Protective or Risk Factors for Postoperative Pancreatic Fistulas in Malignant Pathology

Introduction: Malignant tumors are associated with a low incidence of postoperative pancreatic fistulas. The presence of peritumoral fibrosis is considered the protective factor for the development of postoperative pancreatic fistulas after pancreatic resections for pancreatic ductal adenocarcinomas. Methods: We analyzed a series of 109 consecutive patients with pancreatic resections for malignant pathology: pancreatic ductal adenocarcinomas and periampullary adenocarcinomas. The incidence of postoperative pancreatic fistulas has been reported in tumor histological type, in the presence of peritumoral fibrosis, and in the association between adenocarcinomas and areas of acute pancreatitis. The data obtained were processed with the statistical analysis program SPSS, and statistically significant p were considered at a value <0.05. Results: For the entire study group, the incidence of postoperative pancreatic fistulas was 11.01%. The lowest incidence was observed in the group of patients with pancreatic ductal adenocarcinomas (4.06% vs. 25.72% in the group with periampullary adenocarcinoma), with a p = 0.002. The presence of peritumoral fibrous tissue was observed in 49.31% of cases without pancreatic fistulas, and in 54.54% of cases that developed this postoperative complication (p = 0.5). Also, the peritumoral fibrous tissue had a uniform distribution depending on the main diagnosis (56.14% in pancreatic ductal adenocarcinoma group vs. 37.04% in periampullary adenocarcinoma group, with a p = 0.08). In the group of patients who associated areas of acute pancreatitis on the resections, the incidence of postoperative pancreatic fistulas was 7.8 times higher (30% vs. 3.8%, p = 0.026). Conclusions: Peritumoral fibrous tissue was not a factor involved in the developing of postoperative pancreatic fistulas. The association of adenocarciomas with areas of acute pancreatitis has led to a significant increase in postoperative pancreatic fistulas, which is a significant and independent risk factor.

Resection of Non-Functional Pancreatic Neuroendocrine Neoplasms—A Single-Center Retrospective Outcome Analysis

Surgery remains the only curative treatment of pancreatic neuroendocrine neoplasms (pNEN). Here, we report the outcome after surgery for non-functional pNEN at a European Neuroendocrine Tumor Society (ENETS) center in Germany between 2000 and 2019; cases were analyzed for surgical (Clavien–Dindo classification; CDc) and oncological outcomes. Forty-nine patients (tumor grading G1 n = 25, G2 n = 22, G3 n = 2), with a median age of 56 years, were included. Severe complications (CDc ≥ grade 3b) occurred in 11 patients (22.4%) and type B/C pancreatic fistulas (POPFs) occurred in 5 patients (10.2%); in-hospital mortality was 2% (n = 1). Six of seven patients with tumor recurrence (14.3%) had G2 tumors in the pancreatic body/tail. The median survival was 5.7 years (68 months; [1–228 months]). Neither the occurrence (p = 0.683) nor the severity of complications had an influence on the relapse behavior (p = 0.086). This also applied for a POPF (≥B, p = 0.609). G2 pNEN patients (n = 22) with and without tumor recurrence had similar median tumor sizes (4 cm and 3.9 cm, respectively). Five of the six relapsed G2 patients (83.3%) had tumor-positive lymph nodes (N+); all G2 pNEN patients with recurrence had initially been treated with distal pancreatic resection. Pancreatic resections for pNEN are safe but associated with relevant postoperative morbidity. Future studies are needed to evaluate suitable resection strategies for G2 pNEN.

The impact of obesity on the risk of postoperative pancreatic fistula in malignant surgical pathology

Postoperative pancreatic fistulas are one of the most serious postoperative complications, with important implications for the prognosis, postoperative evolution and quality of life. Patients' comorbidities play an important role in the process of producing this postoperative complication. Methods: a retrospective study was performed that included 109 patients with pancreatic resections for malignant pathology. the incidence of pancreatic fistula in relation to the associated pathology was analyzed: obesity, diabetes, hypertension and non-hypertensive cardiac pathology. Results: the incidence of pancreatic fistula on the entire study group was 11.01%. Obesity was the only factor with which a statistically significant association was obtained, the incidence of pancreatic fistula being 3.59 times higher in the group of obese patients. Conclusions: obesity is an important and independent predictive factor, which increases the risk of postoperative pancreatic fistula by increasing the difficulty of pancreatic dissection and anastomosis.

