Additional modifications to the Blumgart pancreaticojejunostomy: Results of a propensity score-matched analysis versus Cattel-Warren pancreaticojejunostomy

Abstract Background Postoperative pancreatic fistula continues to occur frequently after pancreatoduodenectomy. Methods We have described a modification of the Blumgart pancreaticojejunostomy. The modification of the Blumgart pancreaticojejunostomy was compared to the Cattel-Warren pancreaticojejunostomy in cohorts of patients matched by propensity scores based on factors predictive of clinically relevant postoperative pancreatic fistula, which was the primary endpoint of this study. Based on a noninferiority study design, 95 open pancreatoduodenectomies per group were needed. Feasibility of the modification of the Blumgart pancreaticojejunostomy in robotic pancreatoduodenectomy was also shown. All pancreaticojejunostomies were performed by a single surgeon. Results Between October 2011 and May 2019, there were 415 pancreatoduodenectomies with either a Cattel-Warren pancreaticojejunostomy (n = 225) or a modification of the Blumgart pancreaticojejunostomy (n = 190). There was 1 grade C postoperative pancreatic fistula in 190 consecutive modification of the Blumgart pancreaticojejunostomies (0.5%). Logistic regression analysis showed that the rate of clinically relevant postoperative pancreatic fistula was not affected by consecutive case number. After exclusion of robotic pancreatoduodenectomies (the Cattel-Warren pancreaticojejunostomy: 82; modification of the Blumgart pancreaticojejunostomy: 66), 267 open pancreatoduodenectomies were left, among which the matching process identified 109 pairs. The modification of the Blumgart pancreaticojejunostomy was shown to be noninferior to the Cattel-Warren pancreaticojejunostomy with respect to clinically relevant postoperative pancreatic fistula (11.9% vs 22.9%; odds ratio: 0.46 [0.21–0.93]; P = .03), grade B postoperative pancreatic fistula (11.9% vs 18.3%; P = .18), and grade C postoperative pancreatic fistula (0 vs 4.6%; P = .05) as well as to all secondary study endpoints. The modification of the Blumgart pancreaticojejunostomy was feasible in 66 robotic pancreatoduodenectomies. In this subgroup with 1 conversion to open surgery (1.5%), a clinically relevant postoperative pancreatic fistula occurred after 9 procedures (13.6%) with no case of grade C postoperative pancreatic fistula and a 90-day mortality of 3%. Conclusion The modification of the Blumgart pancreaticojejunostomy described herein is noninferior to the Cattel-Warren pancreaticojejunostomy in open pancreatoduodenectomy. This technique is also feasible in robotic pancreatoduodenectomy

Robot-assisted pancreaticoduodenectomy with vascular resection: technical details and results from a high-volume center

