Search Results (69)

Background: Spleen-preserving (SP) distal pancreatectomy (DP) with splenic vessel resection (SVR) (Warsaw procedure, WP) is an option for the treatment of tumors with low malignant potential. The reverse blood flow through the short gastric arteries (SGA) explains the preservation of the spleen after SVR, but leaves the source of the blood supply to the SGAs hidden. The types of blood supply to the spleen after WP and their incidence have not been previously described, nor has the significance of these types for locally advanced pancreatic head cancer (LAPHC) surgery been determined. Aim: To determine the main types of spleen blood supply after WP, and to assess the feasibility and safety of splenic artery (SA) rotation for the organ-preserving surgery of LAPHC. Methods: Retrospective analyses of demographic and perioperative data, including CT scans, overall (OS) and progression-free (PFS) survival after 71 SP DP SVR and 41 SP SVR pancreaticoduodenectomies (PD) and total pancreatectomies (TP) for LAPHC (2007–2025). Results: In 134 SP procedures, SA was resected in 115 cases (71DP, 9 TP, 3 central, and 32 PD). Indications for surgery were MCN (41), IPMN (14), CSA (3), NEN (25), SPPN (8), PHDAC (40), sarcoma (1), autoimmune (1), and calculous chronic pancreatitis (1). There were no deaths or ischemia-related splenectomies. Morbidity—31% (n23); Dindo–Clavien (D-C) > 3b-2.8%; POPF-grade B-n7 (10.6%); splenic infarctions on CT after SVR-n18 (23%), one symptomatic. CT revealed three types of arterial blood supply to the spleen after SPDP SVR: left gastric artery (LGA) type (n50, 70, 5%), gastro-epyploic arcade (GEA) type (n9, 12, 5%), and an intermediate type (n12, 17%). Spleen- and pancreas tail-preserving SVR pancreatectomies for LAPHC (n41) were accompanied by rotation of the SA to substitute resected SMA (n19) and CHA (n15) for 26 Whipples and 8TPs. There were no ischemic complications. D-C > 3–19.5%. Median OS and PFS for PDAC were 35 and 21 months for 29.5 months median follow-up. Conclusions: Despite the preservation of blood flow through all potential sources of splenic blood supply following resection of the splenic artery, the main collaterals supplying the spleen after WP are LGA branches (~90%). This knowledge, with strict adherence to the developed criteria, allows for the safe preservation of the spleen, pancreatic tail, and stomach during pancreatectomies with SA resection, including its rotation for the substitution of the SMA and CHA in LAPHC. Full article

Background: This study investigates textbook oncologic outcomes (TOO), a measurement operationally defined to produce a holistic measure of surgical success, with respect to patients diagnosed with pancreatic adenocarcinoma undergoing distal (left) pancreatectomy for pancreatic adenocarcinoma. This study aims to identify factors associated with achieving TOO, emphasizing the role of hospital type. Methods: The NCDB (2010–2022) was queried for patients with clinical stage I–III pancreatic adenocarcinoma. Inclusion criteria consisted of patients > 18 who underwent curative partial or total pancreatectomy. The primary outcome was the achievement of TOO—operationally defined as R0 resection, ≥12 lymph nodes examined, no prolonged hospital stay, absence of 30-day mortality, and no readmissions. Logistic regression analyses were conducted to identify predictors of TOO. Results: Analysis of 11,194 patients showed that 38.9% achieved TOO. Achievement of TOO was associated with a median increase in one year in overall survival. Factors associated with TOO achievements in the adjusted model include female sex, private insurance, a lower Charlson/Deyo score, minimally invasive surgery (MIS), and high-volume centers. Notably, MIS emerged as a significant factor associated with 26% higher TOO (OR 1.26, 95% CI: 1.14–1.40) while treatment at high-volume hospitals was associated with 28–112% increased TOO (OR 1.28, 95% CI: 1.08–1.54 for Q3 volume and OR 2.12, 95% CI: 1.76–2.55 for Q4 volume). Conclusions: Achieving TOO is significantly influenced by patient demographics, clinical characteristics, and notably, the case volume of the treatment facility. These findings underscore the importance of considering centers experienced in surgical planning and patient counseling to optimize outcomes in distal pancreatectomies. Full article

