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Context The impact on heath care service of pancreatic resections in elderly patients is unknown. Objective To evaluate the costs of postoperative stay in elderly patients undergone pancreatic resections for malignancy. Methods From 2004 to 2013, 213 patients underwent pancreatic resections and were recorded in a prospective data base. They were divided in three groups (Results The total costs of postoperative stay of pancreatic resections was higher in patients aged 70-80 years (11,461±9,352€; P=0.050) and in those ≥80 years (13,130±10,000€; P=0.032) in comparison to patients Conclusions Pancreatic resections in elderly patients with comorbidities affected by ductal adenocarcinoma were not cost-effective., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Serous cystic tumours (SCTs) of the pancreas are regarded as a benign entity with rare malignant potential. Surgical resection is generally considered curative. It was usually performed in large, symptomatic tumours or in cases in which the diagnosis was not clear. Objective To evaluate factors related to the surgical indication. Methods From 2000 to 2013, data of 43 patients affected by SCTs were collected in a prospective database. Demographics, clinical, radiological, surgical and pathological data were considered as factors related to surgical indication. After 2000 all patients were observed by a dedicated team including radiologists, surgeons, gastroenterologists and pathologists. Thus, patients were divided in two periods, before and after the 2000, to assess if there had been difference over the time in the management of this type of tumours. Univariate and multivariate analysis were performed. Results Thirty-three patients (76.7%) underwent surgical resection, while 10 (23.3%) entered in a surveillance program. At univariate analysis, factors related to surgery were: symptoms (P=0.026), radiological presence of microcysts of diameter Conclusions In our experience the only factor related to surgery was the presence of symptoms., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Interventional radiology (IR) have increased for the first-line management of postoperative complications after pancreatic resections. Objective To evaluate frequency, safety and usefulness of IR. Methods Patients with postoperative complications after pancreatic resections were analyzed for the use of IR procedures. Patients in which IR was performed were compared with those in which IR was not performed, regarding type of pancreatic resections, diagnosis, post-operative mortality and morbidity according Clavien-Dindo classification, post­operative pancreatic fistula (POPF), post­pancreatectomy hemorrhage (PPH), bile leakage, reoperations rate and length of hospital stay (LOS). Results Two-hundred and ninety patients were recorded: 182 (72.8%) experienced postoperative complications, 67 (36.8%) Clavien grade ≥3. IR was performed in 37 cases (20.3%): in 28 (75.7%) a percutaneous drainage (PD) of an abdominal fluid collection, in 8 (21.6%) a transhepatic biliary drainage (PTBD) and an arterial embolization (AE) in 3 cases (8.1%). IR was performed 14±6.7 days after surgery, with technical success in all cases and clinical success in 75.7%. Re-operation rate after IR was 13.5%, thus re-operations were avoided in 32 (86.5%) cases. Mortality after IR was 16.2%; 4 (66.7%) patients died after a re-laparotomy post-IR. Mean LOS was 18.3±14.4 days. There were no statistical differences between the IR group and the non-IR group regarding type of resection, pathological diagnosis, postoperative mortality and reoperation rate. Patients with clinically relevant POPF and bile leak were treated with IR more frequently than without IR (Pvs. 18.7±11.7 days; PConclusions IR procedures are feasible and safe especially for postoperative pancreatic fistula and bile leak. They are useful because promptly can resolve several life-threatening complications avoiding re-operations., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Soft pancreatic parenchyma is the most widely recognized risk factor for pancreatic fistulas. Objective To evaluate factors related to a “soft pancreas”. Methods Retrospective study of patients who underwent pancreaticoduodenectomy or left pancreatectomy. Factors considered were: sex, age, co-morbidities, body mass index, American Society of Anesthesiologists (ASA) score, characteristics of the pancreatic remnant and preoperative diagnosis. Principal endpoints were: to recognize preoperative factors related to a soft pancreatic remnant and to establish if they are useful in predicting a pancreatic fistula. Results Two hundred and eight patients were recorded. The pancreatic fistula rate was 29.3% and it was significantly related to the type of resection, the soft texture of the pancreatic remnant (P=0.037), a Wirsung duct diameter 24 kg/m2 (P=0.011); a Wirsung duct size ≤3 (PConclusions Body mass index >24 kg/m2, Wirsung duct size, JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Decision’s algorithms proposed in recent guidelines for pancreatic cystic tumors assumed a correct radiological diagnosis. Objective To