A Surface Plasmon Resonance Plastic Optical Fiber Biosensor for the Detection of Pancreatic Amylase in Surgically-Placed Drain Effluent

Postoperative pancreatic fistula (POPF), the major driver of morbidity and mortality following pancreatectomy, is caused by an abnormal communication between the pancreatic ductal epithelium and another epithelial surface containing pancreas-derived, enzyme-rich fluid. There is a strong correlation between the amylase content in surgically-placed drains early in the postoperative course and the development of POPF. A simple and cheap method to determine the amylase content from the drain effluent has been eagerly advocated. Here, we developed an amylase optical biosensor, based on a surface plasmon resonance (SPR) plastic optical fiber (POF), metallized with a 60 nm layer of gold and interrogated with white light. The sensor was made specific by coupling it with an anti-amylase antibody. Each surface derivatization step was optimized and studied by XPS, contact angle, and fluorescence. The POF-biosensor was tested for its response to amylase in diluted drain effluents. The volume of sample required was 50 \ub5L and the measurement time was 8 min. The POF-biosensor showed selectivity for amylase, a calibration curve log-linear in the range of 0.8\u201325.8 U/L and a limit of detection (LOD) of ~0.5 U/L. In preliminary tests, the POF-biosensor allowed for the measurement of the amylase content of diluted surgically-placed drain effluents with an accuracy of >92% with respect to the gold standard. The POF-biosensor allows for reliable measurement and could be implemented to allow for a rapid bedside assessment of amylase value in drains following pancreatectomy

Preoperative anxiety in patients with pancreatic cancer: what contributes to anxiety levels in patients waiting for surgical intervention

Pancreatic cancer is one of the most lethal malignancies. Currently, the only treatment is surgical resection, which contributes to significant preoperative anxiety, reducing quality of life and worsening surgical outcomes. To date, no standard preventive or therapeutic methods have been established for preoperative anxiety in pancreatic patients. This observational study aims to identify which patients' socio-demographic, clinical and psychological characteristics contribute more to preoperative anxiety and to identify which are their preoperative concerns. Preoperative anxiety was assessed the day before surgery in 104 selected cancer patients undergoing similar pancreatic major surgery, by administering the STAI-S (State-Trait Anxiety Inventory Form) and the APAIS (Amsterdam Preoperative Anxiety and Information Scale). Our data suggest that patients with high STAI-S showed higher levels of APAIS and that major concerns were related to surgical aspects. Among psychological characteristics, depressive symptoms and trait anxiety appeared as risk factors for the development of preoperative anxiety. Findings support the utility of planning a specific psychological screening to identify patients who need more help, with the aim of offering support and preventing the development of state anxiety and surgery worries in the preoperative phase. This highlights also the importance of good communication by the surgeon on specific aspects related to the operation

Biliary fistula after pancreaticoduodenectomy: data from 1618 consecutive pancreaticoduodenectomies

Background: Biliary fistula (BF) occurs in 3-8% of patients following pancreaticoduodenectomy (PD). It usually pursues a benign course, but rarely may represent a life-threatening event.Study design: Data from 1618 PDs were collected prospectively. BF was defined as the presence of bile stained fluid from drains by post-operative day 3 and confirmed by sinogram in the majority of cases. Three classifications were validated.Results: BF occurred in 58 (3.6%) patients. In 22 cases was associated with pancreatic fistula (POPF). POPF, PPH, operative time and a smaller common bile duct (CBD) were significantly associated with BF. Only CBD diameter (HR 0.55, CI 95% 0.44-0.7, p < 0.01) was an independent predictor of BF. Patients with smaller CBDs developing concomitant BF and POPF carried the highest mortality rate (34.8%, n = 8/22). All the existing classifications resulted in discrete categories of BFs when considering hospital stay and total cost as dependent variables.Conclusions: Biliary fistula is rare, but it can be life threatening when associated with POPF. As the sole independent risk factor is the CBD diameter, surgical technique is crucial. Regardless of the existing classification systems, further studies must assess the additive burden of BF when a concomitant POPF is present

Vanishing Pancreatic Cysts during Follow-Up: Another Step Towards De-Emphasizing Cyst Size as a Major Clinical Predictor of Malignancy

