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Introduction: Hepatic artery anomalies (HAA) may have an impact on surgical and oncological outcomes of patients undergoing pancreaticoduodenectomy (PD). Methods: Patients who underwent PD at our institution between July 2015 and January 2020 were retrospectively reviewed and classified into two groups: group 1, with presence of HAA, and group 2, with no HAA. A weighted logistic regression model was employed to assess the association between HAA and postoperative complications, and to assess the association between HAA and R status in patients with pancreatic cancer. Results: 502 patients were considered for analysis, with 75 (15%) of them in group 1. They had either an accessory (n = 28, 40.8%) or replaced (n = 26, 36.6%) right hepatic artery. Most patients underwent surgery for a malignancy (n = 451; 90%); among them, vascular resection was performed in 69 cases (15%). The presence of a HAA was reported at preoperative imaging only in 4 cases (5%) and the aberrant vessel was preserved in 72% of patients. At weighted multivariable logistic regression analysis, HAA were not associated to higher odds of morbidity (odds ratio [OR]: 0.753, 95% confidence interval [CI]: 0.543–1.043) nor to R1 status in case of pancreatic cancer (OR: 1.583, 95% CI: 0.979–2.561). Conclusion: At our institution, the presence of HAA does not have an impact on postoperative outcomes or affects oncological clearance after PD. Hospitals', surgeons', volume and systematic review of preoperative imaging are all factors that help reduce possible adverse events. [ABSTRACT FROM AUTHOR]

Introduction: Intraductal papillary mucinous neoplasms (IPMNs) represent the most common precancerous cystic lesions of the pancreas. The aim of our study was to investigate if resection for non-invasive IPMNs alters quality of life (QoL) in a long-term follow-up. Methods: Patients (n = 50) included in the analysis were diagnosed and resected from 2010 to 2016. QoL was assessed at a median of 5.5 years after resection. At that point in time, the current QoL as well as the QoL before resection was evaluated retrospectively. The standardised European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for Pancreatic Cancer (EORTC QLQ – PAN26) was applied for the QoL assessment. Results: After a median of 66 months postoperatively, the total QoL score significantly worsened (92.13 vs. 88.04, p = 0.020, maximum achievable score = 100) for patients (median age at surgery 68.0 years), mostly due to digestive symptoms. During the same follow-up period, median Eastern Cooperative Oncology Group (ECOG) performance status did not worsen (p = 0.003). Conclusions: Long-term QoL statistically significantly worsened after pancreatic resection for IPMN. The extent of worsening, however, was small, and QoL still remained excellent. Therefore, resection in cases of IPMN is appropriate, if indicated carefully. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic distal pancreatectomy (LDP) has been adopted relatively slowly despite the benefits of minimally invasive approach. The robotic approach can overcome the limitations of LDP, thus increasing the acceptance of minimally invasive distal pancreatectomy. Methods: We performed a 1:1 retrospective case-matched comparison among 2 groups of 35 patients who underwent robotic-assisted distal pancreatectomy (RDP) or LDP from August 2014 to April 2017. Results: The operative time was similar in both groups (230 RDP vs. 205 LDP min, p = 0.382). The robotic group had a lower estimated blood loss (95 vs. 275 mL, p = 0.035). The spleen preservation rate was higher in the RDP group (100 vs. 66.7%, p = 0.027), while the conversion rate to open surgery was higher in the laparoscopic group (14.3 vs. 2.9%, p = 0.048). The overall complication rate was lower in the robotic group (25.7 vs. 37.1%, p = 0.044). There was no statistically significant difference in oncologic outcomes between the groups in terms of R0 resection rate (100% RDP vs. 85% LDP, p = 0.233) and number of harvested lymph nodes (14.4 RDP vs. 10.8 LDP, p = 0.678). Conclusions: The RDP showed a lower estimated blood loss, conversion, and morbidity rate. It offered a higher spleen preservation rate in comparison to LDP while maintaining comparable oncologic outcomes. [ABSTRACT FROM AUTHOR]

Background: One of the most challenging operations is the resection of the pancreas, which is associated with high morbidity. Metabolic control during the perioperative period remains an issue that is sometimes difficult to manage. Objectives: Exercise has a positive effect on glycaemic control. The objective of this trial was determining whether exercise has any benefit for oxidative stress and glucose levels. Method: The study was an open-label, randomised clinical trial. It has been registered in the International Standard Randomised Controlled Trial registry. The patients were selected according to the Consolidated Standard of Reporting Trials criteria. Results: In total, 56 patients were assessed for eligibility. There was no statistical difference between the 2 groups (the exercise and the control one) regarding the disease characteristics, morbidity or influence of exercise on oxidative stress; however, the control of glucose was superior in the exercise group. Conclusions: Exercise has a positive effect on glycaemic control in patients after pancreatic resection. [ABSTRACT FROM AUTHOR]