evaluate the degree of discordance between radiological (RD) and pathological diagnosis (PD) in operated pancreatic cystic tumors. Methods From January 1990 to January 2013, 117 patients were operated for pancreatic cystic tumors. After 2000 all patients were observed by a dedicated team including radiologist, surgeons, gastroenterologist and pathologist. Demographics, clinical, radiological, surgical and pathological data were considered. RD was related to PD and factors influencing radiological pitfalls were studied with multivariate analysis. Results Twenty-one patients (17.9%) had RD of serous cystic tumors (SCT), 37 (31.6%) of IPMN, 11 (9.4%) of mucinous cystic tumors (MCT) and 48 (41.1%) non specified cystic lesion (NCL). PD were 29 (24.8%) SCT, 39 (33.3%) IPMN, 37 (31.6%) MCT, and 12 rare or non neoplastic lesions (10.3%). The degree of correlation between RD and DP was higher (PConclusion Risk of radiological pitfalls in pancreatic cystic tumors was high. The dedicated team could be reduce mistakes in preoperative diagnosis., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context The incidence of pancreatic and peri-ampullary cancer is expected to increase significantly among the elderly population. Recently, several authors have published data on peri-operative outcomes of pancreatic resections among the elderly. Objective Primary endpoint was to assess the difference in term of post-operative mortality after pancreatic resections between patients Methods Articles were extracted from MEDLINE, Cochrane Library, Scopus and ISI-Web of Science until April 24th, 2013. Articles were excluded when they were not in English; when the study population was divided in group of ages by using a cut-off different from 80 years; if they were case-reports, review, guidelines, abstracts and letters to editor. The quality of selected studies was assessed with the Newcastle-Ottawa scale. Odds ratios (ORs) were compared with Mantel-Haenzel method by using the statistical software Review Manager Version 5.2 (The Cochrane Collaboration, Software Update, Oxford, London). Results Initial search identified 1,518 reference articles, of these 19 relevant articles were selected and reviewed. Data were extracted from 9 studies (no. of cases 12,930) which met the inclusion criteria. Patients aged ≥80 years had a significantly higher postoperative mortality (OR=2.16, 95% CI: 1.61-2.89; PConclusions According to the results of this meta-analysis, pancreatic resections in patients aged ≥80 should be carefully planned because of an increased risk of morbidity, cardiac complications, longer hospital stay and, most of all, an increased risk of postoperative mortality., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context The safety of pancreatic resections in very elderly patients is still controversial. Objective To evaluate postoperative mortality, morbidity, type of discharge and length of hospital stay (LOS) in octogenarians who underwent pancreatic resections for malignancy. Methods From 2004 to 2013, 213 patients underwent pancreatic resections and were recorded in a prospective data base. They were divided in three groups: Results Mortality rate was higher (P=0.029) in patients ≥80 years (16.7%) only when compared with patients Conclusions Age ≥80 years increased the risk of postoperative mortality and discharge to health care facility after pancreatic resections., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Safety and cost-effectiveness of venous resection (VR) in resectable/borderline resectable ductal adenocarcinoma of the pancreatic head is still debate. Objectives Primary end point was to compare post-operative mortality between patients treated with a standard resection and patients treated with a VR. Secondary end points were postoperative morbidity, type of discharge, costs of hospitalization, R1 rate, and overall (OS) and disease free (DFS) survivals. Methods From 2001 to 2013, data of 291 pancreatic resections were collected. All patients (n=91) affected by head ductal adenocarcinoma were divided in two groups: with (group B; n=15) or without vascular resection (group A; n=76). The two groups were compared for postoperative course, OS and DFS. Multivariate analysis was carried out in order to evaluate the role of demographic, clinical, surgical (including VR) and pathological factors on mortality, morbidity, type of discharge, costs, R1 rate, OS and DFS. Results Postoperative mortality, morbidity and type of discharge were similar in the two groups. The total costs of hospitalization was similar, while the costs of ICU stay were higher in group B (P=0.012). No differences between two groups about R1 rate, DFS and OS were detected. Age >80 years was the only factor related to postoperative mortality (OR=3.9, P=0.048). ASA score increased the risk of postoperative complications (OR=2.9, P=0.029). Discharge to health care facility was more frequent in patients with age >80 years (OR=405.3, P=0.001) and with an higher preoperative total bilirubin (OR=1.2, P=0.042). ASA score increase by 34% the total hospital stay (P=0.004), by 48% the total hospital costs (PG1 at imaging were all predictive of a worse DFS (HR=3.2, P=0.050; HR=2.6, P=0.027; and HR=1.6, P=0.043, respectively). Conclusions VR is safe and useful to reach an R0 resection. VR affects the costs of postoperative management. OS and DFS were similar in patients with or without VR., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context The natural history of intraductal papillary mucinous neoplasms (IPMNs) is unknown even if we well-know that a pancreatic IPMN has malignant potential as the disease process follows the adenoma-carcinoma sequence. The vast majority of our resections were done to prevent the development of invasive cancer. Herein, we report the 14-year natural history of a IPMN. Case report In 1999, a 60-year-old man was observed for the incidental US finding of a cystic lesion (diameter 30 mm) in the head of the pancreas. MRI and cholangiopancreatography confirmed the finding. The past medical history reported a diagnosis of diabetes mellitus in 1998. FNA-US aspiration was performed and high levels of CEA (104 ng/mL) and amylase (1,230 U/L) were detected. The patient underwent surgery but an explorative laparotomy was performed because cystic lesion disappeared. The patient undergone to a surveillance program with yearly US scans. After five years (2004), an US showed a cystic lesion (diameter: 17 mm) of the pancreatic head without Wirsung dilatation. Re-evaluations by US scan showed stable disease until April 2013, when an increased size of the cystic lesion (diameter 29x32 mm) was revealed. A cholangio-Wirsung magnetic resonance (CWMR) showed a further cystic enlargement (60x26 mm) and showed a diffuse Wirsung duct dilatation (8 mm). Finally, an endosonography revealed the presence of “fish-eye” sign, confirmed the diffuse dilatation of the Wirsung duct (maximum diameter 15 mm), a 3 cm cyst communicating with the main duct and revealed several contrast-enhancing mural nodules. A FNA did not show malignant cells. Considering the presence of these “high-risk-stigmata” the diagnosis of main duct IPMN with high risk of progression to invasive carcinoma was made and the patient underwent a total pancreatectomy. Pathological diagnosis confirmed an IPMN diffuse to the whole pancreas with an invasive carcinoma of the pancreatic head. Conclusions Our case showed that in fourteen years an IPMN may become malignant. Thus, a surveillance program has to be performed for a long time, especially in young patients with a long expectancy of life. Surgery has to be strongly considered in young fit patients with cystic lesion greater than 2 cm in diameter., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context In the last twenty years the knowledge of natural history of the pancreatic cystic lesion have changed as well as many improvement in radiological diagnosis has been observed. Objective To evaluate the factors influencing surgical indication in patients with pancreatic cystic tumors. Methods From January 1990 to January 2013, 253 patients with pancreatic cystic tumors were observed. Demographics, clinical, radiological, surgical, pathological and follow-up-data were collected prospectively from 2000. The surgical indication was based by clinical examination, CT scan and evaluation of CA 19.9. After 2006, we introduced routinarely the use of MRI in first radiological evaluation. All non-surgical managed patients were followed with annual clinical and radiological examination and evaluation of CA 19.9. Uni- and multi-variate analyses were carried out. Results One-hundred and twenty-five patients (49.4%) received surgical indication. Univariate analysis showed that mean age of operated patients was lower than those in follow-up (60 vs. 70 years; Pvs. 5.5%; Pvs. 19 mm, Pvs. 53.9%; Pvs. 2.3%; Pvs. 36.7%; P=0.001) or Wirsung dilated (29.6% vs. 14.1%; P=0.004). Complete radiological evaluation (including CT scan and MRI or EUS) was performed more frequently in non surgical patients (85.9% vs. 33.6%; P=0.001). IPMN type II (79.7%) was the radiological diagnosis more frequent in follow-up group while 40.8% of patients was operated without a proper radiological diagnosis (Pvs. 0%). Multivariate analysis confirmed that presence of symptoms (OR=13; PConclusion The surgical indication remains still associated to presence of symptoms, size of tumors, solid component or septa., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Patients with locally advanced pancreatic cancer are usually treated with chemoradiotherapy and rarely they became resectable. Herein, we present the case of a patient with locally advanced pancreatic cancer. Case report A 56-year-old man was observed in October 2011 because of high blood levels of CA 19.9 (>230 U/mL) and the presence of a pancreatic mass of the uncinate process (diameter 3.8x3.5 cm) revealed by US and CT scan. An US-guided biopsy allowed the diagnosis of well differentiated pancreatic adenocarcinoma, biliopancreatic type. CT scan showed a vascular involvement of both superior mesenteric vein and artery. The disease was defined as locally advanced unresectable pancreatic cancer. The patient started chemotherapy with gemcitabine and oxaliplatin. Five months later, CT scan re-evaluation of the disease showed a stable disease. Thus, a