. Long term intravenous inotrope infusion therapy has the potential to reduce cardiovascular hospitalizations in patients with HFpEF. Given that heart failure is a progressive disease, the absence of an increase in the number of all-cause hospitalizations over a prolonged follow-up period is encouraging. [ABSTRACT FROM AUTHOR]

It is difficult to successfully deliver multimodality therapy to patients with operable pancreatic cancer. Data on the natural history of such efforts are necessary for physicians to guide shared decision-making with patients and families. We report the survival of consecutive patients with borderline resectable pancreatic cancer who received neoadjuvant therapy before surgery. Data regarding demographics, neoadjuvant therapy, surgery, pathology, and survival duration were abstracted on consecutive patients with borderline resectable pancreatic cancer diagnosed between 2009 and 2017 and not treated on available clinical trials. Borderline resectable pancreatic cancer was defined based on ≥1 of the following: local tumor anatomy, pretreatment serum carbohydrate antigen 19-9 >2,000 U/mL, and the presence of radiographic lesions indeterminate for metastases. Neoadjuvant therapy was delivered to 185 patients with borderline resectable pancreatic cancer who were not enrolled in competing clinical trials; 13 (7%) patients received chemoradiation, 12 (7%) received chemotherapy, and 160 (86%) received both. Of the 185 patients, 115 (62%) completed all intended neoadjuvant therapy and surgery; 81 (70%) of 115 underwent pancreaticoduodenectomy; and vascular reconstruction was performed in 51 (44%). A margin negative resection was achieved in 111 (97%) of 115 patients, and 83 (72%) were node negative. Median overall survival for all 185 patients was 20 months; 31 months for the 115 patients who completed all neoadjuvant therapy and surgery as compared to 13 months for the 70 patients who were not resected (P <. 0001). After neoadjuvant therapy, surgical resection was performed in 62% of patients with borderline resectable pancreatic cancer. Those who normalized preoperative serum carbohydrate antigen 19-9 and had node negative pathology achieved the longest survival. To further improve median survival for all patients, we are incorporating adaptive approaches to neoadjuvant therapy sequencing based on objective assessments of response. [ABSTRACT FROM AUTHOR]

Background Patients with locally advanced pancreatic cancer have historically been considered inoperable. The purpose of this report was to determine resectability rates for patients with locally advanced pancreatic cancer based on our recently described definitions of type A and type B locally advanced pancreatic cancer. Methods An institutional prospective pancreas cancer database was queried for consecutive patients with locally advanced pancreatic cancer treated between January 2009 and June 2017. All pretreatment imaging was re-reviewed and patients were categorized as locally advanced pancreatic cancer type A or type B. Demographics, induction therapy, resection type, and outcomes were reviewed. Results We identified 108 consecutive patients; 12 were excluded from analysis due to the absence of available pretreatment imaging or they had not yet completed all intended neoadjuvant therapy. Of the remaining 96 patients (45 type A, 51 type B), disease progression occurred in 19 (20%) during induction therapy and 30 (31%) were deemed inoperable at final preoperative restaging. Therefore, 47 (49%) of 96 patients were taken to surgery and 40 (42%) underwent successful resection (28 [62%] of 45 type A and 12 [24%] of 51 type B); an RO resection was achieved in 32 (80%). Metastatic disease was found intraoperatively (6 at laparoscopy, 1 at laparotomy) in 7 (15%) of 47 patients. There were no mortalities; 6 (15%) patients experienced major postoperative complications. Resected patients had a median overall survival of 38.9 months. Conclusion Locally advanced pancreatic cancer can be dichotomized into type A and B with distinctly different probabilities of completing all therapy to include surgery; thereby allowing goals of therapy to be established at the time of diagnosis. Multimodality therapy that includes surgery can be accomplished in selected patients with locally advanced pancreatic cancer and is associated with a median overall survival that approximates earlier stages of disease. (Surgery 2017;160:XXX-XXX.) [ABSTRACT FROM AUTHOR]

At academic institutions, overnight call has traditionally been provided by radiology residents; however, in recent years, there has been a growing trend toward 24-h attending coverage with immediate final reports. For instance, results from a recent survey of six academic radiology departments indicate that many residents and attending radiologists believe this new model to have an overall negative effect on resident training and their confidence regarding independent practice [[2]]. Like many academic radiology departments across the country, we have recently shifted to in-house radiology attending staffing for overnight hours (9 pm to 7 am), which has been made possible by the creation of a separate Emergency Radiology section within the department. [Extracted from the article]

