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

Tips and tricks for robotic pancreatoduodenectomy with superior mesenteric/portal vein resection and reconstruction

Background Open pancreatoduodenectomy with vein resection (OPD-VR) is now standard of care in patients who responded to neoadjuvant therapies. Feasibility of robotic pancreatoduodenectomy (RPD) with vein resection (RPD-VR) was shown, but no study provided a detailed description of the technical challenges associated with this formidable operation. Herein, we describe the trips and tricks for technically successful RPD-VR.Methods The vascular techniques used in RPD-VR were borrowed from OPD-VR, as well as from our experience with robotic transplantation of both kidney and pancreas. Vein resection was classified into 4 types according to the international study group of pancreatic surgery. Each type of vein resection was described in detail and shown in a video.Results Between October 2008 and November 2021, a total of 783 pancreatoduodenectomies were performed, including 233 OPDs-VR (29.7%). RPD was performed in 256 patients (32.6%), and RPDs-VR in 36 patients (4.5% of all pancreatoduodenectomies; 15.4% of all pancreatoduodenectomies with vein resection; 14.0% of all RPDs). In RPD-VR vein resections were: 4 type 1 (11.1%), 10 type 2 (27.8%), 12 type 3 (33.3%) and 10 type 4 (27.8%). Vascular patches used in type 2 resections were made of peritoneum (n = 8), greater saphenous vein (n = 1), and deceased donor aorta (n = 1). Interposition grafts used in type 4 resections were internal left jugular vein (n = 8), venous graft from deceased donor (n = 1) and spiral saphenous vein graft (n = 1). There was one conversion to open surgery (2.8%). Ninety-day mortality was 8.3%. There was one (2.8%) partial vein thrombosis, treated with heparin infusion.Conclusions We have reported 36 technically successful RPDs-VR. We hope that the tips and tricks provided herein can contribute to safer implementation of RPD-VR. Based on our experience, and according to data from the literature, we strongly advise that RPD-VR is performed by expert surgeons at high volume centers

REDISCOVER International Guidelines on the Perioperative Care of Surgical Patients With Borderline-resectable and Locally Advanced Pancreatic Cancer

OBJECTIVE: The REDISCOVER consensus conference aimed at developing and validate guidelines on the perioperative care of patients with borderline resectable (BR-) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC).SUMMARY BACKGROUND DATA: Coupled with improvements in chemotherapy and radiation, the contemporary approach to pancreatic surgery supports resection of BR-PDAC and, to a lesser extent, LA-PDAC. Guidelines outlining the selection and perioperative care for these patients are lacking.METHODS: The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used to develop the REDISCOVER guidelines and create recommendations. The Delphi approach was used to reach consensus (agreement ≥80%) among experts. Recommendations were approved after a debate and vote among international experts in pancreatic surgery and pancreatic cancer management. A Validation Committee used the AGREE II-GRS tool to assess the methodological quality of the guidelines. Moreover, an independent multidisciplinary advisory group revised the statements to ensure adherence to non-surgical guidelines.RESULTS: Overall, 34 recommendations were created targeting centralization, training, staging, patient selection for surgery, possibility of surgery in uncommon scenarios, timing of surgery, avoidance of vascular reconstruction, details of vascular resection/reconstruction, arterial divestment, frozen section histology of perivascular tissue, extent of lymphadenectomy, anticoagulation prophylaxis and role of minimally invasive surgery. The level of evidence was however low for 29 of 34 clinical questions. Participants agreed that the most conducive mean to promptly advance our understanding in this field is to establish an international registry addressing this patient population ( https://rediscover.unipi.it/ ).CONCLUSIONS: The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with BR- and LA-PDAC, and serve as the basis of a new international registry for this patient population.</p

REDISCOVER International Guidelines on the Perioperative Care of Surgical Patients With Borderline-resectable and Locally Advanced Pancreatic Cancer