protocol of radio-chemotherapy was suggested. Eight months later from diagnosis, the mass was still unresectable. Other eight cycles of gemcitabine and oxaliplatin were performed. In February 2013 a further CT scan evaluation demonstrated a smaller lesion (3.5x2.2 cm) and also the vascular involvement was decreased, still without a normal fat plane between the tumor and the vessels. Another cycle of gemcitabine and oxaliplatin was completed. At the end of May 2013, the 18FDG-PET was negative; CT scan demonstrated a further decreased of the mass (maximum diameter: 2.5 cm) while the mesenteric vessels involvement still remained. Moreover, the genomic characteristics of the patient DNA were different from other the pancreatic cancer. Because of the long-term survival of the young patient, the partial regression of the disease and the genomic characteristics of the tumor, a surgical approach was indicated. The patient underwent to a total pancreatectomy with splenectomy plus segmental resection of portal mesenteric trunk. Pathological diagnosis confirmed a well-differentiated ductal pancreatic carcinoma, biliopancreatic type (T4), with R0 resection. Conclusion Our case suggests that there are locally advanced pancreatic cancers in which chemoradiotherapy can allow surgical pancreatic resection probably because they have particular genomic characteristics., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Groove pancreatitis is a chronic inflammation of ectopic pancreatic tissue within the duodenal C-loop and the head of the pancreas. Case report A 56-year-old man affected by Crohn’s disease was admitted to our Surgical Unit in 2010 for epigastric pain associated with jaundice, weight loss and vomiting. He was not an alcohol drinker. Laboratory tests revealed abnormal levels of total bilirubin (25.6 mg/dL), amylase and lipase (108 and 293 UI/L, respectively) and CA 19-9 (2,435 IU/mL). An US and a CT scan showed dilatation of common bile duct, a 30 mm iso-hypodense area in the head of pancreas involving the duodenal wall and a dilatation of the main pancreatic duct (6 mm). A FNAB revealed the presence of a poorly differentiated adenocarcinoma. Finally, a 18F-FDG PET-CT scan showed an hyperfixation (SUVmax=4.3) of the pancreatic lesion. Thus, the patient underwent a pylorus-preserving pancreaticoduodenectomy. The postoperative course was regular, with discharge in postoperative day 14th. Macroscopically, the pathological specimen showed a 50 mm multicystic paraduodenal mass and a solid 30 mm pancreatic nodule. Microscopically, the first lesion was consistent with a pancreatic hamartoma of the duodenal wall, with morphologic aspects of “groove pancreatitis”, while the solid nodule was a poorly differentiated pancreatic adenocarcinoma. Moreover, the adjacent pancreatic parenchyma was affected by a diffuse lymphoplasmacytic and eosinophilic autoimmune pancreatitis with epithelial granulocytic lesions. Five lymph nodes were metastatic (n=22), while resection margins were free. Patient is well and alive at 2 years from surgery. Conclusion A recent literature review of 348 patients with groove pancreatitis showed the association either with chronic pancreatitis (62.5%) and ductal adenocarcinoma (0.3%), separately. Our case is peculiar because the groove pancreatitis is associated with both pancreatic adenocarcinoma and autoimmune pancreatitis. Furthermore, there is no evidence that these pathologic entities could be connected each other., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context Intraductal papillary mucinous neoplasms (IPMN) of the pancreas represent an evolving pancreatic disease. Case report A 68-year-old asymptomatic woman, mild smoker, with clinical history of gallstones, arterial hypertension and surgical treatment for breast carcinoma, was admitted to our surgical unit in January 2012. An ultrasound examination, performed as a follow-up for gallstones, showed a cystic lesion of the pancreatic head. Laboratory tests revealed an increase of pancreatic amylases (114 U/L; reference range: 8-52 U/L) and lipases (89 U/L; reference range: 8-78 U/L), while tumor markers were within reference range. A contrast-enhanced CT scan showed the presence of a 22 mm diameter, multilocular, cystic lesion of the pancreatic head, with contrast-enhanced mural nodules. An endoscopic ultrasonography confirmed the lesion, the mural nodules and showed no dilatation of the main pancreatic duct (MPD); a fine needle aspiration (FNA) revealed an increase of CEA (416.6 ng/mL; reference range: 0-192 ng/mL) in the cystic fluid and cytological analysis showed mild to high grade dysplasia. The CEA levels were suggestive of a mucinous cystic neoplasm, while the presence of mural nodules suggested a malignant type II IPMN. Thus, a pancreaticoduodenectomy was performed. The postoperative course was uneventful and the patient was discharged in postoperative day 18th. The pathological specimen macroscopically showed a solid 14 mm diameter microcystic lesion with endoluminal micropapillae. Microscopically, the lesion was characterized by a carcinoma with tubulo-papillary pattern of growth, atypical cube-shaped cells without