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Intraperitoneal drain placement decreases morbidity and mortality in patients who develop a clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). It is unknown whether multiple drains mitigate CR-POPF better than a single drain. We hypothesized that multiple drains decrease the complication burden more than a single drain in cases at greater risk for CR-POPF.The Fistula Risk Score (FRS), mitigation strategies (including number of drains placed), and clinical outcomes were obtained from a multi-institutional database of PDs performed from 2003 to 2020. Outcomes were compared between cases utilizing 0, 1, or 2 intraperitoneal drains. Multivariable regression analysis was used to evaluate the optimal drainage approach.A total of 4,292 PDs used 0 (7.3%), 1 (45.2%), or 2 (47.5%) drains with an observed CR-POPF rate of 9.6%, which was higher in intermediate/high FRS zone cases compared with negligible/low FRS zone cases (13% vs 2.4%, P.001). The number of drains placed also correlated with FRS zone (median of 2 in intermediate/high vs 1 in negligible/low risk cases). In intermediate/high risk cases, the use of 2 drains instead of 1 was not associated with a reduced rate of CR-POPF, average complication burden attributed to a CR-POPF, reoperations, or mortality. Obviation of drains was associated with significant increases in complication burden and mortality - regardless of the FRS zone.In intermediate/high risk zone cases, placement of a single drain or multiple drains appears to mitigate the complication burden while use of no drains is associated with inferior outcomes.

Early drain removal when postoperative day (POD) one drain fluid amylase (DFA) was ≤5000 U/L reduced complications in a previous randomized controlled trial. We hypothesized that most surgeons continue to remove drains late and this is associated with inferior outcomes.We assessed the practice of surgeons in a prospectively maintained pancreas surgery registry to determine the association between timing of drain removal with demographics, comorbidities, and complications. We selected patients with POD1 DFA ≤5000 U/L and excluded those without drains, and subjects without data on POD1 DFA or timing of drain removal. Early drain removal was defined as ≤ POD5.Two hundred and forty four patients met inclusion criteria. Only 90 (37%) had drains removed early. Estimated blood loss was greater in the late removal group (190 mL versus 100 mL, P = 0.005) and pathological findings associated with soft gland texture were more frequent (97 [63%] versus 35 [39%], P 0.0001). Patients in the late drain removal group had more complications (84 [55%] versus 30 [33%], P = 0.001) including pancreatic fistula (55 [36%] versus 4 [4%], P 0.0001), delayed gastric emptying (27 [18%] versus 3 [3%], P = 0.002), and longer length of stay (7 d versus 5 d, P 0.0001). In subset analysis for procedure type, complications and pancreatic fistula remained significant for both pancreatoduodenectomy and distal pancreatectomy.Despite level one data suggesting improved outcomes with early removal when POD1 DFA is ≤ 5000 U/L, experienced pancreas surgeons more frequently removed drains late. This practice was associated with known risk factors (estimated blood loss, soft pancreas) and may be associated with inferior outcomes suggesting potential for improvement.

Background Identification of incidental pancreatic lesions is increasing because of advancements in imaging. Diagnosis remains a challenge for clinicians, with intrapancreatic accessory spleens (IPAS) posing a unique dilemma. IPAS are frequently resected because of inability to exclude alternate diagnoses, subjecting patients to unnecessary risk. The purpose of this study was to examine our institutional experience with IPAS and develop a multidisciplinary algorithm to improve preoperative diagnosis. Materials and methods Patients who underwent a distal pancreatectomy at a single institution from 2005 to 2018 were identified from a prospectively maintained database. Examination of final pathology for a diagnosis of IPAS yielded the final cohort. Demographics, preoperative workup, and operative course were reviewed and analyzed. A diagnostic algorithm was composed based on the consensus of a panel of expert pancreatic surgeons, a radiologist, and a pathologist. Results Ten patients of 303 patients who underwent a distal pancreatectomy were identified with a final pathology of IPAS. The average age was 54 y, 80% were white, and 60% were male. Lesions ranged in size from 7 mm to 5.1 cm in largest diameter (mean 2.2 cm). Lesions were described as round, well-marginated, and enhancing masses within the pancreatic tail. Preoperative workup was variable in terms of imaging and laboratory testing. Diagnostic workups were examined and combined with multidisciplinary input to create a diagnostic algorithm. Conclusions Incidental pancreatic lesions like IPAS remain a diagnostic challenge for clinicians. Employing a diagnostic algorithm as proposed may aid in the distinction of malignant and premalignant pathology and prevent unwarranted pancreatic resections.

