Limited Resection Versus Pancreaticoduodenectomy for Duodenal Gastrointestinal Stromal Tumors? Enucleation Interferes in the Debate: A European Multicenter Retrospective Cohort Study

Background The optimal surgical procedure for duodenal gastrointestinal stromal tumors (D-GISTs) remains poorly defined. Pancreaticoduodenectomy (PD) allows for a wide resection but is associated with a high morbidity rate. Objectives The aim of this study was to compare the short- and long-term outcomes of PD versus limited resection (LR) for D-GISTs and to evaluate the role of tumor enucleation (EN). Methods In this retrospective European multicenter cohort study, 100 patients who underwent resection for D-GIST between 2001 and 2013 were compared between PD (n = 19) and LR (n = 81). LR included segmental duodenectomy (n = 47), wedge resection (n = 21), or EN (n = 13). The primary objective was to evaluate disease-free survival (DFS) between the groups, while the secondary objectives were to analyze the overall morbidity and mortality, radicality of resection, and 5-year overall survival (OS) and recurrence rates between groups. Furthermore, the short- and long-term outcomes of EN were evaluated. Results Baseline characteristics were comparable between the PD and LR groups, except for a more frequent D2 tumor location in the PD group (68.3% vs. 29.6%; p = 0.016). Postoperative morbidity was higher after PD (68.4% vs. 23.5%; p < 0.001). OS (p = 0.70) and DFS (p = 0.64) were comparable after adjustment for D2 location and adjuvant therapy rate. EN was performed more in American Society of Anesthesiologists (ASA) stage III/IV patients with tumors < 5 cm and was associated with a 5-year OS rate of 84.6%, without any disease recurrences. Conclusions For D-GISTs, LR should be the procedure of choice due to lower morbidity and similar oncological outcomes compared with PD. In selected patients, EN appears to be associated with equivalent short- and long-term outcomes. Based on these results, a surgical treatment algorithm is proposed

Pancreaticoduodenectomy in the presence of a common hepatic artery originating from the superior mesenteric artery. Technical implications

Pancreaticoduodenectomy (PD) is considered a technically demanding task. Anatomic variations in duodenopancreatic vascularization [celiac axis and the superior mesenteric artery (SMA)] may carry a risk of potentially life-threatening vascular injury. We retrospectively report a modified PD technique performed in two patients presenting with a Common Hepatic Artery (CHA) originating from SMA. The CHA anatomical pattern was known prior surgical procedure. The main modification consisted in cutting pancreas prior dividing the CHA and the gastroduodenal artery. No intraoperative incident was reported. Perioperative outcomes were unremarkable, no vascular injury or hepatic ischemia was reported. Surgeons planning a PD must analyze in depth imaging (CT-scan with 3D angiography) and try to find these patterns. Furthermore, some rare arterial variations may be met and change typical surgical plan. Knowing prior procedure the arterial pattern and keeping in mind expendable or vital vessels allow to accomplish unusual but effective operations

Prevalence of and Risk Factors for Morbidity After Elective Left Colectomy Cancer vs Noncomplicated Diverticular Disease

Hypothesis: Independent risk factors for postoperative morbidity after colectomy are most likely linked to disease characteristics. Design: Retrospective analysis. Setting: Twenty-eight centers of the French Federation for Surgical Research. Patients: In total, 1721 patients (1230 with colon cancer [CC] and 491 with diverticular disease [DD]) from a databank of 7 prospective, multisite, randomized trials on colorectal resection. Intervention: Elective left colectomy via laparotomy. Main Outcome Measures: Preoperative and intraoperative risk factors for postoperative morbidity. Results: Overall postoperative morbidity was higher in CC than in DD (32.4% vs 30.3%) but the difference was not statistically significant (P=.40). Two independent risk factors for morbidity in CC were antecedent heart failure (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.42-6.32) (P=.003) and bothersome intraluminal fecal matter (2.08; 1.42-3.06) (P=.001). Three independent risk factors for morbidity in DD were at least 10% weight loss (OR, 2.06; 95% CI, 1.25-3.40) (P=.004), body mass index (calculated as weight in kilograms divided by height in meters squared) exceeding 30 (2.05; 1.15-3.66) (P=.02), and left hemicolectomy (vs left segmental colectomy) (2.01; 1.19-3.40) (P=.009). Conclusions: Patients undergoing elective left colectomy for CC or for DD constitute 2 distinct populations with completely different risk factors for morbidity, which should be addressed differently. Improving colonic cleanliness (by antiseptic enema) may reduce morbidity in CC. In DD, morbidity may be reduced by appropriate preoperative nutritive support (by immunonutrition), even in patients with obesity, and by preference of left segmental colectomy over left hemicolectomy. By decreasing morbidity, mortality should be lowered as well, especially when reoperation becomes necessary

Limited Resection Versus Pancreaticoduodenectomy for Duodenal Gastrointestinal Stromal Tumors? Enucleation Interferes in the Debate: A European Multicenter Retrospective Cohort Study

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