cytoplasmatic mucin and intralesional necrotic foci. Moreover, in the pathological specimen, clusters of IPMN gastric-subtype, with low to moderate dysplasia, were detected. These findings suggested the diagnosis of a well differentiated tubulo-papillary carcinoma associated to a mild dysplasia type II IPMN. All lymph nodes were negative. The patient is well and alive at 6 months from surgery. Conclusion To our knowledge, in literature only ten cases of ITPN were reported and its peculiar characteristic seems to be a more aggressive natural history., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context Rates of microscopic margin involvement (R1), after pancreaticoduodenectomy for peri-ampullary cancer, vary markedly from 16% to more than 75% .One of the reasons is the lack of international consensus protocol for the pathological examination. Objectives To evaluate the rates of R1 in patients undergoing pancreaticoduodenectomy for peri-ampullary malignancy after the application of a standardized protocol of specimen’s margination. Methods From January 2010 to May 2012 data regarding 71 patients (Group A) undergoing pancreaticoduodenectomy for periampullary cancer, were collected in a prospective database. In all patients the histological examination was carried out according of a standardized protocol of specimen’s margination. R1 was defined as the presence of microscopic involvement Results The two groups were similar regarding sex, age, type and extension of resection and histological data (T, N, type of tumor). R1 rate was statistically significant higher in Group A than Group B (89.2% vs. 66.7%, P=0.015). The logistic regression, conducted for all patients, showed that presence of ductal adenocarcinoma or cholangiocarcinoma and T status increased significantly the risk of R1 (OR=41.4, P=0.004 and OR=6.3, P=0.050, respectively). The multivariate analysis including the type of margination showed that also the application of a standardized margination protocol was an independent factor related to R1 (OR=4.3; P=0.030). Conclusion Lack of standardization of pathological examination and controversy regarding the definition of microscopic margin involvement have resulted in variation of reported R1 rates Margin involvement in pancreatic cancer is a frequent and prognostically significant finding when specimens are assessed using a standardized protocol of specimen’s margination., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context Inflammatory myofibroblastic tumors (IMTs), although originally described in the pulmonary system, are being reported in different anatomical locations. Case report A 55-year-old, asymptomatic man with clinical history of arterial hypertension and past smoking behavior, was admitted to our Surgical Unit in March 2012. A previous CT scan, performed for benign prostatic hyperplasia, revealed a 30 mm diameter mass in the pancreatic tail. Laboratory tests were within normal range. A further contrast-enhanced CT scan confirmed the presence of a nodular hypodense lesion with calcifications in the pancreatic tail, with no involvement of the spleen. A CWRM showed no communication with the main pancreatic duct. Finally, a 18F-FDG PET-CT scan showed no areas of pathological hyperfixation. The patient underwent a laparoscopic distal pancreatectomy. During the surgical procedure, due to the infiltration of transverse mesocolon and retroperitoneal fat, an en-block resection of pancreatic body-tail, spleen and splenic flexure of the colon was performed. The postoperative course was uneventful and the patient was discharged in postoperative day 9th. Macroscopically, the pathological examination showed a whitish, solitary, calcific, irregular shaped nodule. Microscopically, the lesion was characterized by myofibroblastic spindle cells mixed with diffuse inflammation made up of lymphocytes, plasmacells and eosinophils. Moreover, a myxoid struma together with a rich vascular growth was detected. These findings were consistent with a fasciitis-like variant of IMT. The patient is well and alive at 3 months from surgery. Conclusion To our knowledge, only 26 case of pancreatic IMT are reported in literature. They were mostly discovered incidentally and surgically treated, as in our case. This management seems to be correct because IMT is described as a neoplasm of intermediate biological behavior, with tendency for local recurrence instead of distant metastasizing., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context Carcinosarcomas are neoplasms with mixed carcinomatous and sarcomatous elements, which rarely occur in the pancreas. Case report A 62-year-old man was admitted to our institute for the presence of intense abdominal pain, worsening of a type II diabetes and weight loss (10 kg in 3 months). The tumor markers (CEA, CA 19-9) were within normal range. A CT scan showed a large pancreatic head solid mass of about 5 cm in diameter, with central necrotic area with septa, peripheral contrast-enhancement and compression and dislocation of the superior mesenteric vein for a tract of 2.5 cm (G3). An US-guided percutaneous biopsy diagnosed a malignant, high grade spindle cells neoplasia with