Surgical Options to Mitigate the Consequences of Pancreatic Anastomosis Leak after Pancreaticoduodenectomy

Pancreaticoduodenectomy is still the only treatment option that offers a chance to cure patients with pancreatic cancer and malignant periampullary tumors. Pancreaticojejunal anastomosis is the preferred method of reconstruction after pancreaticoduodenectomy. However, because of the high incidence of anastomotic leak and subsequent severe consequences, pancreaticojejunal anastomosis still remains the Achilles’ heel of the operation. Several technical modifications of pancreaticojejunal anastomosis exist, but none completely eliminates anastomotic leak, postoperative pancreatic fistula, or severe complications. Therefore, considerable efforts have been made to study and develop surgical options that can mitigate the severity and avoid fatal consequences of postoperative pancreatic fistula. This chapter presents and discusses some of the existing and emerging surgical strategies devoted to mitigating the catastrophic consequences of pancreatic anastomotic leaks

Primary Cystic Echinococcosis of the Pancreas

Primary cystic echinococcosis of the pancreas is rare, even in endemic regions. The clinical presentation depends on the affected part of the pancreas and the presence of local complications, but there are no specific symptoms, which can be a clue to diagnosis. Imaging studies usually reveal avascular lesions in the pancreas that are most frequently misdiagnosed as pseudocysts or neoplastic cystic tumors. The treatment options vary from evacuation and drainage to formal resection of the pancreas, with no evidence of the best treatment strategy. This chapter provides a comprehensive review of the current knowledge of the clinical presentation, diagnosis, and treatment of primary cystic echinococcosis of the pancreas. Acute thrombosis of the splenic artery which leads to massive splenic infarction and abscess, a previously unreported initial manifestation of cystic echinococcosis of the pancreas is also presented, as well as the first use of intraoperative pancreaticoscopy to clear the mean pancreatic duct from membranes of the parasite

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Determination of the Length of Pancreatic Ductotomy by Pancreaticoscopy During Frey’s Procedure for Chronic Pancreatitis

Objective:. To study the impact of pancreaticoscopy during Frey’s procedure for treating chronic pancreatitis (CP). Background:. Excision of the central part of the head of the pancreas along with longitudinal pancreaticotomy (Frey’s procedure) is widely performed for the treatment of CP. However, there is no reliable method to determine the necessary length of longitudinal pancreaticotomy during surgery for CP. Methods:. Thirty-five consecutive patients with CP were scheduled for Frey’s procedure with intraoperative pancreaticoscopy. The length of the longitudinal pancreaticotomy was tailored by pancreaticoscopy in the following manner: (1) it did not extend beyond the neck in case of a uniformly dilated main duct with patent branch duct confluences and a clear lumen; (2) in case of an obstructed main duct or branch duct confluence of any cause, the main duct was opened to include the most distal obstruction. Results:. All patients underwent Frey’s procedure and intraoperative pancreaticoscopy. Based on the pancreaticoscopy findings, pancreaticotomy over the body of the gland was not necessary in 34% of the patients. A short (4–6 cm) ductotomy extension over the pancreatic body was required in 14% of the patients. Full-length pancreaticotomy was required in 52% of the patients. The median operative time was 145 minutes, and the median blood loss was 70 mL. Four patients (11.4%) experienced postoperative complications. There were no 90-day postoperative mortality or hospital readmission rates. At the median follow-up of 19 months, 31 patients (88.5%) had no pain attacks requiring medication. Conclusions:. Intraoperative pancreaticoscopy helps to determine the length of longitudinal pancreaticotomy and reduce pancreatic trauma during Frey’s procedure for treating CP

Current status of liver surgery for non-colorectal non-neuroendocrine liver metastases: the NON.LI.MET. Italian Society for Endoscopic Surgery and New Technologies (SICE) and Association of Italian Surgeons in Europe (ACIE) collaborative international survey

Despite the increasing trend in liver resections for non-colorectal non-neuroendocrine liver metastases (NCNNLM), the role of surgery for these liver malignancies is still debated. Registries are an essential, reliable tool for assessing epidemiology, diagnosis, and therapeutic approach in a single hub, especially when data are dispersive and inconclusive, as in our case. The dissemination of this preliminary survey would allow us to understand if the creation of an International Registry is a viable option, while still offering a snapshot on this issue, investigating clinical practices worldwide. The steering committee designed an online questionnaire with Google Forms, which consisted of 37 questions, and was open from October 5th, 2022, to November 30th, 2022. It was disseminated using social media and mailing lists of the Italian Society of Endoscopic Surgery and New Technologies (SICE), the Association of Italian Surgeons in Europe (ACIE), and the Spanish Chapter of the American College of Surgeons (ACS). Overall, 141 surgeons (approximately 18% of the total invitations sent) from 27 countries on four continents participated in the survey. Most respondents worked in general surgery units (62%), performing less than 50 liver resections/year (57%). A multidisciplinary discussion was currently performed to validate surgical indications for NCNNLM in 96% of respondents. The most commonly adopted selection criteria were liver resectability, RECIST criteria, and absence of extrahepatic disease. Primary tumors were generally of gastrointestinal (42%), breast (31%), and pancreaticobiliary origin (13%). The most common interventions were parenchymal-sparing resections (51% of respondents) of metachronous metastases with an open approach. Major post-operative complications (Clavien-Dindo > 2) occurred in up to 20% of the procedures, according to 44% of respondents. A subset analysis of data from high-volume centers (> 100 cases/year) showed lower post-operative complications and better survival. The present survey shows that NCNNLM patients are frequently treated by surgeons in low-volume hospitals for liver surgery. Selection criteria are usually based on common sense. Liver resections are performed mainly with an open approach, possibly carrying a high burden of major post-operative complications. International guidelines and a specific consensus on this field are desirable, as well as strategies for collaboration between high-volume and low-volume centers. The present study can guide the elaboration of a multi-institutional document on the optimal pathway in the management of patients with NCNNLM