OBJECTIVE: The REDISCOVER consensus conference aimed at developing and validate guidelines on the perioperative care of patients with borderline resectable (BR-) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC).SUMMARY BACKGROUND DATA: Coupled with improvements in chemotherapy and radiation, the contemporary approach to pancreatic surgery supports resection of BR-PDAC and, to a lesser extent, LA-PDAC. Guidelines outlining the selection and perioperative care for these patients are lacking.METHODS: The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used to develop the REDISCOVER guidelines and create recommendations. The Delphi approach was used to reach consensus (agreement ≥80%) among experts. Recommendations were approved after a debate and vote among international experts in pancreatic surgery and pancreatic cancer management. A Validation Committee used the AGREE II-GRS tool to assess the methodological quality of the guidelines. Moreover, an independent multidisciplinary advisory group revised the statements to ensure adherence to non-surgical guidelines.RESULTS: Overall, 34 recommendations were created targeting centralization, training, staging, patient selection for surgery, possibility of surgery in uncommon scenarios, timing of surgery, avoidance of vascular reconstruction, details of vascular resection/reconstruction, arterial divestment, frozen section histology of perivascular tissue, extent of lymphadenectomy, anticoagulation prophylaxis and role of minimally invasive surgery. The level of evidence was however low for 29 of 34 clinical questions. Participants agreed that the most conducive mean to promptly advance our understanding in this field is to establish an international registry addressing this patient population ( https://rediscover.unipi.it/ ).CONCLUSIONS: The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with BR- and LA-PDAC, and serve as the basis of a new international registry for this patient population.</p

LA CHIRURGIA EPATICA DEL RISPARMIO D'ORGANO

LA CHIRURGIA EPATICA DEL RISPARMIO DI PARENCHIMA Abstract: La chirurgia epatica resettiva con risparmio di parenchima ha come obiettivo l’asportazione radicale di lesioni tumorali preservando la maggiore quantità possibile di tessuto sano. Tale approccio è ad oggi l’evoluzione d’avanguardia rispetto alla chirurgia tradizionale che prevede il sacrificio di ampie porzioni di fegato. Lo studio della morfologia epatica affonda le radici nei vaticini che i Babilonesi eseguivano a scopo divinatorio già 5000 anni fa; in epoca moderna il punto di arrivo è costituito dalla classificazione di Couinaud (1957) che schematizza il fegato in 8 segmenti sulla base dei rapporti anatomici interni tra le diramazioni del sistema portale e del sistema delle vene sovraepatiche. Le tecniche di resezione tradizionali formalizzate in maniera autorevole da Bismuth (1982) e riorganizzate nella classificazione di Brisbane (2000) hanno come proprio razionale l’utilizzo dei grossi assi vascolari come riferimento per la realizzazione dei piani di sezione. L’avanzamento delle tecniche di imaging preoperatorie e l’introduzone dell’ecografia intraoperatoria hanno raggiunto un tale livello di accuratezza da permettere la pianificazione di interventi mirati nel rispetto delle strutture vascolari nobili basati non più su modelli ideali bensì sulla reale anatomia del singolo paziente. L’identificazione di vene comunicanti e le ricostruzioni vascolari con o senza l’utilizzo di protesi rendono ad oggi resecabili anche lesioni che infiltrano una o più vene sovraepatiche alla confluenza epatocavale con il sacrificio di minime quantità di parenchima epatico. La chirurgia con risparmio di parenchima, assicurando un adeguato “future liver remnant” costituisce una risorsa concreta nell’ambito di una gestione multidisciplinare della patologia oncologica complessa

Analisi della sopravvivenza nell'adenocarcinoma duttale del pancreas (PDAC) trattato con chemioterapia neoadiuvante e chirurgia resettiva: confronto tra borderline resectable (BR) e locally advanced (LA) PDAC