immunophenotypic pattern of sarcomas. Surgical approach was planned and a total pancreatectomy with vascular resection was performed. The vascular resection included a 8 cm tract of portal-mesenteric trunk and the reconstruction was performed using a donor’s femoral vein homograft. Pathological examination of the specimen showed a solid mass of 6 cm in diameter, with infiltration of the portal vein. Lymph nodes (n=48) were negative and the surgical margins were tumor-free. Microscopically the tumor was characterized by high grade, polymorphous, intensely desmin-positive spindle cells mixed with areas of moderately differentiated ductal adenocarcinoma. The remaining pancreatic gland was interested by a diffuse lympho-plasmacellular GEL-type acute pancreatitis. A final diagnosis of carcinosarcoma, pT3N0M0, was performed. The postoperative course was uneventful and the patient was discharged in post-operative day 14th. He is dead, 4 months after surgery. Conclusion In literature only 10 cases of pancreatic carcinosarcomas have been described All cases were treated surgically and they showed a poor prognosis (average 6 months) and a rapid recurrence of the disease as in our case., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context In 2012 the International Consensus Guidelines for the management of IPMNs changed the criteria for surgery and the definition of “malignancy”, reserving this term only for invasive carcinoma. Objectives To evaluate the accuracy of surgical criteria to predict malignancy. Methods From 2003 to 2012, data regarding 184 patients with IPMNs, were recorded in a prospective database. Forty-two (22.8%) patients, undergoing surgery, were evaluated according to the new guidelines. Criteria for surgery (cyst size, Wirsung dilatation, symptoms and presence of solid endocystic component) were studied to assess the malignancy in patients affected by IPMNs. Multivariate analysis was carried out comparing the new (only invasive carcinoma) and old definition of malignancy (invasive carcinoma and high grade dysplasia). Results All operated patients presented criteria for surgery: 9 (21.4%) had pancreatitis, 12 (28.6%) showed enhancing solid component (ESC), 28 (66.7%) had main pancreatic duct (MPD) dilated and in 18 (42.9%) cases cystic size was ≥30 mm. Malignancy was recorded in 21 (50.0%) and 17 (40.5%) patients, according to the Sendai and Fukuoka definitions. At multivariate analysis no factors predicted malignancy according to Fukuoka definition, while presence of ESC (RR 14.2; 95% CI 1.8-113.5; P=0.012) and cystic size (RR 1.1; 95%CI 1.02-1.20; P=0.019) were related to malignancy according to Sendai definition. A dimensional cut-off of the cystic lesion of 26 mm was obtained with a ROC curve (AUC=0.724; P=0.013). At the multivariate analysis, this cut-off resulted the strongest independent factor predicting malignancy according to Sendai definition (RR 8.0; 95%CI 1.13-56.95; P=0.037). Conclusion In our experience, surgical criteria seem to be inefficacy to predict presence of invasive carcinoma. ESC and cystic size were the only factors able to detect patients with high grade dysplasia or invasive carcinoma and to suggest the surgical approach., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context Abdominal compartment syndrome (ACS) is one of the most worrisome complications of hemorrhagic necrotic pancreatitis (HNP) and its prevention or correct treatment is crucial for patient survival. Case report A 29-year-old male patient with clinical history of sarcoidosis and alcoholic consumption was admitted to our Surgical Unit in March 2012 with diagnosis of severe acute pancreatitis. Clinical evaluation and laboratory tests revealed concurrent sepsis and anemia (WBC 34.91 x103/µL; PCR 34.76 mg/dL; LDH 714 U/L; Hb 10.1 g/L); a CT scan showed a wide pancreatic necrosis and multiple abdominal collections. These findings were suggestive of an infected pancreatic necrosis. A surgical abdominal toilette, necrosectomy and drainage of a large serous-hematic retroperitoneal collection were performed. In postoperative day 3, a gradual increase of intra-abdominal pressure (IAP: 22 mmHg) led up to an ACS, with respiratory distress, acute renal failure and paralytic ileus. Therefore, the patient underwent a second abdominal toilette, with laparostomy covered by a Bogota bag. This latter was replaced every 72 hours. In postoperative day 12, the onset of severe anemia brought to a third operation consisting in abdominal toilette, wide necrosectomy, hemostasis of proper hepatic artery and replacement of the Bogota bag. In postoperative day 22, the Bogota bag was replaced with a vacuum assisted closure (VAC) therapy. VAC therapy was then changed every 48-72 hours. Clinical conditions improved rapidly, in postoperative day 43 the laparostomy was closed with a biological mesh and a CT scan, performed in postoperative day 45, showed the complete resolution of abdominal inflammation and peripancreatic collections. Patient was discharged in postoperative day 68. Conclusion In literature, a standardized surgical strategy for ACS developed from HNP is missing. While the use of laparostomy is widely accepted, only few