Introduction: In the management of pancreatic cystic neoplasms (PCN), size plays a crucial role as the expression of disease progression. While many evidences regarding the natural history of growing pancreatic cysts exist, almost no data are available regarding cysts with a reduction in size. Methods: Radiological and clinical data from patients of the dedicated pancreatic cysts outpatient clinic of the Department of General and Pancreatic Surgery, University of Verona Hospital were retrospectively reviewed. Patients diagnosed with PCNs reducing in size during follow-up were reviewed. Results: From a total of 3,146 patients, we identified 12 (0.38%) vanishing/reducing cysts without a history of pancreatitis. Most of them were presumed IPMN (66.6%). The median follow-up was 69 months and the median cyst's size 30 mm (range 10-49). Most of the patients (75%) experienced a reduction in cyst size (median reduction of 8 mm, range 6-22) after a median time of 12 months (range 6-63), 3 patients experienced a complete disappearance of the cyst. Conclusion: Cyst size reduction during follow-up is a rare phenomenon of unknown explanation. It adds to the debate regarding the role of size as a clinical predictor whenever a definite diagnosis of a PCN cannot be reached

Over 700 Whipples for Pancreaticobiliary Malignancies: Postoperative Morbidity Is an Additional Negative Prognostic Factor for Distal Bile Duct Cancer

Background: Distal cholangiocarcinomas and pancreatic cancers both arise from pancreaticobiliary epithelium. Despite their common origin, there is a possible discrepancy in outcome. We analysed the surgical, pathological and survival outcome of resected distal cholangiocarcinoma compared with pancreatic cancer. Methods: All cases of resected distal cholangiocarcinoma and pancreatic cancer from 1998 to 2014 were extracted from our database. Outcomes were compared. Results: There were 54 (7.6%) cases of cholangiocarcinoma and 656 (92.4%) pancreatic cancer. Cholangiocarcinoma showed lower T and N stage, lymphatic and perineural invasion (p < 0.05), worse surgical outcome (p < 0.05) and less access to adjuvant therapy if compared with pancreatic cancer (72.7 vs. 83.1%, p = 0.05). Both showed a similar disease-specific survival (35 vs. 29 months, p = 0.3). Independent predictors of prognosis for pancreatic cancer were resection margin, grading, perineural invasion, T and N status, whereas for cholangiocarcinoma were grading and occurrence of POPF. Conclusion: Considering a large cohort of resected periampullary cancers, cholangiocarcinoma is extremely rare. An earlier diagnosis is associated with better pathological predictors of outcome but increased postoperative morbidity compared to pancreatic cancer, particularly POPF. Consequent decrease in the access to adjuvant therapy for complicated cholangiocarcinoma might explain why survival is as poor as for pancreatic cancer

"Trivial" Cysts Redefine the Risk of Cancer in Presumed Branch-Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Potential Target for Follow-Up Discontinuation?

OBJECTIVES: The management of small and incidental branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) still is of concern. The aim is assessing the safety of a surveillance protocol through the evaluation of their progression to malignancy.METHODS: All presumed BD-IPMNs observed from 2000 to 2016 were included. Only patients presenting without worrisome features (WFs) and high-risk stigmata (HRS) at diagnosis were included. Development of WF, HRS, pancreatic cancer (PC), and survival were analyzed. BD-IPMNs were defined as trivial in the continuing absence of WF/HRS after 5 years of surveillance. The age-specific standardized incidence ratio of PC in the general population was used for comparison.RESULTS: A total of 1,036 BD-IPMNs without WF/HRS at diagnosis were included, 4.2% developed WF or HRS, and 1.1% developed PC after a median of 62 months. The median cyst growth rate was 0 mm/yr. A growth rate >= 2.5 mm/yr and the development of WF resulted independent predictors of PC. The standardized incidence ratio of PC for trivial BD-IPMN (n = 378) was 22.45 (95% confidence interval 8.19-48.86), but considering only patients aged >65 years (n = 198), it decreased to 3.84 (95% confidence interval 0.77-11.20).DISCUSSION: Surveillance of the vast majority of presumed BD-IPMNs is safe, as the risk of PC is comparable to postoperative mortality of pancreatic surgery. A growth rate >= 2.5 mm/yr is the main predictor of PC, reinforcing the role of repeated observations. A trivial BD-IPMN in patients aged >65 years might not increase the risk of developing PC compared with general population, identifying potential targets for follow-up discontinuation

Central pancreatectomy for benign or low-grade malignant pancreatic lesions - A single-center retrospective analysis of 116 cases

Background: Central pancreatectomy (CP) is a parenchyma-sparing surgery for benign or low-grade malignant pancreatic tumors. This study aimed to evaluate the safety of the procedure and to analyze the long-term pancreatic function. The age-specific incidence ratio (IR) was calculated based on the incidence of diabetes mellitus in the general Italian population of Italy. Materials and methods: Patients submitted to CP from January 1990 to December 2017 at the Department of General and Pancreatic Surgery of the Pancreas Institute of Verona, Italy, were evaluated. Results: The final population was composed of 116 patients. There was a clear prevalence of females (74.1%), the mean age was 48 +/- 15 years and the main indication for surgery was a pancreatic neuroendocrine tumor (45.7%). A pancreojejunal anastomosis was performed more frequently than a pancreogastric anastomosis (78.4% vs 11.6%). The mean length of stay was 20 +/- 33 days. The overall abdominal complications rate was 62%. The frequency of clinically relevant postoperative pancreatic fistula (grades B and C) was 26.7%. The mortality rate was 0%. The rate of RI-resection was 0.8%, as was the recurrence rate. After a mean follow-up of 12.8 years +/- 6.5, 6 patients developed new onset diabetes (NODM, 7.5%), and the IR was 1.36 (95%CI 0.49-2.96). Conclusions: CP is associated with high rates of abdominal complications, however, considering the amount of the normal pancreas that was spared, it might be indicated for selected benign or low-malignancy pancreatic tumors. CP patients have the same incidence of diabetes than the general population