Pancreatic ductal adenocarcinoma (PDAC) is associated with high mortality due to its aggressive tumour biology, chemo-resistance and insidious onset.. Late diagnosis of PDAC is the norm due to the nonspecific nature of symptoms, with only 20% of patients meeting criteria for upfront resection and 50-55% of patients having metastatic disease at initial presentation. The remaining 25-30% of patients present with vascular involvement and are classed as either borderline resectable (BR-PDAC) or locally advanced (LA-PDAC) pancreatic ductal adenocarcinoma as per National Comprehensive Cancer Network (NCCN) Guidelines. The treatment of borderline resectable and locally advanced pancreatic ductal adenocarcinoma has evolved with a wider application of neoadjuvant chemotherapy (NACHT). Vascular conflict in BR tumors is typically less extensive, which might allow for upfront surgical resection with a more extensive surgical procedure. Nowadays, NACHT is also recommended for BR. In contrast, LA tumors generally undergo NACHT in an attempt to downsize the tumor to resectable disease. However, the evaluation of response to NACHT, whether resorting to iconographic response evaluation criteria in solid tumors (RECIST) or monitoring a decrease of the tumor marker CA 19.9, lacks the specificity needed to predict surgical resectability. As a result, it necessitates surgical exploration for patients who show no evident progression and maintain a favorable performance status. Within this context, the question arises as whether BR and LA should be considered as distinct entities, defined by specific anatomical boundaries with differing prognoses, or if they should be viewed as a continuum of the same advanced disease. Disease that studies have shown to be systemic from the earliest stages This study aims to investigate the effects of neoadjuvant treatment on overall survival (OS) and recurrence-free survival (RFS) in borderline resectable (BRPC) and locally advanced (LAPC) pancreatic adenocarcinoma followed by curative resection. L'adenocarcinoma duttale del pancreas (PDAC) è associato ad un'elevata mortalità a causa della sua aggressiva biologia tumorale, della sua chemioresistenza e della modalità insidiosa in cui insorge. La diagnosi tardiva del PDAC è la norma a causa della natura aspecifica dei sintomi, con solo il 20% dei pazienti che soddisfa i criteri per una resezione upfront e il 50-55% dei pazienti con malattia metastatica alla diagnosi. Il restante 25-30% dei pazienti presenta un coinvolgimento vascolare e viene classificato come adenocarcinoma duttale pancreatico borderline resectable (BR-PDAC) o localmente avanzato (LA-PDAC) secondo le linee guida del National Comprehensive Cancer Network (NCCN). Il trattamento dell'adenocarcinoma duttale pancreatico borderline resectable e localmente avanzato si è evoluto con una più ampia applicazione della chemioterapia neoadiuvante (NACHT). L’interessamento vascolare nei tumori BR è tipicamente meno esteso, il che potrebbe consentire una resezione chirurgica upfront con una procedura chirurgica più estesa. Ad oggi comunque la NACHT è raccomandata anche per i BR-PDAC. Al contrario, i LA-PDAC sono generalmente sottoposti a NACHT nel tentativo di ridurre il tumore a malattia resecabile. Tuttavia, la valutazione della risposta alla NACHT, sia che si ricorra ai criteri iconografici di valutazione della risposta nei tumori solidi (RECIST) sia che si monitorizzi la diminuzione del marcatore tumorale CA 19.9, manca della specificità necessaria per predire la resecabilità chirurgica e oncologica. Di conseguenza, è necessaria una esplorazione chirurgica per i pazienti che non mostrano una progressione evidente e mantengono un performance status favorevole. In questo contesto, ci si chiede se i BR-PDAC e i LA-PDAC debbano essere considerate entità distinte, definite da specifici confini anatomici con prognosi diverse, o se debbano essere considerate come un continuum della stessa malattia avanzata. Malattia che studi hanno dimostrato essere sistemica fin dai primi stadi. Questo studio si propone di analizzare gli effetti del trattamento neoadiuvante sulla sopravvivenza globale (OS) e sulla sopravvivenza libera da recidiva (DFS) nell'adenocarcinoma pancreatico borderline resectable (BR-PDAC) e localmente avanzato (LA-PDAC) seguito da resezione curativa

Robot-assisted spleen preserving distal pancreatectomy (RA-SPDP): a single center experience