cases treated with VAC therapy are described. In our experience, laparostomy seemed a good “bridge” treatment, but the best results in terms of clinical response have been gained with the use of VAC therapy., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context The role of lymph node ratio (LNR) has been recognized as a prognostic factor in several malignancies. Objectives To evaluate the role of LNR in patients affected by pancreatic neuroendocrine tumors (pNETs). Methods Data regarding 45 patients were extracted from a dedicate database containing 92 patients undergone surgical exploration for pNETs. Patients who underwent palliative operation or enucleoresection or without Ki-67 determination were excluded. Sex, age, presence of symptoms, hormonal status, site of tumor, presence of MEN1, surgical procedure, R status, TNM-ENETS stage, WHO 2010 classification, Ki-67, and LNR were studied as possible factors influencing disease free survival (DFS) with univariate and multivariate analyses. Results Mean age of patients was 60±13 years. There were 22 (51.2%) female and 21 (48.8%) male. Symptoms were present in 27 (62.8%) patients. 34 (79.1%) patients had non-functioning pNETs and more frequently the tumor was located in the body (46.5%). Five (11.6%) patients were affected by MEN1. R0 resection was carried out in 38 (88.4%) cases. There were 17 (39.5%) pNETs G1, 24 (55.8%) pNETs G2 and 2 (4.7%) pancreatic neuroendocrine carcinomas (pNECs) G3. Mean Ki-67 was 6±10%. According to TNM-ENETS stage there were 17 (39.5%), 2 (4.7%), 17 (39.5%), and 7 (16.3%) patients in stage I, II, III, and IV, respectively. LNR was 0 in 26 (60.5%) patients, between 0 and 0.2 in 8 (18.6%) patients, and >0.2 in 9 (20.9%) patients. Mean DFS was 48±56 months. Multivariate analysis found that TNM-ENETS stage (HR 5.0; P=0.036) and Ki-67 (HR 1.2; P=0.016) were significantly related to DFS. There were no differences between patients with LNR=0 and LNR between 0 and 0.2 (HR 5.9; P=0.172) while patients with LNR between 0 and 0.2 had better DFS respect to those with LNR >0.2 (HR=0.2; P=0.01). A new cut off for LNR of 0.07 was obtained by ROC curve (AUC 0.771; P=0.008). Considering the new cut off, the multivariate analysis showed that LNR Conclusion LNR can be considered an important prognostic factor predicting DFS in patients affected by pNETs., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context IPMNs can be surgically treated or managed conservatively. Objectives To evaluate the effectiveness of the follow-up strategy for IPMN. Methods From January 2003 to June 2012, data regarding 184 patients with IPMNs, as well as type of management (surgery or follow-up), were recorded in a prospective database. Indication to surgery was established according to international consensus guidelines. The patients were divided in three groups: group A (G1), patients with criteria for surgery selected for surgical treatment; group B (G2) patients without criteria for surgery selected for radiological follow-up; group C (G3) patients with criteria for surgery but with high surgical risk selected for radiological follow-up. Failures of our strategy was a pathological diagnosis of benign IPMN in G1 or deaths for malignant IPMN in G2 and in G3. The intention to treat analysis was carried out. Finally we evaluated overall survival (OS) and disease-specific survival (DSS) among the three groups. Results Sex, age and presence of co-morbidities were similar among the three groups. Surgical treatment was proposed in 42 (22.8%) patients (group A). Radiological follow-up was suggested in 142 (77.2 %) patients. Of these, 119 (83.8%) did not present criteria for surgery (group B), while only 23 (16.2%) had one or more criteria (group C). Overall mean follow-up was 30.5±22.4 months. Rate of success was lower in group A than in groups B and C (45.2%, 100%, and 95.7% respectively; PConclusion For patients without criteria of malignancy a follow-up strategy seems effective. Patients with criteria for surgery, without high surgical risk, have to be surgically treated., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context Mucinous cystic neoplasms (MCN) of the pancreas concern usually female patients and are characterized by an ovarian-type stroma. Case report A 65-year-old man was admitted to our Institute for the incidental finding, at ultrasonography, of a cystic mass of the body-tail of the pancreas. Laboratory tests, including tumor markers (CEA and CA 19-9), were within normal range. A CT scan confirmed the mass, hypodense, unilocular, 45 mm in diameter, regular shaped and without neither contrast enhancement nor signs of infiltration of adjacent structures. A CWRM showed a well-shaped pancreatic gland with a 49 mm in diameter fluid mass of the body, without septa or endoluminal solid nodules, without a clear communication with the main pancreatic duct. Contrast enhanced-US confirmed a strict connection with the splenic vessels, without infiltration, and revealed the absence of contrast-enhancement as well as the presence of communication with the pancreatic duct. These features suggested an IPMN branch duct type larger than 3 cm. The patient underwent a