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A triple-row stapler is widely used to divide the pancreas in distal pancreatectomy (DP). However, the selection criteria of the stapler cartridge to prevent postoperative pancreatic fistula (POPF) remain unclear. The objective of this study was to determine if factors concerning pancreatic thickness or staple size affect POPF after DP.Datasets of patients from the Mayo Clinic and National Cancer Center Hospital East who underwent DP using a triple-row stapler were merged. Risk of POPF was analyzed using clinicopathological variables, including data for pancreatic thickness and staple height. A compression index was defined as the designated staple height (mm) after closure divided by the pancreatic thickness (mm).Among the 277 patients, POPF occurred in 65 (23%) patients. The median pancreatic thickness was 13.7 mm and the median compression index was 0.137. Multivariable logistic models showed that a greater pancreatic thickness (odds ratio, 1.190, P 0.001) and a compression index ≤0.160 (odds ratio, 4.754, P 0.001) were independently related with POPF.In patients undergoing DP using a triple-row stapler, the thickness of the pancreas was related with the occurrence of POPF. Selection of the stapler cartridge with a compression index of ≤0.160 may reduce the occurrence of POPF.

Intrahepatic lesions of mixed hepatocellular (HCC) and intrahepatic cholangiocellular carcinoma (ICC) histology are rare. The aim was to describe the natural history of these tumors relative to monomorphic ICC or HCC utilizing the National Cancer Data Base (NCDB).Patients with ICC, HCC, and mixed histology (cHCC-CCA) were identified in the NCDB (2004-2012). Inter-group comparisons were made. Kaplan-Meier and multivariable Cox Proportional Hazards analyzed overall survival.The query identified 90,499 patients with HCC; 14,463 with ICC; and 1141 with cHCC-CCA histology. Patients with cHCC-CCA histology were relatively young (61 vs. 62 (HCC, p = 0.877) and 67 (ICC, p 0.001) years) and more likely to have poorly differentiated tumor (29.2% vs. 10.3% (HCC) and 17.2% (ICC) p 0.001). Median overall survival for cHCC-CCA was 7.9 months vs. 10.8 (HCC) and 8.2 (ICC, all p 0.001). Stage-specific survival for mixed histology tumors was most similar to that of HCC for all stages. cHCC-CCA were transplanted at a relatively high rate, and transplant outcomes for mixed tumors were substantially worse than for HCC lesions.cHCC-CCA demonstrate stage-specific survival similar to HCC, but post-surgical survival more consistent with ICC. Patients with a pre-operative diagnosis of cHCC-CCA should undergo resection when appropriate.

BackgroundElderly patients undergoing open pancreatoduodenectomy (OPD) are at increased risk for surgical morbidity and mortality. Whether totally laparoscopic pancreatoduodenectomy (TLPD) mitigates these risks has not been evaluated.MethodsA retrospective review of outcomes in patients submitted to pancreatoduodenectomy during 2007–2014 was conducted (n = 860). Outcomes in elderly patients (aged ≥70 years) were compared with those in non elderly patients with respect to risk adjusted postoperative morbidity and mortality. Differences in outcomes between patients submitted to OPD and TLPD, respectively, were evaluated in the elderly subgroup.ResultsIn elderly patients, the incidences of cardiac events (odds ratio [OR] 3.21, P

Background A delayed post pancreatoduodenectomy haemorrhage is associated with a significant increase in peri operative mortality. Endovascular techniques are frequently used for a delayed haemorrhage. However, limited data exists on the short and long term outcomes of this approach. A retrospective review over a 10 year period at a quaternary referral pancreatic centre was performed. Methods Between 2002–2012, 1430 pancreatoduodenectomies were performed, and 32 patients had a delayed haemorrhage (occurring >24 h post operatively) managed by endovascular techniques. The clinicopathological variables related to a haemorrhage were investigated. Results A total of 42 endovascular procedures were performed at a median of 25 days, with the majority of delayed haemorrhages occurring after 7 days. There were four deaths (13%) with three occurring in patients with a grade C haemorrhage. Seven patients (22%) experienced rebleeding, and two patients developed hepatic abscesses. Conclusion A delayed haemorrhage post pancreaticoduodenectomy can be managed by endovascular techniques with acceptable morbidity and mortality. Rebleeding and hepatic abscesses may occur and can be managed non operatively in most cases. The association of a delayed haemorrhage with a pancreatic fistula makes this a challenging clinical problem.