Background: Pancreatic exocrine insufficiency (PEI) is characterized by inadequate production, insufficient secretion, and/or inactivation of pancreatic enzymes, resulting in maldigestion. The aim of this review was to analyze the prevalence and pathophysiology of PEI resulting from gastrointestinal (GI) surgery and to examine the use of pancreatic enzyme replacement therapy (PERT) for effectively managing PEI. Summary: A targeted PubMed search was conducted for studies examining the prevalence and pathophysiology of PEI in patients following GI surgery and for studies assessing the effects of PERT in these patients. PEI is a common complication following GI surgery that can lead to nutritional deficiencies, which may contribute to morbidity and mortality in patients. Timely treatment of PEI with PERT can prevent malnutrition, increase quality of life, and possibly reduce the associated mortality. Treatment of PEI should aim not only to alleviate symptoms but also to achieve significant improvements in nutritional parameters. Dose optimization of PERT is required for effective management of PEI, in addition to regular assessment of nutritional status, appropriate patient education, and reassessment if symptoms return. Key Messages: Difficulties in detecting PEI following GI surgery can result in undiagnosed and untreated maldigestion, leading to metabolic complications and increased morbidity. Both are preventable by early administration and monitoring for optimal doses of PERT. [ABSTRACT FROM AUTHOR]

Background: Gastric traction is essential in laparoscopic distal pancreatic resections. We already described the single gastric hanging providing good exposure on the left pancreas and we herein introduce a modification named the double gastric hanging. Methods: The double gastric hanging in which 2 surgical tapes encircle the body and antrum of the stomach is indicated in patients who requiring pancreatic neck resection, dissection along the celiac trunk collaterals and lymph nodes, the duodenal wall, and the gastroduodenal artery. We describe our surgical technique, we compare our results between the double and single gastric hanging and we illustrate by 2 shorts videos for distal pancreatectomy and central pancreatectomy. Results: Between September 2016 and December 2017, this technique was performed in 36 patients who underwent central pancreatectomy (n = 18), distal pancreatectomy (n = 14), and enucleation (n = 4). There was no conversion, no transfusion, no mortalities, and no gastric related complications or reinterventions. Although not significant, the double gastric hanging and compared to single gastric hanging showed more favorable operative results with shorter operative time, less blood loss, and higher number of harvested lymph nodes. In patients operated for pancreatic adenocarcinoma, the mean number of harvested lymph nodes was higher with the double gastric hanging (23 vs. 14, p = 0.027). Conclusion: The double gastric hanging provides excellent exposure of the pancreatic neck, celiac trunk collaterals, and lymph nodes for better technical and oncological resections with no related complications. [ABSTRACT FROM AUTHOR]

Background: Stomach traction done to expose the pancreas is still a problem in laparoscopic left pancreatic resections. We developed a simple hanging maneuver to retract the stomach rapidly and effectively. Methods: After dividing the gastrocolic ligament, the stomach was encircled with a tape, turned along its horizontal axis and pulled with an epigastric trocar, which was later removed. This technique was used in all patients who underwent laparoscopic left pancreatic resections including 165 distal pancreatectomies (DP), 35 central pancreatectomies (CP) and 18 enucleations (En). Demographics, surgical and postoperative outcome data were recorded. Results: There were no mortalities. The mean operative time for DP, CP and En were 174, 191 and 104 min, respectively. The transfusion (0-4%) and conversion (0-3%) rates were low for all procedures. Morbidity was mainly represented by pancreatic fistula and grades (B + C) for DP, CP and En were observed in 26, 22 and 17%, respectively. No complication related to hanging of the stomach, like gastric perforation, was observed. Re-intervention and the mean hospital stay for DP, CP and En were observed in 5, 11 and 0% and were 16, 22 and 12, respectively. The readmission rate was low (0-9%). Conclusions: Hanging maneuver of the stomach is a simple procedure to rapidly, safely and effectively retract the stomach during left laparoscopic pancreatic resections. [ABSTRACT FROM AUTHOR]