Background With advances in cross-sectional imaging, pancreatic cysts are more frequently diagnosed and have become a common indication for pancreatectomy. The impact of pancreatectomy in these patients is important. The purpose of this study was to assess short-term outcomes, long-term nutritional status, quality of life (QOL), and pancreas function after pancreatectomy for cystic neoplasms. Materials and methods At a single institution, patients at least 3 y post-pancreatectomy for benign cystic neoplasms were identified. Using a validated questionnaire, short-term outcomes, long-term outcomes including endocrine and exocrine insufficiency, long-term nutritional status, and preoperative and postoperative QOL were compared based on operation and indication for resection. Results Among 102 eligible patients, 70 had valid contact information and 51 (72.9%) agreed to participate. Median follow-up was 6 (4-8) y. Patients undergoing pancreatoduodenectomy for benign cysts had higher morbidity than a similar cohort resected for pancreatic adenocarcinoma (patients with at least 1 ≥ grade 2 complication [49.0% versus 31.6%, P = 0.038]). After long-term follow-up, pancreatectomy did not significantly affect perceived QOL. Half of patients had mild-moderate or severe malnourishment, but pancreatic enzyme replacement was reported by only 4 (7.8%) patients. New-onset diabetes was present in 15 (29.4%) patients with median time-to-diagnosis of 6 (1-12) mo after resection. Conclusions Pancreatectomy for benign cysts did not negatively impact patients' perceived QOL. However, after long-term follow-up, malnutrition and pancreatic insufficiency occurred in a significant percentage and may be greater than previously estimated. Consideration of short- and long-term outcomes should factor into preoperative counseling, especially in cysts with minimal risk of progression to malignancy.

Although current guidelines recommend multimodal therapy for all patients with pancreatic ductal adenocarcinoma, it is unclear the extent to which clinical stage I patients are accurately staged and how this may affect management.In this retrospective cohort study of 4,404 patients aged 18-79 years with clinical stage 1 (ie, T1N0 or T2N0) pancreatic ductal adenocarcinoma treated with upfront resection in the National Cancer Database (2004-2014), understaging was ascertained by comparing pretreatment clinical stage with pathologic stage. The association between adjuvant treatment and overall risk of death among true stage I and understaged patients was evaluated using multivariable Cox regression.Upstaging was identified in 72.6% of patients (62.8% T3/4, 53.9% N1) of whom 69.7% received adjuvant therapy compared with 47.0% with true stage I disease. Overall survival at 5 years among those with true stage I disease was significantly higher than those who had been clinically understaged (42.9% vs 16.6%; log-rank, p 0.001). For true stage I patients, adjuvant therapy was not associated with risk of death (hazard ratio: 1.07, 95% confidence interval: 0.89-1.29). For understaged patients, adjuvant therapy significantly decreased risk of death (hazard ratio: 0.64, 95% confidence interval: 0.55-0.74).The majority of clinical stage I pancreatic ductal adenocarcinoma patients actually have higher-stage disease and benefit from multimodal therapy; however, one third of understaged patients do not receive any adjuvant treatment. Clinicians should discuss all potential treatment strategies with patients (in the context of the acknowledged risks and benefits), including the utilization of neoadjuvant approaches in those presenting with potentially resectable disease.