Background and Clinical Significance: Hepatic encephalopathy (HE) is a reversible brain dysfunction typically associated with cirrhosis and portal hypertension. In these patients, portosystemic shunts allow ammonia and other toxins to bypass hepatic metabolism, leading to neurological symptoms. However, HE can also occur in non-cirrhotic patients through congenital shunts or, less commonly, through iatrogenic shunts following abdominal trauma or surgery. This case is clinically significant as it illustrates a rare presentation of recurrent HE caused by a de novo portosystemic shunt following major abdominal surgery in a patient without underlying liver disease. Case Presentation: A 76-year-old male was admitted with confusion, lethargy, and flapping tremors. His medical history included a total pancreatectomy for pancreatic adenocarcinoma six months prior. Laboratory tests revealed hyperammonemia and altered liver enzymes likely related to ongoing chemotherapy, but no signs of hepatic insufficiency or cirrhosis. A review of recent CT imaging identified a new portosystemic shunt between the portal territory and the azygous vein that was absent prior to his pancreatectomy. This iatrogenic shunt likely formed via the re-vascularization of vestigial vessels following surgical de-vascularization. The patient was successfully managed with lactulose and rifaximin. At 3-month follow-up, no further HE episodes had occurred. Conclusions: This case highlights that HE should be considered in patients without cirrhosis presenting with altered mental status and hyperammonemia, especially following abdominal surgery. It underscores the importance of a multidisciplinary approach and meticulous re-evaluation of imaging to identify iatrogenic vascular shunts that may be amenable to medical or interventional management. Full article

Background/Objectives: Fully robotic pancreatic resections using the Hugo™ RAS platform have not yet been described in the literature. Methods: A 72-year-old male with a cystic lesion in the pancreatic tail underwent a fully robotic distal pancreatectomy and splenectomy using the Hugo RAS platform and the newly introduced robotic vessel sealer LigaSure RAS. The proposed configurational setup and technical details are described. Results: The procedure was completed safely without complications: blood loss was <50 mL, total duration of surgery was 305 min, and console time was 195 min. The postoperative period was uneventful, and the patient was discharged on postoperative day 7. Conclusions: Distal pancreatectomy with the Hugo RAS platform may be feasible and safe in selected cases. Full article

Intraoperative assessment of pancreatic quality, followed by sampling for the potential isolation of Langerhans islets for subsequent autotransplantation, is currently a key component of post-total pancreatectomy diabetes mellitus treatment. The aim of this study was to quantitatively evaluate pancreatic parenchymal stiffness using optical coherence elastography (OCE) imaging, and to investigate the utility of the OCE method as a potential indicator of islet yield after pancreatectomy. A total of 41 freshly excised human pancreatic specimens, containing pancreatic ductal adenocarcinoma (PDAC) and surrounding non-tumorous tissues post-pancreatectomy, were studied. In this research, the stiffness (Young’s modulus, kPa) and its color-coded 2D distribution were calculated for various pancreatic samples using compression OCE. Stiffness values were compared between intact pancreatic parenchyma (islet-poor and islet-rich) and pancreatic lesion groups (parenchymal fibrosis and/or PDAC invasion). The data were confirmed by histological analysis. In addition, the measured stiffness values for various morphological groups of the pancreatic samples were compared with the number of isolated islets obtained from pancreatic samples after collagenase treatment. The study demonstrated that OCE can effectively distinguish areas of pancreatic lesions and identify intact pancreatic parenchyma containing Langerhans islets. A highly significant increase in mean stiffness (p < 0.0001) was observed in postoperative pancreatic samples exhibiting signs of parenchymal fibrosis or PDAC invasion compared to unaffected, intact pancreatic parenchyma. For the first time, a relationship between stiffness values and the number of isolated pancreatic islets was demonstrated; in particular, the number of isolated islets significantly decreased (≤110 pcs/g) in samples exhibiting stiffness values above 150 kPa and below 75 kPa. The optimal stiffness range for the efficient isolation of islets (≥120 pcs/g) from pancreatic tissue was identified as 75–150 kPa. The study introduces a novel approach for rapid and objective intraoperative assessment of pancreatic tissue quality using real-time OCE data. This technique facilitates the identification of regions affected by pancreatic lesions and supports the selection of intact pancreatic parenchyma, potentially enhancing the accuracy of Langerhans islet yield predictions during surgical resection. Full article