Prevalence of depression in a cohort of 400 patients with pancreatic neoplasm attending day-hospital for major surgery. Role on depression of psycho-social functioning and clinical factors

Objective: 1.To determine the prevalence and type of depressive symptoms at day hospital clinical evaluation, before undergoing major surgery in patients diagnosed with pancreatic neoplasm; 2. To analyze the association between depression and socio-demographic, clinical and psycho-social variables; 3. To understand how coping strategies, perceived social support and self-efficacy might affect depressive symptoms in this cohort of patients. Methods: Secondary data analysis collected during the baseline phase of a RCT performed at the Pancreas Institute of the University Hospital of Verona, Italy, between June 2017 and June 2018. Results: 18.5% of pancreatic patients had a PHQ-9 score >10 (cut-off). Depressed patients were basically more often female, (p=0.07), younger (p=0.06) and married/with a partner (p=0.02). Depression was associated to high trait anxiety (p<0.01), the use of anxiolytics (p<0.01), sleep-inducing drugs (p<0.01) and painkillers (p<0.01). Among psycho-social variables, depressed patients showed lower perceived self-efficacy (p<0.01) and family and friends social support (p<0.01) and used significantly more often dysfunctional coping strategies (p<0.01), compared to non-depressed. A logistic multivariate model using psycho-social variables as explanatory and depression as dependent was calculated and post-hoc analyses were conducted to describe the contribution of each psycho-social variable on depression. Conclusions: Our study advocates the need for screening for distress and depression in cancer surgery units and recommends to strengthen patients' adaptive coping, social support and sense of effectiveness in facing the challenges related to the medical condition and treatment process. This article is protected by copyright. All rights reserved. Keywords: Psycho-Oncology; anxiety; coping; depressive symptoms; emotional distress; pancreatic cancer/neoplasm; prevalence of depression; psychological support; self-efficacy; social support

Negative pressure wound therapy for prevention of surgical site infection in patients at high risk after clean-contaminated major pancreatic resections: A single-center, phase 3, randomized clinical trial

BACKGROUND: Surgical site infections are an important burden of pancreatic surgery, prolonging hospitalization and delaying adjuvant treatment. The aim of this study was to compare negativepressure wound therapy with standard sterile dressing in terms of the prevention of non-organ-space surgical site infection (superficial and deep surgical site infection) in the high-risk setting.METHODS: The trial was conducted at the University of Verona Hospital Trust, Verona, Italy, from July 25, 2018, through October 10, 2019, among adults undergoing surgery for periampullary neoplasms. Only patients at high-risk for surgical site infection based on body mass index, diabetes, steroids, neoadjuvant therapy, American Society of Anesthesiologists score, Charlson comorbidity index, duration of surgery, and blood loss were included and randomized.RESULTS: A total of 351 patients were screened, 100 met the inclusion criteria and were 1:1 allocated in the 2 arms. The difference in terms of non-organ-space surgical site infection comparing negative pressure wound therapy with standard sterile dressing was not significant (10.9 vs 12.2%, risk ratio [RR] 1.144, confidence interval [CI] 95% 0.324-4.040, P= 1.000). Hematomas (4.3 vs 2%, RR 1.565, CI 95% 0.312-7.848, P= .609) and organ-space infections (46.7 vs 43.8%, RR 1.059, CI 95% 0.711-1.576, P= .836) were similar. Negative pressure wound therapy prevented the development of seromas (0 vs 12.2%, RR 0.483, CI 95% 0.390-0.599, P= .027). The aesthetic result assessed on postoperative day 7 was better in the negative pressure wound therapy group (visual analogue scale, 8 vs 7, P= .029; Stony Brook Scar Evaluation Scale, 3.2 vs 2.5, P= .009), but it was no more evident on postoperative day 30 after a total number of 23 dropouts.CONCLUSION: Compared with standard sterile dressing, negative pressure wound therapy is not associated with an improved rate of non-organ-space surgical site infection after surgery for periampullary neoplasms in patients at high risk for surgical site infection. Additional studies will help identify the population that could benefit most from this intervention