BackgroundThe 7th edition of the American Joint Committee on Cancer (AJCC) staging system has recently been validated and shown to predict survival in patients with intrahepatic cholangiocarcinoma (ICC). The present study attempted to investigate the validity of these findings.MethodsA single‐centre, retrospective cohort study was conducted. Histopathological restaging of disease subsequent to primary surgical resection was carried out in all consecutive ICC patients. Overall survival was compared using Kaplan–Meier estimates and log‐rank tests.ResultsA total of 150 patients underwent surgery, 126 (84%) of whom met the present study's inclusion criteria. Of these 126 patients, 68 (54%) were female. The median length of follow‐up was 4.5 years. The median patient age was 58 years (range: 24–79 years). Median body mass index was 27 kg/m2 (range: 17–46 kg/m2). Staging according to the AJCC 7th edition categorized 33 (26%) patients with stage I disease, 27 (21%) with stage II disease, five (4%) with stage III disease, and 61 (48%) with stage IVa disease. The AJCC 7th edition failed to accurately stratify survival in the current cohort; analysis revealed significantly worse survival in those with microvascular invasion, tumour size of >5 cm, grade 4 disease, multiple tumours and positive lymph nodes (P < 0.001). A negative resection margin was associated with improved survival (P < 0.001).ConclusionsThe AJCC 7th edition did not accurately predict survival in patients with ICC. A multivariable model including tumour size and differentiation in addition to the criteria used in the AJCC 7th edition may offer a more accurate method of predicting survival in patients with ICC.

BackgroundNew‐onset diabetes mellitus after a pancreaticoduodenectomy (PD) remains poorly defined. The aim of this study was to define the incidence and predictive factors of immediate post‐resection diabetes mellitus (iPRDM).MethodsRetrospective review of patients undergoing PD from January 2004 through to July 2010. Immediate post‐resection diabetes mellitus was defined as diabetes requiring pharmacological treatment within 30 days post‐operatively. Logistic regression was conducted to identify factors predictive of iPRDM.ResultsOf 778 patients undergoing PD, 214 were excluded owing to pre‐operative diabetes (n= 192), declined research authorization (n= 14) or death prior to hospital discharge (n= 8); the remaining 564 patients comprised the study population. iPRDM occurred in 22 patients (4%) who were more likely to be male, have pre‐operative glucose intolerance, or an increased creatinine, body mass index (BMI), pre‐operative glucose, operative time, tumour size or specimen length compared with patients without iPRDM (P < 0.05). On multivariate analysis, pre‐operative impaired glucose intolerance (P < 0.001), pre‐operative glucose ≥ 126 (P < 0.001) and specimen length (P= 0.002) were independent predictors of iPRDM. A predictive model using these three factors demonstrated a c‐index of 0.842.DiscussionNew‐onset, post‐resection diabetes occurs in 4% of patients undergoing PD. Factors predictive of iPRDM include pre‐operative glucose intolerance, elevated pre‐operative glucose and increased specimen length. These data are important for patient education and predicting outcomes after PD.

BackgroundPrimary gastrointestinal stromal tumours (GISTs) of the duodenum are rare. The aim of this study was to review the surgical management of GISTs in this anatomically complex region.MethodsRetrospective review from January 1999 to August 2011 of patients with primary GISTs of the duodenum.ResultsForty-one patients underwent resection of duodenal GISTs. All operations were performed with intent to cure with negative margins of resection. The most common location of origin was the second portion of the duodenum. Local excision (n= 19), segmental resection with primary anastomosis (n= 11) and a pancreatoduodenectomy (n= 11) were performed. Two patients underwent an ampullectomy with local excision. Peri-operative mortality and overall morbidity were 0 and 12, respectively. Patients with high-risk GISTs (P= 0.008) and those who underwent a pancreatoduodenectomy (P= 0.021) were at a greater risk for morbidity. The median follow-up was 18 months. Eight patients developed recurrence. High-risk GISTs and neoplasms with ulceration had the greatest risk for recurrence (P= 0.017, P= 0.029 respectively). The actuarial 3- and 5-year survivals were 85% and 74%, respectively.ConclusionThe choice and type of resection depends on the proximity to the ampulla of Vater, involvement of adjacent organs and the ability to obtain negative margins. The morbidity depends on the type of procedure for GIST.