Background/Objectives: Accurate volumetry of the remnant pancreas after pancreatectomy is crucial for assessing postoperative endocrine and exocrine function but remains challenging due to anatomical variability and complex postoperative morphology. This study aimed to develop and validate a deep learning (DL)-based model for automatic segmentation and volumetry of the remnant pancreas using abdominal CT images. Methods: A total of 1067 CT scans from 341 patients who underwent pancreaticoduodenectomy and 512 scans from 184 patients who underwent distal pancreatectomy were analyzed. Ground truth masks were manually delineated and verified through multi-expert consensus. Six 3D segmentation models were trained and compared, including four convolution-based U-Net variants (basic, dense, residual, and residual dense) and two transformer-based models (Trans U-Net and Swin U-Net). Model performance was evaluated using five-fold cross-validation with sensitivity, specificity, precision, accuracy, and Dice similarity coefficient. Results: The Residual Dense U-Net achieved the best performance among convolutional models, with dice similarity coefficient (DSC) values of 0.7655 ± 0.0052 for pancreaticoduodenectomy and 0.8086 ± 0.0091 for distal pancreatectomy. Transformer-based models showed slightly higher DSCs (Swin U-Net: 0.7787 ± 0.0062 and 0.8132 ± 0.0101), with statistically significant but numerically small improvements (p < 0.01). Conclusions: The proposed DL-based approach enables accurate and reproducible postoperative pancreas segmentation and volumetry. Automated volumetric assessment may support objective evaluation of remnant pancreatic function and provide a foundation for predictive modeling in long-term clinical management after pancreatectomy. Full article

Background: Surgical procedures and alterations of the gastrointestinal (GI) tract increase the risk of small intestinal bacterial overgrowth (SIBO), which is associated with GI symptoms and complications that compromise postoperative recovery. However, the prevalence and clinical impact of SIBO after various upper GI surgical procedures remain poorly understood. Objective: This study aimed to evaluate the prevalence of SIBO after different types of upper GI surgery and to investigate the associated clinical factors. Methods: We conducted an observational study involving 157 patients with a history of upper GI surgery: Roux-en-Y gastric bypass (RYGB), laparoscopic single-anastomosis gastric bypass (OAGB), subtotal (STG) or total gastrectomy (TG), subtotal (SP)or total pancreatectomy (TP), cephalic duodenopancreatectomy (WR), and small bowel resection for Crohn’s disease. A glucose–hydrogen breath test was performed, and demographic, clinical, and treatment-related data were collected. Statistical analyses included t-tests, non-parametric tests, ANOVA, and correlation analyses using R software. Results: At a median follow-up of 25.7 ± 18.1 months, 31% (48/157) of patients tested positive for SIBO. The highest prevalence was observed after RYGB and OAGB (43%), followed by TG (30%), STG (29%), TP/WR (28%), and Crohn’s disease bowel resection (19%). No cases of SIBO were observed after SP. SIBO positivity was significantly associated with bloating and flatulence (p = 0.002), lactose intolerance (p = 0.047), systemic sclerosis (p = 0.042), T2D (p = 0.002), and exposure to adjuvant chemotherapy (p = 0.001) and radiotherapy (p = 0.027). In addition, the risk of SIBO increased proportionally with the duration of GI resection or exclusion (p = 0.013). Conclusions: In our study, the prevalence of SIBO after upper GI surgery was 31%, with the highest incidence (43%) observed in metabolic surgery patients. Importantly, adjuvant radio/chemotherapy was associated with an increased risk of SIBO, and extensive small bowel resection or exclusion was strongly associated with an increased risk of SIBO. Furthermore, the limitations of current diagnostic methods, which lack sufficient sensitivity and specificity, highlight the importance of early screening and standardization of diagnostic techniques to improve patient management and outcomes. Full article