Aim: To define the outcome of robot-assisted spleen preserving distal pancreatectomy (RA-SPDP) in a highvolume center. Methods: A retrospective analysis of a prospectively maintained database was performed to identify RA-SPDP performed at our Center between April 2008 to October 2017. Results: During the study period, RA-SPDP was attempted in 54 patients. The spleen was preserved, always along with the splenic vessels (Kimura procedure), in 52 patients (96.3%). There were no conversions to open or laparoscopic surgery. Mean operative time was 260 min (231.3-360.0). Grade B post-operative pancreatic fistula (POPF) occurred in 19 patients (35.2%). There were no grade C POPF. Two patients required repeat surgery because of postoperative bleeding and splenic infarction, respectively. There were no post-operative deaths at 90 days. Excluding one patient with known diagnosis of metastasis from renal cell carcinoma, malignancy was eventually identified in 7 of 53 patients (13.2%). Conclusion: In the hands of dedicated pancreatic surgeons, robotic assistance results in a high rate of spleen preservation with good clinical outcomes. Despite careful preoperative selection, several patients can be found to have a malignant tumor. Taken altogether these results suggest that patients requiring these procedures should be preferentially referred to specialized centers

Safety and safety protocols for living donor nephrectomy in Italy

: Living donor kidney transplantation (LDKTx) is recommended by all scientific societies. Living donor nephrectomy (LDN) is probably one of the safest surgical procedures, but it carries some risk for healthy donors. The aim of this study is to provide a snapshot of LDKTx activities in Italy and ask about safety measures implemented in LDN. Data on LDKTx were extracted from the national database. Safety measures were examined through a specific survey. Between 2001 and 2022 40,663 kidney transplants (31.4 per million population-pmp) were performed, including 4731 LDKTx (3.7 pmp). There was no postoperative death of the donor. After a median follow-up&nbsp;of 52.2&nbsp;months [IQR:17.9-99.5], the 10-year donor survival rate was 93.38% (CI:97.52-98.94). There was evidence of renal disease in 65 donors (1.8%), including 42 (1.1%) with stage III end-stage renal disease. Twenty-nine out of 35 transplant centers (TC) involved in LDKTx responded to the survey (82.9%). Six TCs (21.4%) had a total experience of 20 or fewer LDN. Minimally invasive LDN was the first choice at 24 TC (82.8%). At 10 TC (37.0%) only one surgeon performed LDN. Nineteen TCs (65.5%) had a surgical safety checklist for LDN and 14 had a&nbsp;postoperative surveillance protocol. The renal artery was occluded in 3 TCs (10.3%) mainly by non-transfixion methods (including clips). Redundancy of key safety systems in the operating room was available in 22 of 29 centers (75.8%). In summary, LDKTx should be further implemented in Italy. Donor safety should be improved through the implementation of a national procedural protocol

Robot-assisted spleen preserving distal pancreatectomy (RA-SPDP): a single center experience

Aim: To define the outcome of robot-assisted spleen preserving distal pancreatectomy (RA-SPDP) in a high-volume center.Methods: A retrospective analysis of a prospectively maintained database was performed to identify RA-SPDP performed at our Center between April 2008 to October 2017.Results: During the study period, RA-SPDP was attempted in 54 patients. The spleen was preserved, always along with the splenic vessels (Kimura procedure), in 52 patients (96.3%). There were no conversions to open or laparoscopic surgery. Mean operative time was 260 min (231.3-360.0). Grade B post-operative pancreatic fistula (POPF) occurred in 19 patients (35.2%). There were no grade C POPF. Two patients required repeat surgery because of postoperative bleeding and splenic infarction, respectively. There were no post-operative deaths at 90 days. Excluding one patient with known diagnosis of metastasis from renal cell carcinoma, malignancy was eventually identified in 7 of 53 patients (13.2%).Conclusion: In the hands of dedicated pancreatic surgeons, robotic assistance results in a high rate of spleen preservation with good clinical outcomes. Despite careful preoperative selection, several patients can be found to have a malignant tumor. Taken altogether these results suggest that patients requiring these procedures should be preferentially referred to specialized centers