Background: Pancreaticoduodenectomy with vein resection (PD-VR) is widely accepted as a standard procedure to achieve a higher rate of R0 resections in borderline resectable pancreatic tumors. Thanks to the availability of newer technologies, such as the da Vinci Surgical System, several high-volume centers are reporting small series of minimally invasive PD-VR. Methods: A retrospective review of a prospectively maintained database was performed to identify patients who underwent robot-assisted PD-VR (RAPD-VR) between May 2011 and December 2019. The following factors were specifically analyzed: intraoperative results, post-operative complications, mortality at 90 days, patency of vascular reconstructions, overall survival (OS) and disease-free survival (DFS). Results: During the study period 184 patients underwent RAPD, including 22 who received a RAPDVR (12.0%). The superior mesenteric vein was resected in 9 patients (40.9%), the portal vein in 3 patients (13.6%) and the spleno-mesenteric junction in 10 patients (45.5%). Based on the classification provided by the International Study Group on Pancreatic Surgery these procedures were classified as follows: 1 type I (4.5%), 3 type II (13.6%), 10 type III (45.5%) and 8 type IV (36.4%). In no patient the splenic vein was ligated and left behind. The splenic vein was always reimplanted either on the porto-mesenteric axis or in the inferior vena cava. All but one procedure, were completed under robotic assistance (conversion rate 1/22; 4.5%) after a mean operative time of 610.0±83.5 minutes. Median estimated blood loss was 899.7 mL (719.4–1,430.2 mL), with 2 patients (9.1%) receiving intraoperative blood transfusions. Sixteen patients developed post-operative complications (72.7%), graded ≥III (according to Clavien-Dindo) in 5 patients (22.7%). Two patients died within 90 days, accounting for a postoperative mortality of 9.1%. Interestingly, post-operative pancreatic fistula (grade B) occurred in only 1 patient (4.5%). Repeat surgery was required in 4 patients (18.2%) and hospital readmission in 1 patient (4.5%). At the longest available follow-up, vein reconstruction was patent in 19 patients (86.4%). Eighteen patients had a final diagnosis of pancreatic ductal adenocarcinoma (81.8%). After circumferential study of resection margins, microscopic tumor residual ≤1 mm was found in 11 patients (50.0%). The mean number of examined lymph nodes was 42.2 (±16.3), and vascular infiltration was confirmed in 13 patients (59.1%). Median OS was 39.7 (27.5–not available) and DFS 32.9 (11.5–45.8). Tumor recurrence was identified in 6 patients (27.3%). One patient (4.5%) developed isolated local recurrence. Conclusions: We have shown the feasibility of RAPD-VR. The results reported herein need to be confirmed in larger series and their generalizability remains to be established

Association between a polymorphic variant in the CDKN2B-AS1/ANRIL gene and pancreatic cancer risk

Genes carrying high-penetrance germline mutations may also be associated with cancer susceptibility through common low-penetrance genetic variants. To increase the knowledge on genetic pancreatic ductal adenocarcinoma (PDAC) aetiology, the common genetic variability of PDAC familial genes was analysed in this study. We conducted a multi-phase study analysing 7,745 single nucleotide polymorphisms (SNPs) from 29 genes reported to harbour a high-penetrance PDAC-associated mutation in at least one published study. To assess the effect of the SNPs on PDAC risk, a total of 14,666 PDAC cases and 221,897 controls across five different studies were analysed. The T allele of the rs1412832 polymorphism, that is situated in the CDKN2B-AS1/ANRIL, showed a genome-wide significant association with increased risk of developing PDAC (OR=1.11, 95%CI=1.07-1.15, P=5.25×10-9 ). CDKN2B-AS1/ANRIL is a long non-coding RNA, situated in 9p21.3, and regulates many target genes, among which CDKN2A (p16) that frequently shows deleterious somatic and germline mutations and deregulation in PDAC. Our results strongly support the role of the genetic variability of the 9p21.3 region in PDAC aetiopathogenesis and highlight the importance of secondary analysis as a tool for discovering new risk loci in complex human diseases. This article is protected by copyright. All rights reserved

First World Consensus Conference on pancreas transplantation: Part II - recommendations.

Funder: Fondazione Pisa, Pisa, Italy; Id: http://dx.doi.org/10.13039/100007368Funder: Tuscany Region, Italy; Id: http://dx.doi.org/10.13039/501100009888Funder: Pisa University Hospital, Pisa, ItalyFunder: University of Pisa, Pisa, Italy; Id: http://dx.doi.org/10.13039/501100007514The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246

Duodenocefalopancreasectomia robotica versus open per adenocarcinoma duttale del pancreas: analisi del residuo tumorale microscopico (R) e della sopravvivenza.