Introduction: After total pancreatectomy, patients inevitably develop pancreatogenic diabetes with marked glycemic variability and high risk of malnutrition due to both endocrine and exocrine insufficiency. Weight loss and malnutrition can occur even in those with adequate dietary intake and plausible pancreatic enzyme replacement. We hypothesized that glycemic variability is associated with nutritional decline. Methods: We retrospectively analyzed 14 patients who underwent continuous glucose monitoring (CGM) after total pancreatectomy. Nutritional status was assessed using the Geriatric Nutritional Risk Index (GNRI), and patients were classified into malnutrition-risk progression or nutrition-maintaining groups. Then, we evaluated glycemic indices, dietary intake, anthropometry, and pancreatic enzyme replacement therapy (PERT). Results: Insulin use, PERT dose, and dietary intake were approximately comparable between groups. In contrast, the malnutrition-risk progression group showed significantly higher mean glucose and time above range, and lower time in range (TIR). Importantly, TIR consistently showed an inverse association with malnutrition-risk progression across models adjusted for clinical covariates, including time since pancreatectomy, primary diagnosis, insulin regimen, and pancrelipase dose. These findings indicate that the observed relationship between lower TIR and worsening GNRI was independent of dietary intake and adequacy of enzyme replacement therapy, underscoring TIR as a clinically meaningful indicator of nutritional decline in this population. Conclusions: Hyperglycemia and reduced TIR were significantly associated with worsening GNRI after total pancreatectomy, independent of dietary intake or PERT. CGM-based glycemic metrics may help identify patients at risk of malnutrition and guide postoperative management. Full article

Background and Objectives: Preoperative biliary drainage (PBD) in patients with periampullary neoplasms remains a debated topic, with various techniques available and conflicting evidence regarding their impact on postoperative outcomes. This study aimed to assess, in a high-volume pancreatic surgery center, whether the choice among endoscopic, surgical, or no preoperative biliary drainage influences postprocedural and postoperative complication rates. Materials and Methods: A retrospective cohort study was conducted at the Surgical Department of the “Octavian Fodor” Regional Institute of Gastroenterology and Hepatology in Cluj-Napoca, Romania, between January 2017 and May 2023. A total of 655 patients undergoing pancreaticoduodenectomy or total pancreatectomy for resectable periampullary tumors were divided into three groups: no PBD, endoscopic PBD, and surgical PBD. Clinical, procedural, and postoperative variables were collected and statistically analyzed. Results: Endoscopic drainage was associated with a significantly higher rate of postoperative intra-abdominal abscesses, postoperative pancreatic fistula (POPF), and pancreaticojejunostomy fistula compared to surgical drainage and no PBD. Patients in the endoscopic group also exhibited significantly higher rates of positive bile cultures, particularly with pluribacterial populations. Procedure-related complications, such as pancreatitis and cholangitis, were significantly lower in the surgical drainage group. No significant differences were found among groups regarding postoperative hospital stay, relaparotomy rates, or 90-day mortality. Conclusions: Surgical biliary drainage was associated with lower perioperative morbidity compared to endoscopic drainage. While endoscopic drainage remains the most commonly used approach, surgical drainage may offer a safer alternative in selected patients. Prospective randomized controlled trials are warranted to validate these findings. Full article