BackgroundAdjuvant treatment for pancreatic adenocarcinoma has been shown to improve survival. An increasingly recognized ‘subtype’ of pancreatic adenocarcinoma is invasive intraductal papillary mucinous neoplasm (IPMN). It is unclear whether adjuvant treatment for invasive IPMN improves survival. This study aimed to determine the impact of adjuvant treatment in invasive IPMN.MethodsWe conducted a retrospective analysis of merged clinical databases including 412 patients undergoing resection for IPMN at two academic institutions between 1989 and 2006.ResultsOf 412 patients with IPMN who underwent pancreatectomy, 98 had invasive carcinoma. Median survival in invasive IPMN was 32months. Adjuvant treatment did not affect median survival in node-positive or node-negative invasive IPMN. Biopsy-proven recurrence of invasive IPMN occurred in 45 patients (46%). The median disease-free interval from resection to recurrence was 27months. Treatment of recurrences with chemotherapy or radiation therapy was not associated with a difference in survival; however, a subgroup of patients with recurrence in the remnant pancreas who underwent re-resection appeared to have more favourable outcomes.ConclusionsAn invasive component measuring >2cm and lymph node involvement are associated with poorer prognosis. Adjuvant therapy in invasive IPMN appears to confer no survival benefit. In selected patients with recurrence of invasive IPMN in the remnant pancreas, re-resection should be considered.

Objective. Distinguishing between malignant and benign biliary strictures remains problematic. The aim of this study was to compare and contrast the clinical features of patients with benign and malignant biliary strictures. Methods. Medical records of patients who underwent surgical resection for presumed cholangiocarcinoma were reviewed. Immunohistochemistry for hypoxia inducible factor-1-alpha (HIF-1-alpha) was performed on all bile ductule samples. Results. Twelve patients with benign strictures (group I) were compared to 26 patients with cholangiocarcinoma (group II). Group I was predominantly female (ratio 2: 1), (p100 U/ml in 1 patient of group I and 100 in 11 patients in group II. Half of the patients in group I had positive immunoreactivity for HIF-1-alpha in bile ductules. Conclusion. Benign biliary strictures masquerading as cholangiocarcinomas occur more often in women, are less often Bismuth-Corlette type III, have serum CA 19-9 values

Background Despite increasing numbers of reports, biliary tract intraductal papillary mucinous neoplasm (BT-IPMN) is not yet recognized as a unique neoplasm. The aim of the present study was to define the presence of BT-IPMN in a large series of resected biliary neoplasms. Methods From May 1994 to December 2006, BT-IPMN cases were identified by reviewing pathology specimens of all resected cholangiocarcinomas and other biliary neoplasms when cystic, papillary or mucinous features were cited in pathology reports. Results BT-IPMN was identified in 23 out of 253 (9%) specimens using the strict histopathological criteria of IPMN. The most common presenting symptom was abdominal discomfort which was present in 15 patients (65%). Only one of the original operative pathology reports used the term IPMN; 16 (70%) used the terms cystic, mucinous and/or papillary. BT-IPMN was isolated to non-hilar extra-hepatic ducts in 12 (52%), intra-hepatic ducts in 6 (26%) and hilar extra-hepatic ducts in 5 patients (22%). Carcinoma was found in association with BT-IPMN in 19 patients (83%); 5-year survival was 38% after resection. Conclusion BT-IPMN occurs throughout the intra- and extra-hepatic biliary system and can be identified readily as a unique neoplasm. Broader acceptance of BT-IPMN as a unique neoplasm may lead to a better understanding of the pathogenesis of biliary malignancies.