Purpose of review Allogeneic hematopoietic stem cell transplantation has proven curative for a range of malignant and nonmalignant disorders. However, the clinical success of this therapy is marred by the morbidity associated with viral infections, which are frequent (cytomegalovirus 15.6-28%, adenovirus 3-21%, BK virus 18.5-20.7%) post-transplant. These infections occur as a consequence of transplant conditioning regimens designed to eliminate not only malignant cells but also host immune cells that might interfere with stem cell engraftment. The result is a transient period of immune compromise when hematopoietic stem cell transplant recipients are at risk of infectious complications associated with both latent (cytomegalovirus, Epstein-Barr virus, BK virus, human herpes virus 6, herpes simplex virus, varicella-zoster virus) and community-acquired viruses including adenovirus, respiratory syncytial virus, and parainfluenza virus. Recent findings Current standard of care for many of these infections involves pharmacologic agents, which are often ineffective and associated with side effects including nephrotoxicity and hepatotoxicity. Ultimately, because these agents do not address the underlying immune compromise, viral rebound often occurs. Thus, a number of groups have explored the clinical potential of adoptively transferred virus-specific T cells (VSTs) as an approach to prevent/treat virus-associated complications. Summary The current review will highlight recent publications showcasing VST manufacturing technologies and clinical experience with such cells.

The objective of this study was to investigate the prevalence of incidental findings in pan-computed tomography (CT) scans of trauma patients and the communication of significant findings requiring follow-up to the patient. A retrospective chart review of adult trauma patients was performed during the period of January 1, 2011, to August 31, 2011. During that period, 990 patient charts were examined and 555 charts were selected based on the inclusion criteria of a pan-CT scan including the head, neck, abdomen/pelvis, and chest. Patient demographics such as age, gender, mechanism of injury, and Injury Severity Score were collected. Nontraumatic incidental findings were analyzed to establish the prevalence of incidental findings among trauma patients. Discharge summaries were also examined for follow-up instructions to determine the effectiveness of communication of the significant findings. Between the 555 pan-CT scans (1759 total scans), 1706 incidental findings were identified with an incidence of 3.1 incidental findings per patient and with the highest concentration of findings occurring in the abdomen/pelvis. The majority of findings were benign including simple renal cysts with a prevalence of 7.7 per cent. However, 282 significant findings were identified that were concerning for possible malignancy or those requiring further evaluation, the most common of which were lung nodules, which accounted for 21.6 per cent of significant findings. However, only 32.6 per cent of significant findings were documented as reported to the patient. With the use of pan scans on trauma patients, many incidental findings have been identified to the benefit of the patient. The majority of these are clinically insignificant; however, only 32.6 per cent of potentially significant findings were communicated to the patient. The advantage of early detection comes from proper communication and this study demonstrates that there could be improvement in conveying findings to the patient.

The objective of this study was to investigate the prevalence of incidental findings in pan-computed tomography (CT) scans of trauma patients and the communication of significant findings requiring follow-up to the patient. A retrospective chart review of adult trauma patients was performed during the period of January 1, 2011, to August 31, 2011. During that period, 990 patient charts were examined and 555 charts were selected based on the inclusion criteria of a pan-CT scan including the head, neck, abdomen/pelvis, and chest. Patient demographics such as age, gender, mechanism of injury, and Injury Severity Score were collected. Nontraumatic incidental findings were analyzed to establish the prevalence of incidental findings among trauma patients. Discharge summaries were also examined for follow-up instructions to determine the effectiveness of communication of the significant findings. Between the 555 pan-CT scans (1759 total scans), 1706 incidental findings were identified with an incidence of 3.1 incidental findings per patient and with the highest concentration of findings occurring in the abdomen/pelvis. The majority of findings were benign including simple renal cysts with a prevalence of 7.7 per cent. However, 282 significant findings were identified that were concerning for possible malignancy or those requiring further evaluation, the most common of which were lung nodules, which accounted for 21.6 per cent of significant findings. However, only 32.6 per cent of significant findings were documented as reported to the patient. With the use of pan scans on trauma patients, many incidental findings have been identified to the benefit of the patient. The majority of these are clinically insignificant; however, only 32.6 per cent of potentially significant findings were communicated to the patient. The advantage of early detection comes from proper communication and this study demonstrates that there could be improvement in conveying findings to the patient.