Background Enthusiasm for neoadjuvant therapy is growing from the emerging consensus that pancreatic cancer is a systemic disease at the time of diagnosis. Those who remain in favor of upfront surgery often cite the lack of reported data to support alternative treatment sequencing. We therefore report the results of all patients treated outside of a clinical trial under the direction of a multidisciplinary pancreatic cancer working group. Methods We reviewed all patients with resectable pancreatic cancer treated with neoadjuvant therapy (NeoTx) from 2009 to 2013; we excluded those patients treated on prospective clinical trials as they will be the subject of subsequent reports. Data regarding demographics, NeoTx, operative outcomes, pathology, and survival data were abstracted from a prospective database. Results NeoTx was initiated in 69 patients; median age was 65 years (interquartile range [IQR]: 11) and median carbohydrate antigen 19-9 at diagnosis was 96.5 (IQR 210). NeoTx consisted of chemotherapy alone ( n = 10, 14%), chemotherapy and radiation (chemoradiation, n = 53, 77%), or both ( n = 6, 9%). Median carbohydrate antigen 19-9 after NeoTx was 39 (IQR 104) corresponding to a median decrease of 60%. Operative resection was completed in 60 (87%) of the 69 patients. At restaging after NeoTx, 5 (7%) of 69 patients were not considered candidates for surgery because of the development of metastatic disease ( n = 4) or an inadequate performance status ( n = 1). At the time of surgery, 4 (6%) of 64 patients had metastatic disease found at laparoscopy. Of the 60 patients who underwent surgical resection, a complete pathologic response was observed in 2 (3%) patients; 20 (33%) had positive lymph nodes, and the median number of positive lymph nodes was 2 (IQR 3). R0 resections were achieved in 58 (97%) of the 60 patients. Additional postoperative adjuvant therapy was administered to 37 (62%) of the 60 patients. Median survival of all 69 patients was 31.5 months; 44.9 months for the 60 patients who completed all NeoTx and resection compared with 8.1 months for the 9 patients who were not resected (log rank P < .001). Conclusion NeoTx for resectable pancreatic cancer was associated with a median overall survival of 32 months; something not reported for patients treated with surgery first if based on intent-to-treat analysis. Treatment sequencing may provide an oncologic benefit beyond that of the selection bias afforded surgery after a period of induction therapy. [ABSTRACT FROM AUTHOR]

Background: Tumor-induced arterial abutment/encasement has been traditionally a contraindication to surgery in patients with localized pancreatic cancer (PC). One recent meta-analysis reported greater mortality rates in this setting. We report herein a series of planned arterial resections in carefully selected patients who responded favorably to combined modality therapy for localized PC. Methods: We reviewed all patients with PC and arterial encasement treated between May 2011 and September 2013; all patients received an extensive course of neoadjuvant therapy before surgery. Results: Of 15 patients taken to surgery, 2 had peritoneal disease at laparoscopy, and therefore, laparotomy was not performed. Pancreatectomy (pancreaticoduodenectomy, 3; distal, 8; central pancreatectomy, 1; total, 1) was performed in the remaining 13, 10 of whom required arterial resection. The most common operation was an Appleby procedure. Of 10 patients who underwent combined pancreatectomy and arterial resection, their median age was 62 years (range, 33–75), median operative time was 7.5 hours, and median blood loss was 725 mL. Complications occurred in 3 of 15 patients with no perioperative mortality. Median duration of hospital stay was 9 days (range, 5–19). An R0 resection was achieved in 11 (85%) of 13 patients. At a median follow-up of 21 months, 8 of these 13 resected patients (62%) are alive without disease. Conclusion: Planned arterial resection at the time of pancreatectomy can be performed with acceptable morbidity and mortality; patient selection and induction therapy are likely critically important variables that seem to impact patient outcome. Those patients with stable or responding disease after induction therapy represent the subset of patients with potentially favorable tumor biology in whom extended resections may enhance survival duration. [Copyright &y& Elsevier]

Colorectal cancer is the fourth most diagnosed cancer and has a rising incidence in patients under the age of 65. The new standard of care for locally advanced rectal cancer is total neoadjuvant therapy (TNT) with radiation doses of 4500 to 5040 cGy given over 25-28 fractions. In general, this dose is not considered tumoricidal. Despite this, non-operative strategies for organ preservation have been reported with this radiation dose in TNT strategies. Intensification of radiation therapy (RT) may provide a higher rate of organ preservation in this setting. No studies to date have utilized real-time MRI guidance of dose-escalated RT. We hypothesize that higher doses of adaptive MRI-guided RT can be determined in a phase I setting with acceptable toxicity. This study is a prospective, open-label, phase I single-arm clinical trial of dose escalation with adaptive MR-guided external beam RT for organ preservation in adult patients with locally advanced rectal adenocarcinoma who are fit to undergo all treatments. Radiation dosing is applied as a 45-60Gy dose to nodes in 25 fractions + variable boost (B) to tumor and nodes in the following 3 arms: i) 64 Gy over 32-34 total fractions, ii) 68 Gy total over 34-36 total fractions and iii) 72 Gy total over 36-38 total fractions. A two-stage adaptive time-to-event continual reassessment method (TITE-CRM) is used for enrolling patients. Primary objective is to determine the maximum tolerated dose of radiation with both early (3 months) and late (12 months) toxicities monitored. Most common anticipated toxicities include diarrhea, bleeding, and proctitis. Secondary endpoints include quality of life reports including bowel function, surgical complication rates, and radiographic predictors of local disease progression or recurrence. Patients are evaluated with imaging and endoscopic exams prior to and following radiation to assess efficacy of treatment. TBD TBD. The study is open and recruiting at the Medical College of Wisconsin, NCT04808323. [ABSTRACT FROM AUTHOR]