Surgical management of Pancreatic Mucinous Cystic Neoplasms (MCNs)

Background: Pancreatic mucinous cystic neoplasms (MCN) are rare mucin-producing cystic tumors. They are predominantly found, incidentally, in middle-aged women and usually located in the pancreatic body or tail. They are differentiated from other mucin producing neoplasms by the presence of ovarian-type stroma. The current management of MCN is defined by the consensus European, International Association of Pancreatology (IAP) and the American Association of Gastroenterology guidelines. However, the malignant potential of these lesions remains uncertain, with differing rates of malignant potential being described. Since the criteria for surgical resection differs between the current guidelines, the aims of this large multi-institution study were to determine the rate of associated malignancy in resected MCNs and to determine predictor features, clinical and radiological, for malignant transformation in MCN. Methods: All surgically resected MCNs between January 2003 and December 2015 were included in this international multicentre retrospective study. Lesions without ovarian type stroma were excluded. All lesions found in men had the diagnosis of MCN confirmed by two experienced pancreatic pathologists. Malignant MCNs were defined by the presence of invasive adenocarcinoma. Results: 211 patients with a confirmed and surgically resected MCN were included. Median age was 53 (range 18\u201382) years, and 95.7% (202/211) were in women. Median pre-operative tumour size was 52 (range 12-230) mm. 16.1% (34/211) were malignant. The rates of malignancy (33.3% (3/9) vs. 15.3% (31/202)) and high-grade dysplasia (33.3% (3/9) vs. 15.8% (32/202) were double in men compared to women. In all cases of malignancy or high-grade dysplasia, at least one of the following characteristics was seen: male patient, symptoms, or a preoperative worrisome feature (solid component, septations, main pancreatic duct dilatation >6mm, elevated serum ca 19-9). A total of five cases of malignant transformation occurred in MCNs less than 4 cm in size. All these cases were associated with features of concern on pre-operative cross-sectional imaging. Conclusion: In female patients in this large multicentre study, malignancy or high-grade dysplasia was solely seen in MCNs with symptoms or worrisome features on preoperative imaging, regardless of the size of the tumour. In males, the risk of malignancy was significantly higher than in females, suggesting that operative treatment should be considered in all male patients with a suspected MCN of any size. In female patients, conservative management seems to be a safe approach for suspected MCNs of any size without symptoms or worrisome features

Sphincter preservation in patients with low rectal cancer: striking the right oncological balance

Background: The surgical treatment options for low rectal cancer patients include the Abdominoperineal Resection and the sphincter saving Low Anterior Resection. There is growing evidence towards better outcomes for patients being treated with a Low Anterior Resection compared to an Abdominoperineal Resection. Objective: The aim of this study was to evaluate the short term and oncological outcomes in low rectal cancer treatment. Design: This is a retrospective cohort study of prospectively collected data. Setting: Rectal cancer patients from a single center in the United Kingdom. Patients: Patients included all low rectal cancer patients (≤ 6 cm from the anal verge) undergoing Low Anterior Resection or Abdominoperineal Resection between 2006 and 2016. Outcome measures: To identify differences in postoperative complications and disease free and overall survival. Results: A total of 262 patients were included for analysis (Low Anterior Resection n = 170, Abdominoperineal Resection n = 92). Abdominoperineal Resection patients were significantly older (69 versus 66 years), had lower tumours (3 versus 5 cm), received more neo-adjuvant radiation, had longer hospital stay and more complications (wound infections and wound dehiscence). Low Anterior Resections had a significantly higher number of harvested lymph nodes (17 versus 12) however there was no difference in nodal involvement and R0 resection rate. No significant difference was found for recurrence, overall survival and disease free survival. Limitation: Retrospective review of cancer database and single center data. Conclusion: In the treatment of low rectal cancer Abdominoperineal Resection is associated with higher rates of postoperative complications and longer hospital stay compared to the Low Anterior Resection, with similar oncological outcomes

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

Abstract Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions. </jats:sec

Pancreaticoduodenectomy for nonampullary duodenal lesions: indications and results

PD carries a high mortality and morbidity, especially for duodenal lesions. We recommend a careful endoscopic review after the index case with a high-definition optical evaluation of duodenal lesions. This, in addition to an experienced histological assessment of the index biopsy material, forms an essential prerequisite in aiding the multidisciplinary team in the decision-making process with respect to triage of these lesions to conservative management, surveillance, endoscopic resection or finally surgical resection