An elective total pancreatectomy (TP) was first performed by Eugene Rockey of Portland, Oregon, in 1942. In the 1960s and 1970s, TP was the routine resection for pancreatic cancer in many centers because of fear of a leaking pancreatojejunostomy and multicentricity of the disease but the result used to be dreadful (in today's perspective). However, more recently, postoperative mortality and morbidity after pancreatic resections have improved due to better anastomotic technique and pre-, peri- and postoperative care. Today, TP - despite being a more extensive operation - can be offered with about the same operation risk as that of a Whipple procedure. Also, major improvements in the control of diabetes have been seen and there is actually an ongoing discussion on the actual severity of the diabetic state after TP. Also, the development of modern pancreatic enzyme preparations with sufficient control of endocrine and exocrine pancreatic insufficiency provides options for overcoming the postoperative problems following TP. Due to the improved results, there are today different - and more specific - indications than before for TP: malignant tumors growing from the pan-creatic head into the left pancreas, pancreatic head cancer where it is not possible to secure a tumor-free resection margin with extended resection or with dubious changes in the pancreatic main duct at frozen section, recurrent malignancy in the pancreatic remnant, at cancer surgery with resection of the celiac trunk, rescue pancreatectomy after a leaking pancreatojejunostomy with sepsis or bleeding after a Whipple-type first resection, multifocal intraductal papillary mucinous neoplasm with potentially malignant foci present in all parts of the gland, multiple metastases of renal cell carcinoma and melanoma without any residual tumor outside the pancreatic gland (possibly also other specified but uncommon metastatic tumors with a potential for cure by pancreatectomy), multifocal neuroendocrine tumors including multiple endocrine neoplasia and hereditary pancreatic cancer with a high grade of cancer penetration risk for the bearers. [ABSTRACT FROM AUTHOR]

Background: Portal-superior mesenteric vein (PV/SMV) resection during pancreatic resection has been widely applied in clinical practice. Methods: From a prospective data base of pancreatic resections, patients undergoing PV/SMV resection and reconstruction with a cryopreserved arterial homograft were extracted with the aim of evaluating the safety, feasibility and reproducibility of the procedure. Data regarding patient demographics, preoperative staging, surgery, histopathology and postoperative outcomes were analyzed. Results: Five patients were extracted in the last year. Indications for this technique were type IV-V degree of vein involvement and a 3.5 cm median length of vein infiltration. Median operative and clamping times were satisfactory (385 and 27 min, respectively), postoperative outcomes were good and there was no graft infection, thrombosis or stenosis occurred postoperatively and during the follow-up period. Conclusion: The use of a cryopreserved arterial homograft for PV/SMV reconstruction after pancreatic resection seems to be a feasible, safe and easily reproducible surgical technique in high-volume specialized centers and can be added to the pool of surgical solutions in selected patients. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background/Aims: Fibrin sealants containing both fibrin and thrombin have been used to control bleeding, reinforce suture lines and enhance tissue healing. However, the literature provides contradictory results. Methods: A systematic literature search was performed to determine the use of fibrin sealants in pancreatic surgery. These articles were then critically appraised according to their methodologies, outcomes and conclusions. Results: Twenty-four studies were found, including 6 controlled randomized trials. Of these, 16 studies were analyzed. Many methodological flaws and lack of consistency in definitions were found, making comparisons between studies difficult if not impossible. Conclusion: Because of the heterogeneity and lack of high-level evidence, the current literature does not allow us any conclusion: neither is there proof that fibrin sealants are of any real utility in pancreatic surgery, nor that they do not work. Further large-scale controlled trials are necessary before concluding that they do or do not provide any advantages in pancreatic surgery. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Chyle leaks are a rare complication following abdominal surgery. The aim of this study is to describe the management of chyle leaks following surgery for pancreatico-duodenal malignancy. Methods: Data were collated from a consecutive series of 105 patients who had undergone a pancreatico-duodenectomy for malignancy. From this cohort, patients who developed significant chyle leaks, defined as drainage of more than 600 ml of amylase-poor chylous fluid per day, were identified and their management reviewed. Results: A total of 7 (6.7%) patients with significant chyle leaks were identified. All but one of the chyle leaks were identified between the 5th and 9th post-operative day. Early restoration of enteral feeding appeared to increase the incidence of chyle leak. Six of the 7 patients were successfully treated conservatively with total parenteral nutrition and after a median of 7.5 days the chyle leak had resolved. One patient required a peritoneovenous shunt for chylous ascites. Conclusion: This study has described a high incidence of chyle leak among patients undergoing surgery for pancreatico-duodenal malignancy. Early introduction of enteral feed may encourage development. However, patients who develop an abdominal chyle leak remain clinically well and the leak can be managed relatively easily with parenteral nutrition. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background/Aims: A dysregulated immune response has been suggested to be important for the pathogenesis of chronic pancreatitis (CP). Formation of immunological memory is based on the differentiation of naïve T lymphocytes to memory T lymphocytes after exposure to antigens and specific cytokines. The aim of this study was to analyze peripheral blood mononuclear cells (PBMCs) in patients with CP for different T lymphocyte subsets including naïve and memory T cells. Methods: PBMCs from 9 patients who had undergone pancreatic resection due to CP, 9 CP patients who had not been resected and 9 healthy controls were analyzed by flow cytometry. Results: Patients with CP had a skewed distribution of T lymphocytes, with an increased level of CCR7+/CD45RA– central memory T lymphocytes compared to healthy controls. Nonresected CP patients and subjects who had undergone pancreatic resection due to CP had similar levels of central memory T lymphocytes. Conclusion: Our results indicate that the dysregulation of the immune system in chronic pancreatitis seems to persist even after removal of large parts of the local inflammatory site. We suggest that the increase of central memory T lymphocytes may be important for maintaining the inflammatory process in chronic pancreatitis. Copyright © 2005 S. Karger AG, Basel and IAP [ABSTRACT FROM AUTHOR]