subtotal pancreatectomy with spleen resection. Pathological examination showed a cystic lesion measuring 40 mm in diameter, with unilocular pattern, smooth and white inner walls, containing viscous whitish mucin and without communication with the main pancreatic duct. Microscopically, the lesion showed two components: a mucinous epithelial layer and a low-grade dysplasia ovarian-type stroma. Tumor cells displayed diffuse positivity for estrogen, progesteron and calretinin. Lymph-nodes (n=6) were negative and surgical margins were tumor-free. A final diagnosis of MCN was performed. Postoperative course was complicated by a pancreatic fistula, grade B, treated with a CT-guided abdominal drainage. The patient was discharged in postoperative day 14 with a minimal residual drainage output and he is alive, disease-free at 6 months after surgery. Conclusion Only 9 cases of MCN have been reported in male patients in literature. Thus, the occurrence of MCN in male patients is very rare and its possible pathogenesis could be referred to embryological abnormalities., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context It is well-known that a soft pancreatic stump is related to an increased incidence of postoperative pancreatic fistula (POPF) after pancreatic resection. Objectives To evaluate the presence of preoperative factors predicting soft pancreas in patients who underwent pancreaticoduodenectomy (PD) or left pancreatectomy (LP). Methods From January 2004 to June 2012, data regarding 208 consecutive patients whom underwent PD or LP were collected in a prospective database. For each patients we recorded sex, age, co-morbidities, BMI, ASA score, preoperative diagnosis, type of resection, characteristics of pancreatic remnant, pathological diagnosis and POPF rate. Univariate and multivariate analyses were carried out in order to evaluate the preoperative factors predicting a soft pancreatic stump. Results There were 102 (49%) female and 106 (51%) male with a mean age of 64.5±13.2 years. Co-morbidities were present in 128 (61.5%) patients; 64 patients (30.8%) were ASA II, 128 (61.5%) ASA III and 16 (7.7%) ASA IV. Mean BMI was 25.3±4.4 kg/m2. A pancreatic cancer or a chronic pancreatitis (CP) were suspected in 85 (40.9%) cases. One-hundred and twenty-five (60.1%) patients underwent PD and 83 (39.9%) LP. Pancreatic stump was soft in 129 (62%) cases and Wirsung duct was dilated in 55 cases (26.4%). Sixty-one patients (29.3%) had POPF (9.1% grade A; 19.2% grade B; and 1% grade C). Univariate analysis showed that a non dilated Wirsung duct (P2 was obtained by a ROC curve (AUC=0.607; P=0.010). A further multivariate analysis showed that the cut off of BMI resulted an independent factor predicting soft pancreas (OR 2.5, 95% CI: 1.2-4.8; P=0.009). Conclusion BMI value >24 kg/m2, a non dilated Wirsung duct and a pancreatic lesion different from pancreatic cancer or CP can predict a soft pancreas and subsequently a major risk of POPF., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context Surgeons are performing laparoscopic left pancreatectomy (LLP) with increasing frequency. To our knowledge do not exist studies which defines learning curve (LC). Objectives To define a number of procedures needed to achieve LC in LLP. Methods From January 2008 to June 2012 data regarding 25 patients, undergoing LLP for pancreatic lesions, were collected in a prospective database. All procedures were performed by a single high volume surgeon in advanced laparoscopic and open pancreatic surgery. Decrease of the operative time (OT) was used as parameter to establish the achievement of LC. A preliminary multivariate analysis was carried out to establish which factors influenced OT. Correlation between OT and cumulative sum of procedure (CUSUM) was evaluated to calculate the LC cut-off. Finally multivariate analysis was repeated including LC cut-off. ANOVA test was used to estimate correlation and to calculate multivariate model. Results There were 18 (72%) females and 7 (28%) males with mean age of 55±16 years and mean BMI of 27±5 kg/m2. Patients were more frequently ASA II (64%). Thirteen patients (52%) presented one or more co-morbidity and had a previous surgical abdominal procedure. Splenectomy was carried out in 18 (72% ) cases. An extended resection was conducted in 5 cases (20%). Mean operative time was 219±52 min. Rate of conversion was 16%. Pathological examination showed only in 11 (44%) cases a malignant disease and none ductal adenocarcinoma. Preliminary multivariate analysis showed that splenectomy significantly decreased OT while size of lesion increased OT (P=0.033 and P=0.041, respectively). A significant inverse correlation was found between OT and CUSUM (P=0.050) and the LC cut-off was 14 procedures. Final analysis including LC cut-off showed that the achievement of LC cut-off reduced significantly OT (P=0.047). Instead BMI and extended resection independently increased OT (P=0.030 and P=0.022, respectively) Conclusion In our experience the number of procedure needed to achieve LC was 14 LLP. BMI and extended resection influenced OT even after the achievement of LC., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650