Background/Objectives: Like many other countries, the management of pancreatic cancer in Spain has developed in a fragmented manner. This study analyzes clinical outcomes related to patient volume at different centers after left pancreatectomy (LP). Our goal is to determine whether our practices align with the standards established in the literature and assess whether centralization’s advantages significantly outweigh its disadvantages. Methods: The SPANDISPAN Project (SPANish DIStal PANcreatectomy) is an observational, prospective, multicenter study focused on LP conducted in Spanish Hepato-Pancreato-Biliary (HPB) Surgery Units from 1 February 2022 to 31 January 2023. HPB units were defined as high volume if they performed more than 10 LPs annually. Results: This study included 313 patients who underwent LP at 42 centers across Spain over the course of a year. A total of 40.3% of the procedures were performed in high-volume centers. Significant differences in preoperative variables were only observed in ASA scores, which were higher in the high-volume group. Intraoperatively, minimally invasive surgical techniques were performed more frequently in high-volume centers. Postoperatively, the administration of somatostatin, major complications, and B and C postoperative pancreatic fistula (POPF) were more frequent in low-volume hospitals. Conclusions: The findings revealed that high-volume centers had a higher rate of minimally invasive surgery, lower intraoperative bleeding, fewer complications, and reduced POPFs compared to low-volume centers. However, it is important to note that low-volume centers still demonstrated acceptable outcomes. Thus, the selective referral of more complex laparoscopic procedures could initiate a gradual centralization of surgical practices. Full article

Background/Objectives: The impact of surgical resection for chronic pancreatitis on subsequent endocrine outcomes remains unclear. Methods: A single-center analysis of patients with chronic pancreatitis who underwent either a parenchymal-preserving surgery (PPS) or a total pancreatectomy (TP) with/without islet autotransplantation (IAT) between 2018 and 2024 was performed. Preoperative and postoperative changes in hemoglobin A1C (HbA1C) and long-acting insulin dose were compared. Univariate and multivariate analysis was performed to identify factors associated with 1-year insulin independence. Results: A total of 104 patients underwent surgery for chronic pancreatitis between 2018 and 2024. A total of 35 (33.7%) patients underwent TPIAT, 8 (7.7%) underwent TP, and 61 (58.7%) underwent PPS (n = 18 Whipple, n = 38 distal pancreatectomy, n = 5 drainage procedure). Median HbA1C increased after surgery (5.7% vs. 6.8%, p < 0.001). The majority of patients (n = 73, 70.2%) were discharged postoperatively without any basal insulin requirement. Of the 31 patients discharged on basal insulin, 18 patients (58.1%) were not on basal insulin preoperatively; the other 13 patients (41.9%) that were on basal insulin preoperatively had a median change in their postoperative basal insulin dose of −5 units [IQR: −12–−1]. A total of 46 patients (52.3%) were insulin independent at one year, with PPS more favorable than TPIAT (47.6% vs. 21.7%, p < 0.001) and less likely to have been on preoperative basal insulin. Conclusions: Surgery for chronic pancreatitis resulted in an increase in HbA1C postoperatively; however, diabetes remained well-controlled as the majority of patients remained off basal insulin at one year from surgery. PPS patients were more likely to be insulin-independent. Full article

Background: There is evidence that pancreatic cancer arises from different pre-malignant conditions, which can take decades to transform to invasive cancers. Some individuals can benefit from surveillance and early access to surgery. Patients that have disease that is detected whilst it is resectable may have the disease cured by total or partial pancreatectomy. It is already known that pancreatic cancer, whether advanced or localised, causes impairment in quality of life, and survivors of surgery can have quality of life impaired by recognised and predictable pancreatic deficiencies. Methods: A literature review of key themes affecting quality of life in pancreatic cancer are presented here. Results: The biological features of the precursors of pancreatic cancer are described, with the rationale for surveillance and effects of surgical management in different conditions. Conclusions: Surgery for pancreatic cancer carries the potential for high impact on quality of life after survivorship after initial surgical intervention. Identification of issues that affect patients are discussed with the aim of improving the quality of care for patients. Full article