Background: The aim of the study is to analyze pancreatic metastases and their clinical, radiological, therapeutic and prognostic features. Methods: Three cases of pancreatic metastases observed and a world literature review of 333 cases were recorded. Results: Pancreatic metastases are due more frequently to renal cell carcinoma; they are usually metachronous and characterized by a long period of time between the resection of the primary tumor and their detection. The differential diagnosis with other pancreatic masses is difficult, but an accurate anamnesis, some peculiar findings of imaging techniques and percutaneous fine needle aspiration could allow preoperative diagnosis. Pancreatic resections are the treatment of choice allowing the better palliation and improving survival. 150/234 pancreatic metastases underwent pancreatic resections (resectability index = 64.1%); 88/132 patients are alive with a mean follow-up of 27.1 months; of the 44 dead patients the mean survival time was 21.3 months. Among pancreatic metastases the primary tumor with better prognosis is renal cell carcinoma. Conclusion: Pancreatic metastases are rare; their preoperative diagnosis is difficult but useful and possible. Surgical resection is suggested because the patient still may have a prolonged survival. [ABSTRACT FROM AUTHOR]

Major pancreatic resection can cause pancreatic enzyme insufficiency with fat malabsorption, resulting in symptoms of abdominal pain, steatorrhoea and weight loss which can be extremely debilitating. The most important factors influencing subsequent development of steatorrhoea are the extent and type of surgical resection and the underlying disease process. The resultant steatorrhoea can be marked and difficult to control. There have been relatively few randomised controlled studies which have addressed this particular problem in patients who have had pancreatectomy. The use of effective doses of pancreatic enzyme supplements is essential in those patients who are symptomatic. When stabilised on therapeutically effective doses of pancreatic enzyme supplements, however, over 30% of patients still have evidence of significant levels of steatorrhoea. These results emphasise that the complete eradication of steatorrhoea is still not feasible at the present time, even using the best currently available agents, highlighting the need for further effective therapies. [ABSTRACT FROM AUTHOR]

Introduction: Neuroendocrine pancreatic tumors (NPT) are occasionally associated with mesenchimal tumors in neurofibromatosis type 1 but rarely in sporadic cases. We report five cases of NPT associated with other rare mesenchimal neoplasms of the GI tract, observed in our Department from 2003 to 2011. Aim(s): To evaluate clinical outcome in patients with NPT associated with a rare mesenchimal neoplasm. Materials and methods: All five patients (3M/2F, averaging 67 years) had preoperative diagnosis of NPT. They all underwent surgical resection: one middle pancreatectomy, two left pancreatectomy and two pancreaticoduodenectomy. The following associations were observed: one benign insulinoma with a jejeunal leiomyoma, two nonfunctioning NPT with a gastric GIST and two duodenal GISTs respectively, one non functioning metastatic NPT with a cecal GIST, one malignant metastatic gastrinoma with one jejunal and two duodenal GISTs. In all cases, the mesenchimal lesions were low-risk neoplasms. Results: Mean follow-up was 48.7 months. Two patients are still alive without disease 26 and 57 months after surgery. One patient died postoperatively because of sepsis due to a C grade pancreatic fistula, two patients died for progression of metastatic disease 18 and 94 months after surgery. Conclusion: All mesenchimal tumors of the GI tract were incidental findings, small size and low-risk neoplasms. In no case did they recur after excision or influence the prognosis of the NPT. [ABSTRACT FROM AUTHOR]