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

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

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

Factors predicting survival in patients with locally advanced pancreatic cancer undergoing pancreatectomy with arterial resection

Pancreatectomy with arterial resection is a treatment option in selected patients with locally advanced pancreatic cancer. This study aimed to identify factors predicting cancer-specific survival in this patient population. A single-Institution prospective database was used. Pre-operative prognostic factors were identified and used to develop a prognostic score. Matching with pathologic parameters was used for internal validation. In a patient population with a median Ca 19.9 level of 19.8 U/mL(IQR: 7.1–77), cancer-specific survival was predicted by: metabolic deterioration of diabetes (OR = 0.22, p = 0.0012), platelet count (OR = 1.00; p = 0.0013), serum level of Ca 15.3 (OR = 1.01, p = 0.0018) and Ca 125 (OR = 1.02, p = 0.00000137), neutrophils-to-lymphocytes ratio (OR = 1.16; p = 0.00015), lymphocytes-to-monocytes ratio (OR = 0.88; p = 0.00233), platelets-to-lymphocytes ratio (OR = 0.99; p = 0.00118), and FOLFIRINOX neoadjuvant chemotherapy (OR = 0.57; p = 0.00144). A prognostic score was developed and three risk groups were identified. Harrell’s C-Index was 0.74. Median cancer-specific survival was 16.0 months (IQR: 12.3–28.2) for the high-risk group, 24.7 months (IQR: 17.6–33.4) for the intermediate-risk group, and 39.0 months (IQR: 22.7–NA) for the low-risk group (p = 0.0003). Matching the three risk groups against pathology parameters, N2 rate was 61.9, 42.1, and 23.8% (p = 0.04), median value of lymph-node ratio was 0.07 (IQR: 0.05–0.14), 0.04 (IQR:0.02–0.07), and 0.03 (IQR: 0.01–0.04) (p = 0.008), and mean value of logarithm odds of positive nodes was − 1.07 ± 0.5, − 1.3 ± 0.4, and − 1.4 ± 0.4 (p = 0.03), in the high-risk, intermediate-risk, and low-risk groups, respectively. An online calculator is available at www.survivalcalculator-lapdac-arterialresection.org. The prognostic factors identified in this study predict cancer-specific survival in patients with locally advanced pancreatic cancer and low Ca 19.9 levels undergoing pancreatectomy with arterial resection

Water planning and management in the Cornia river plain by means of the gis-integrated freewat platform

Coastal aquifer, Cornia valley, Tuscany, Managed Aquifer Recharge, FREEWAT platform

Using flood water in Managed Aquifer Recharge schemes as a solution for groundwater management in the Cornia valley (Italy)

The lower Cornia valley aquifer system (Tuscany, Italy) provides the only source of water for drinking, irrigation, industrial purposes and it also contributes to the water needs of the nearby Elba island. Since 60 years, intensive exploitation of groundwater resulted in consistent head lowering and water balance deficit, causing subsidence, reduction of groundwater dependent ecosystems, and salinization of freshwater resources. Rebalancing the water budget of the hydrologic system is the main objective of the LIFE REWAT project (sustainable WATer management in the lower Cornia valley through demand REduction, aquifer Recharge and river REstoration; http://www.liferewat.eu). Here, five demonstration measures (river restoration; Managed Aquifer Recharge; reuse of treated wastewater for irrigation; high irrigation efficiency scheme; leakage management in water distribution systems) are set in place for promoting water resource management, along with capacity building and participatory actions. A pilot Managed Aquifer Recharge (MAR) infiltration basin for using flood-water was designed and set in operation in Suvereto, testing the new-issued Italian regulation on artificial recharge of aquifers (DM 100/2016). The infiltration basin is located at a pre-existing topographical low near the Cornia River. The river, having intermittent flow, provides the recharge water during high flow periods, including floods, and when discharge is above the minimum ecological flow. The infiltration basin is set in a groundwater recharge area where the aquifer is constituted by gravel and sands. A preliminary project and an executive one were prepared and discussed with the relevant authorities, following one-year long monthly monitoring of surface- and ground-water. The project was supported by a groundwater flow modelling-based approach using the FREEWAT platform (www.freewat.eu). The facility consists of the following elements: i) intake work on the River Cornia; ii) the inlet structure control system, managed by quality (mass spectrometer defining surface water spectral signature) and level probes, and allowing pumping into the facility at predefined head and chemical quality thresholds; iii) a sedimentation basin; iv) the infiltration area (less than 1 ha large); v) the operational monitoring system, based on a network of piezometers where both continuous data (head, T, EC, DO) are gathered and discrete measurements/sampling performed. The cost of construction of the plant is about 300000 C well below the cost of a surface water reservoir for a similar storage. Depending on the climatic conditions, the estimated volume of diverted surface water may vary between 300000 m3/year and 2 Mm3/year. Being the facility a pilot one, diverted water discharge ranges between 20 to 50 l/s. Minimal site development and modification was required, resulting in a no-impact water-work, while providing ecosystem benefits by reconnecting and inundating former abandoned riverbeds. The effectiveness of such pilot may demonstrate the potential for Flood-MAR schemes to increase water availability in scarcity prone areas