Background/Objectives: Treatment of borderline resectable (BRPC) and locally advanced (LAPC) pancreatic cancer involves neoadjuvant chemotherapy followed by complex surgery, posing significant risks of toxicity, complications, and changes in quality of life (QoL). This study aims to investigate the impact of neoadjuvant chemotherapy followed by resection on overall survival (OS) and QoL. Methods: Consecutive patients with BRPC and LAPC included in a population-based study (NORPACT-2) from January 2018 to December 2020 were reviewed. Results: A total of 54 patients (BRPC; n = 43, LAPC; n = 11) underwent neoadjuvant chemotherapy followed by pancreatectomy. The majority (66.7%) received (m)FOLFIRINOX. Forty-six (85.2%) patients underwent pancreatoduodenectomy. Vascular resection was performed in 32 (59.3%) patients. Fourteen (25.9%) patients experienced major complications. The majority of the resected specimens demonstrated T2 (63%), N+ (79.6%), and R1 (85.2%) status. Median OS was 31 (CI 24.7–37.3) months. In multivariate analysis, only CAP 3 (p = 0.035) predicted worse survival. Forty (74.1%) patients experienced recurrence. Global QoL (p = 0.031), social and role functioning (p = 0.024, p = 0.031), improved three months after surgery. Pain (p = 0.042), dyspnea (p = 0.004), appetite loss (p = 0.028), and diarrhea (p = 0.007) improved post-resection. Conclusions: Patients with BRPC and LAPC undergoing neoadjuvant chemotherapy and resection have survival comparable to primary resectable pancreatic cancer. Postoperative morbidity was acceptable, and QoL recovered post-surgery. CAP grade was the only independent negative prognostic factor. Full article

Background: Pancreatic ductal adenocarcinoma (PDAC) is the most common pancreatic malignancy and is characterized by a very unfavorable prognosis. Rarely, patients may develop synchronous PDAC and another distinct primary pancreatic tumor, such as a pancreatic neuroendocrine tumor. This systematic review consolidates published case reports describing the presentation, imaging characteristics, management, and outcomes of patients with synchronous PDAC and other pancreatic malignancies. Methods: A comprehensive search of PubMed and Scopus identified 26 relevant case reports, with inclusion criteria focused on histologically confirmed synchronous pancreatic tumors and exclusion of metastatic disease. Results: The majority of patients present with two pancreatic lesions, often located in both the body and tail of the pancreas. Diagnostic imaging modalities, such as computed tomography and endoscopic ultrasound, reveal common findings. Tumor markers, particularly CA 19-9, are often elevated and aid in the diagnosis. Surgical approaches also vary according to tumor location and staging, with procedures ranging from Whipple surgery to total pancreatectomy. Chemotherapy is frequently employed postoperatively. Notably, lymph node involvement and larger tumor size are associated with poorer prognoses. Conclusions: In conclusion, these patients may present with a common or non-common clinical picture as well as laboratory and imaging findings, constituting an important and unique diagnostic and therapeutic challenge. Full article

India’s population complexity presents varied challenges in genetic research, and while facilities have gained traction in tier-1 and -2 cities, reliance on international collaborations often delays such investigations. COVID-19 further exacerbated the issues with such sample sharing. Congenital Hyperinsulinism (CHI) is a rare genetic disorder of pancreatic β-cells causing hypoglycaemia in children due to abnormal insulin secretion. Given India’s high birth rate and consanguineous populations, annual CHI cases are estimated to be around up to 10,000, with up to 50% having unexplained genetic causes. Diffuse or atypical lesions in such patients often necessitate near-total-pancreatectomy, risking pancreatic exocrine insufficiency and diabetes, requiring lifelong therapy. Also, novel genetic variations complicate accurate diagnosis, risk assessment, and counselling, emphasising the need for rapid genetic assessment to prevent neurological injuries and inform treatment decisions. Despite significant efforts at many institutes, there are no dedicated organisations for CHI in India. With the implementation of the National Policy for Rare Diseases 2021, we plan to form a non-profit organisation, “Congenital Hyperinsulinism India Association (CHIA)”, comprising paediatric endocrinologists, paediatricians, geneticists, and independent researchers. The aims of this association are to generate a national database registry of patients, formulate a parent support group and CHIA consortium, design patient information leaflets, as well as foster genomic collaborations and promote clinical trials. Such steps will help sensitise the health authorities and policy makers, urging them to improve the allocation of health budgets for rare diseases, as well as empower patients and their families, contributing towards a better quality of life. Full article