BackgroundStudies of pancreaticoduodenectomy (PD) frequently overlook diagnosis as a variable when evaluating postoperative outcomes or generically group patients according to whether they have ‘benign’ or ‘malignant’ disease. Large multicentre studies comparing postoperative outcomes in PD stratified by diagnosis are lacking. The present study was conducted to verify the hypothesis that postoperative morbidity and length of stay (LoS) following PD vary by diagnosis and that patients may be grouped into low- and high-risk categories.MethodsThe database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was reviewed for all PDs performed during 2005–2011. Diagnoses were identified using ICD-9 codes and grouped based on the incidence of major morbidity. Univariate and multivariate analyses were utilized to assess the impact of diagnosis on PD outcomes.ResultsOf 5537 patients, those with pancreas cancer (n = 3173) and chronic pancreatitis (n = 485) experienced similar incidences of major morbidity (P = 0.95) and were grouped as having low-risk diagnoses. Patients with bile duct and ampullary (n = 1181), duodenal (n = 558) and neuroendocrine (n = 140) disease experienced similar levels of major morbidity (P = 0.78) and were grouped as having high-risk diagnoses. A high-risk diagnosis was identified as an independent risk factor for a prolonged LoS [odds ratio (OR) 1.67], organ space infection (OR 2.57), sepsis or septic shock (OR 1.83), and major morbidity (OR 1.70). Diagnosis did not predict readmission.ConclusionsThe high-risk diagnosis is independently associated with postoperative morbidity and prolonged LoS. Patients with PD should be stratified by diagnosis to more accurately reflect their risk for postoperative complications and the complexity of care they will require.

Historically, total pancreatectomy was reserved as a last resort for patients in whom all other options for managing intractable pain caused by chronic pancreatitis had been exhausted. Typically, completion pancreatectomy was employed in patients in whom either a drainage procedure or a pancreatic resection had failed. Islet autotransplantation has made total pancreatectomy a more attractive primary surgical option because it both preserves endogenous insulin production and removes all of the chronically inflamed and fibrosed pancreatic parenchyma. Moreover, although it does not necessarily prevent any future need for exogenous insulin, the diabetic state that results is less ‘brittle’. Billings et al.1 reported that quality of life following total pancreatectomy with longterm follow-up is decreased compared with that in age- and gender-matched controls, and noted a 3% mortality rate from hypoglycaemia. Islet autotransplantation helps to avoid the dangerous problem of hypoglycaemia unawareness experienced by many patients who undergo total pancreatectomy without it. The durability of islet autotransplantation following total pancreatectomy has been previously reported.2–4 In August's issue, Morgan et al.5 presented 36 patients who underwent total pancreatectomy and islet autotransplantation over a 15-month period. Although follow-up was limited, the main thrust of the authors was that the mode of islet autotransplantation has implications with regard to the overall cost of the procedure. Three techniques have been used to infuse islets into the portal circulation following the obligate delay (approximately 4 h) from harvesting to the completion of islet processing: (i) maintaining the patient under general anaesthesia, with the abdomen open, until the processed islets are returned to the operating room (OR) for infusion into the portal circulation; (ii) postoperative percutaneous transhepatic infusion utilizing interventional radiologic techniques (the procedure used in the present report5), and (iii) operative placement of a catheter in the portal circulation via a colic vein or the recanalized umbilical vein, as reported by Ong et al.,6 with autologous islet infusion conducted via the catheter in a monitored setting (intensive care unit) postoperatively. They report an estimated saving per patient of approximately US$20 000 in decreased OR time, and an opportunity cost-saving of US$12 871 represented by the additional surgeon productivity engendered by more efficient use of the OR and surgeon availability. The authors conclude that postoperative percutaneous transhepatic islet autotransplantation is safe and more cost-effective than the more common procedure of maintaining the patient under anaesthesia in the OR until the islets are available for infusion.5 These conclusions are valid based upon the data presented. At our institution early in our experience with islet autotransplantation, we elected to use postoperative percutaneous transhepatic infusion using interventional radiology expertise. However, of late we have settled on an approach which we believe is safe, effective and more cost-efficient than either intraoperative or percutaneous transhepatic infusion. More recently, we have utilized intraoperative catheter placement into the portal vein via either a colic vein branch or the recanalized umbilical vein. This method of securing the mesocolon or the round ligament to the undersurface of the abdominal wall and bringing the catheter out percutaneously allows the catheter to be removed from the low-pressure portal venous system after islet infusion without the need for an additional surgical procedure. Total pancreatectomy and islet autotransplantation will be offered increasingly to patients with chronic pancreatitis and intractable pain in whom medical and interventional endoscopic management have failed. Although Morgan et al.5 have shown that postoperative percutaneous transhepatic islet autotransplantation after total pancreatectomy for chronic pancreatitis is safe and more cost-effective than intraoperative infusion, all three methods of accessing the portal circulation should remain in the armamentarium of centres performing total pancreatectomy and islet autotransplantation for chronic pancreatitis.