"Propensity score matched analysis" tra pancreaticodigiunoanastomosi secondo la tecnica di Blumgart modificata versus la tecnica "duct-to-mucosa" secondo Cattell-Warren nelle duodenocefalopancreasectomie open e robot-assistite.

L’adenocarcinoma duttale del pancreas (ACDP) è la principale neoplasia pancreatica esocrina e rappresenta più del 90% dei tumori del pancreas. Nonostante sia solamente il decimo tumore per incidenza negli uomini e addirittura l’undicesimo nelle donne, attualmente è considerato come la quarta causa di morte per tumore negli USA in entrambi i sessi (negli uomini rappresenta il 7% delle cause di morte per neoplasia, nelle donne l’8%). Secondo le principali proiezioni statistiche, il carcinoma del pancreas si appresta a diventare la seconda causa di morte per tumore entro il 2030. Le decadi di età maggiormente colpite sono quelle tra i 50 e i 70 anni. In Italia è stata riportata una incidenza di 9.2/100000 abitanti ed il rapporto maschi:femmine è all'incirca 1:1. Sono state riscontrate notevoli differenze razziali nella frequenza di cancro del pancreas, con percentuali sensibilmente superiori nei neri rispetto ai caucasici, mentre le percentuali più basse sono state registrate in alcune popolazioni asiatiche. Le motivazioni non sono ben chiare, probabilmente la razza influisce sulla diversa modalità nel processo di detossificazione delle sostanze carcinogeniche

DUODENOCEFALOPANCREASECTOMIE LAPAROTOMICHE E ROBOTICHE A CONFRONTO

Abstract INTRODUZIONE: la duodenocefalopancreasectomia, eseguita con tecnica mini-invasiva, rimane una delle procedure dichirurgia addominale più impegnativa, e la sua applicazione è scarsamente riportata in letteratura. Ad oggi, sono disponibili pochi di confronto tra un approccio mini-invasivo con il sistema robotico Da Vinci, e la procedura open. SCOPO: lo scopo del seguente studio è quello di confrontare gli interventi di duodenocefalopancreasectomia laparoscopiche robot-assistite e con quelli eseguiti con la tecnica tradizionale, presso la U.O. Chirurgia Generale e dei Trapianti dell' Azienda Ospedaliera Universitaria Pisana (AOUP) tra l' Ottobre 2008 e l' Agosto 2012. MATERIALI E METODI: tra l' Ottobre del 2008 e l' Agosto del 2012 sono state eseguite … duodenocefalopancreasectomie presso un singolo istituto. I pazienti sono stati selezionati e stratificati in due gruppi: open e robotico. RISULTATI: CONCLUSIONI

(Ri)conoscere le Mgf. Riflessioni sulle possibilità di quantificare un fenomeno elusivo”

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