La sopravvivenza globale dell’adenocarcinoma duttale del pancreas (ACDP) risultano ancora oggi modeste e dal punto di vista chirurgico, secondo alcuni autori, sembrerebbero essere influenzate dal residuo microscopico sui margini di resezione. L’intervento ad intento curativo R0 ad oggi risulta essere l’unica possibilità di guarigione dalla malattia. Con l’avvento della chirurgia robotica, alcuni autori nel mondo hanno iniziato ad adottare questo approccio anche nella duodenocefalopancreasectomia (DCP) e, dimostrata la sua fattibilità, si è aperto così il dibattito sull’appropriatezza oncologica. In questo lavoro vengono analizzati il residuo microscopico (R0/R1) e la sopravvivenza confrontando la DCP robotica (DCP-R) e quella open (DCP-O) eseguite per ACDP

The transplant of the uterus

Objective: to estimate the number of potential donors and potential recipients per year for uterus transplantation in the Italian setting. Setting: referral center for transplant and reproductive medicine. Design: survey, retrospective analysis. Patient(s): Patients affected by Mayer-Rokitansky-Küster-Hauser syndrome and deceased donors from 2001 to 2018. Intervention(s): analysis in detail of the deceased donors used in Tuscany from 2001 to 2018 accordingly with a uterus transplant protocol elaborated in our hospital, survey among patients affected by Mayer-Rokitansky-Küster-Hauser syndrome Main Outcome measure(s): estimated number of donors and recipients for uterus transplant per year. Result(s): the number of potential usable donors is estimated in 97 per year in Italy and the number of potential candidates to uterus transplant resulted at least 1,400.We report a pilot survey between women affected by Mayer-Rokitansky-Küster-Hauser syndrome. Thirteen out of 54 (24%) patients responded to a specific questionnaire, 92% have a strong will of motherhood and think UTx an effective solution; 70% are interested in UTx but do not fully understand if the benefits exceed the risks. Conclusion(s): in Italy the need of Utx is real and the number of donors is reasonable to start a pilot clinical trial. Information is mandatory, as it is necessary to create a dedicated multispeciality team to follow candidates before, during and after the path to transplantatio

Trapianto robotico di rene e di pancreas.

Generalità sui trapianti di rene e di pancreas e descrizione del sistema robotico chirurgico "da Vinci". La selezione dei pazienti destinati al trapianto. Trattazione dei dati intraoperatori e post-operatori dei casi e descrizione della tecnica chirurgica di trapianto

Cystic Lesions of the Pancreas: Is Apparent Diffusion Coefficient Value Useful at 3 T Magnetic Resonance Imaging?

Objective: The objective of this study is to determine the role of apparent diffusion coefficient (ADC) value at 3T magnetic resonance imaging (MRI) in the characterization of pancreatic cystic lesions. Methods: We retrospectively selected a total number of 223 patients with a conclusive diagnosis of pancreatic cystic lesion, previously undergoing MR examination on a 3 T system. The MRI protocol first included axial T1/T2-weighted sequences and magnetic resonance cholangiopancreatography. Diffusion-weighted MRI was performed using a spin-echo echo-planar sequence with multiple b values (0, 150, 500, 1000, and 1500 s/mm2) in all diffusion directions, obtaining an ADC map. Contrast-enhanced T1-weighted sequences were performed during the initial work-up of a pancreatic cystic lesion and when signs of malignancy were suspected during the MRI follow-up. The ADC value of each pancreatic lesion was measured using a monoexponential curve fitting with all the multiple b. Results: The final diagnosis of our study group included the following: serous cystadenomas (n = 42), mucinous cystadenomas (n = 14), intraductal papillary mucinous neoplasms (IPMNs) (n = 121), IPMNs with signs of malignancy at histopathologic examination (n = 24), pseudocysts (n = 9), other cystic lesions (n = 13). A statistically significant difference was observed between the ADC values of malignant IPMNs and those of each other group of pancreatic lesions (P < 0.001). The ADC value of benign IPMN was significantly higher than that of serous cystadenomas (P = 0.024). A statistically significant difference was observed between the ADCs of all mucinous cystic tumors (benign IPMNs together to mucinous cystadenomas) and the ADCs of serous cystadenomas (P = 0.014). Conclusions: Fitted ADC value obtained at 3T MRI may be helpful in the characterization of pancreatic cystic lesions with particular regards of differential diagnosis between mucinous and serous cystic tumors and between malignant and benign IPMNs