Clinical Management of Pancreatic Premalignant Lesions

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THE NATURAL HISTORY OF INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM OF THE PANCREAS: REAPPRAISAL OF THE INDOLENT PRECURSOR OF PANCREATIC CANCER

INTRODUCTION Evidences from surgical series have been condensed into several guidelines for the management of Intraductal Papillary Mucinous Neoplasms of the pancreas (IPMNs). However, still a gap must be filled to better understand their biological behavior. Aim of the present study is to describe the natural history of IPMNs observed at a high-volume center for thirty years. METHODS All patients with a radiological or pathological diagnosis of IPMN referred to The Pancreas Institute, University of Verona Hospital Trust, from 1985 to 2016 were included. Growth rates were analyzed through a linear-mixed model. The development of worrisome features (WF), high-risk stigmata (HRS), and pancreatic cancer (PC), survival and risk for surgery were also analyzed. RESULTS Of 2189 observed patients, 1529 were included in the analysis. The overall median follow-up was 43 months. Three hundred and thirteen patients were sent to surgery upfront, while 181 after initial surveillance. The overall growth rate was 1mm/year. For about half of cases any dimensional change was documented. The presence of high risk stigmata (HRS), age 30mm at diagnosis were associated to a faster growth rate. During follow-up, trivial IPMNs developed WF in 6.5% of cases and HRS in 0.6%. Overall, 3.5% of patients developed PC after a median time of 28 months. Of these patients, 72% previously developed HRS/WF. Of 1043 initially observed trivial branch duct (BD) IPMNs, 16 eventually developed PC with 10% occurring after 15 years of follow-up. HRS and growth rate were independent predictors of PC. Growth rate was the only difference between IPMNs developing PC and those remaining stable after more than 5 years of follow-up (n=399). The mean estimated disease specific survival (DSS) for the overall population exceeded 19 years. Only 1.9% of BD-IPMNs developed PC, with a resulting 5-years DSS rate of 99.3%. Standardized incidence ratio of PC for patients with trivial BD-IPMN was 21 (95% CI 10 \u2013 38), whereas was only 1.8 (95% CI 0.5 \u2013 4.7) considering patients > 65 years. CONCLUSIONS IPMN of the pancreas is the indolent precursor of PDAC that will not show a detectable growth during follow-up in half of the cases. Those rapidly growing (>2.50 mm/year) will likely progress to pancreatic cancer through the development of WF and HRS during the first year of follow-up. In patients > 65 y/o, the presence of a BD-IPMN without WF or HRS at diagnosis might not increase the risk of developing PC than in the general populatio

The use of a smartphone application to disseminate guidelines on pancreatic cystic neoplasms

Officially release in October 2019, iCyst was developed as part of the project entitled “Current application of the European evidence‐based guidelines on pancreatic cystic tumors”, which was promoted by the Department of General and pancreatic Surgery – The Pancreas Institute, University of Verona Hospital Trust (Institutional Review Board approval number 2390CESC – Comitato Etico delle Province di Verona e Rovigo), and received funding from the United European Gastroenterology Activity Grants – Support of Standards & Guidelines initiatives, dissemination of existing clinical practice 2019 (endorse by the European Digestive Surgery – EDS)

Cibo e Nutraceutici: direzione salute

Atti congressuali del Convegno “Cibo e nutraceutici: direzione salute”, organizzato a Camerino il 10-07-2018, a cura della Piattaforme Tematiche di Ateneo su “Alimenti e Nutrizione” e “Salute Umana e Animale”

Openly accessed and openly published: a celebration of international high-impact surgical research

Cited by: 0; All Open Access, Gold Open Access, Green Open AccessNon peer reviewe

Openly accessed and openly published: a celebration of international high-impact surgical research

Cited by: 0; All Open Access, Gold Open Access, Green Open AccessNon peer reviewe

Routes of nutrition for pancreatic fistula after pancreatoduodenectomy: a prospective snapshot study identifies the need for therapy standardization

The aim of this study is to describe the current utilization of artificial nutrition [enteral (EN) or total parenteral (TPN)] for pancreatic fistula (POPF) after pancreatoduodenectomy (PD). Prospective data of 311 patients who consecutively underwent PD at a tertiary referral center for pancreatic surgery were collected. Data included the use of EN or TPN specifically for POPF treatment, including timing, outcomes, and adverse events related to their administration. POPF occurred in 66 (21%) patients and 52 (79%) of them were treated with artificial nutrition, for a median of 36 days. Forty (76%) patients were treated with a combination of TPN and EN. The median day of artificial nutrition start was postoperative day 7, with a median drain output of 180 cc/24 h. In 33 (63%) patients, artificial nutrition was started while only a biochemical leak was ongoing. Fungal infections and catheter-related bloodstream infection occurred in 13 (28%) and 15 (33%) TPN patients, respectively; among EN patients, 19 (41%) experienced diarrhea not responsive to pancreatic enzymes and 9 (20%) needed multiple endoscopic naso-jejunal tube positioning. The majority of the patients developing POPF after PD were treated with a combination of TPN and EN, with a clinically relevant rate of adverse events related to their administration. Standardization of nutrition routes in patients developing POPF is urgently needed

Early and Sustained Elevation in Serum Pancreatic Amylase Activity: A Novel Predictor of Morbidity After Pancreatic Surgery

Objective:To characterize early postoperative serum pancreatic amylase (spAMY) trends after pancreatic resections. Summary Background Data:A postoperative spAMY elevation is a common finding but uncertainties remain about its meaning and prognostic implications. Methods:Analysis of patients who consecutively underwent pancreatectomy from 2016 to 2019. spAMY activity was assessed from postoperative day (POD) 0 to 3. Different patterns of spAMY have been identified based on the spAMY standard range (10-52 U/l). Results:Three patterns were identified: (#1) spAMY values always < the lower limit of normal/within the reference range /a single increase in spAMY > upper limit of normal at any POD; (#2) Sustained increase in spAMY activity on POD 0 + 1; (#3) Sustained increase in spAMY activity including POD 1 + 2. Shifting through spAMY patterns was associated with increase morbidity (21% in #1 to 68% in #3 at POD 7; log rank < 0.001). Almost all severe complications (at least Clavien-Dindo >= 3) occurred in patients with pattern #3 (15% vs 3% vs 5% in #1 and #2 at POD 7, P = 0.006), without difference considering >3-times or >the spAMY normal limit (P = 0.85). POPF (9% in #1 vs 48% in #3, P < 0.001) progressively increased across patterns. Pre-operative diabetes (OR 0.19), neoadjuvant therapy (OR 0.22), pancreatic texture (OR 8.8), duct size (OR 0.78), and final histology (OR 2.2) were independent predictors of pattern #3. Conclusions:A sustained increase in spAMY activity including POD 1 + 2 (#3) represents an early postoperative predictor of overall and severe early morbidity. An early and dynamic evaluation of spAMY could crucially impact the subsequent clinical course with relevant prognostic implications