Pancreatic Frozen Section Guides Operative Management With Few Deferrals and Errors

Context.— Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Surgery remains the mainstay of treatment, and frozen section analysis is used to confirm diagnosis and determine resectability and margin status. Objective.— To evaluate use and accuracy of frozen section and how diagnosis impacts surgical procedure. Design.— We reviewed patients with planned pancreatic resections between January 2014 and March 2019 with at least 1 frozen section. Pathology reports including frozen sections, preoperative cytology, and operative notes were reviewed. Frozen sections were categorized by margin, primary pancreatic diagnosis, metastasis, or vascular resectability. The deferral and error rates and surgeons' response were noted. Results.— We identified 898 planned pancreatic resections and 221 frozen sections that were performed on 152 cases for 102 margins, 94 metastatic lesions, 20 primary diagnoses, and 5 to confirm vascular resectability. The diagnosis was deferred to permanent sections in 13 of 152 cases (8.6%) on 16 of 221 frozen sections (7.2%): 6 for metastasis, 8 for margins, and 2 for primary diagnosis. Discrepancies/errors were identified in 4 of 152 cases (2.6%) and 4 of 221 frozen sections (1.8%). Surgeon's response was different than expected in 8 of 221 frozen sections (3.6%), but their actions were explained by other intraoperative findings in 6 of 8. Conclusions.— Frozen section remains an important diagnostic tool used primarily for evaluation of margins and metastasis during pancreatectomy. In most cases, a definitive diagnosis is rendered, with occasional deferrals and few errors. Intraoperative findings explain most cases where surgeons act differently than expected based on frozen section diagnosis.

Sarcopenia as a predictor of postoperative complications in patients with pancreatic cancer

Several studies showed that sarcopenia is associated with an increase of postoperative complications, with worse postoperative results in patients with pancreatic cancer. According to European Working Group on Sarcopenia, it is a "progressive and generalized skeletal muscle loss" characterized by both loss of skeletal muscle mass and strength (Cruz-Jentoft AJ et al., 2019). Aim of our work was to evaluate the effect of sarcopenia on the occurrence of postoperative complications after pancreatic resections in patients with pancreatic and periampullary cancer. We performed a retrospective analysis of treatment of 152 patients who underwent radical pancreatic resections. Sarcopenia was determined by preoperative computed tomography using the Hounsfield Unit Average Calculation (HUAC). In our investigation we measured the psoas area and density (Hounsfield Units) at the level of the third lumbar vertebral body (L3). Sarcopenia was diagnosed in 66 (43.4%) patients. Among patients with sarcopenia complications occurred in 41 (62.1%), mortality was 4 (6.1%). In the group of patients without sarcopenia, complications occurred in 29 (33.7%) of 86 patients, mortality was 2 (2.3%). The level of postoperative complications in patients with sarcopenia was significantly higher (c2 =12.1, p=0.0005). Postoperative mortality in patients with sarcopenia was higher without significant difference (c2 =1.3, p=0.24). Sarcopenia significantly affects the level of postoperative complications and its detection can be used to improve the selection of patients before pancreatic resections in patients with pancreatic cancer.

Improvement in distal pancreatectomy for tumors in the body and tail of the pancreas

Background Pancreatic resections are complex and technically challenging surgical procedures. They often come with potential limitations to high-volume centers. Distal pancreatectomy is a relatively simple procedure in most cases. It facilitates the development of up-to-date minimally invasive surgical procedures in pancreatic surgery including laparoscopic distal pancreatectomy and robot-assisted distal pancreatectomy. Main body To obtain a desirable long-term prognosis, R0 resection and adequate lymphadenectomy are crucial to the surgical management of pancreatic cancer, and they demand standard procedure and multi-visceral resection if necessary. With respect to combined organ resection, progress has been made in evaluating and determining when and how to preserve the spleen. The postoperative pancreatic fistula, however, remains the most significant complication of distal pancreatectomy, with a rather high incidence. In addition, a safe closure of the pancreatic remnant persists as an area of concern. Therefore, much efforts that focus on the management of the pancreatic stump have been made to mitigate morbidity. Conclusion This review summarized the historical development of the techniques for pancreatic resections in recent years and describes the progress. The review eventually looked into the controversies regarding distal pancreatectomy for tumors in the body and tail of the pancreas.