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The role of parenchyma-sparing resections (PSR) and lymph node dissection in small (3 cm) nonfunctional pancreatic neuroendocrine tumors (PNET) is unlikely to be studied in a prospective randomized clinical trial. By combining data from 4 high-volume pancreatic centers we compared postoperative and long-term outcomes of patients who underwent PSR with patients who underwent oncologic resections.Retrospective review of prospectively collected clinicopathologic data of patients who underwent pancreatectomy between 2000 and 2021 was collected from 4 high-volume institutions. PSR and lymph node-sparing resections (enucleation and central pancreatectomy) were compared to those who underwent oncologic resections with lymphadenectomy (pancreaticoduodenectomy, distal pancreatectomy). Statistical testing was performed using χ 2 test and t test, survival estimates with Kaplan-Meier method and multivariate analysis using Cox proportional hazard model.Of 810 patients with small sporadic nonfunctional PNETs, 121 (14.9%) had enucleations, 100 (12.3%) had central pancreatectomies, and 589 (72.7%) patients underwent oncologic resections. The median age was 59 years and 48.2% were female with a median tumor size of 2.5 cm. After case-control matching for tumor size, 221 patients were selected in each group. Patients with PSR were more likely to undergo minimally invasive operations (32.6% vs 13.6%, P0.001), had less intraoperative blood loss (358 vs 511 ml, P0.001) and had shorter operative times (180 vs 330 minutes, P0.001) than patients undergoing oncologic resections. While the mean number of lymph nodes harvested was lower for PSR (n=1.4 vs n=9.9, P0.001), the mean number of positive lymph nodes was equivalent to oncologic resections (n=1.1 vs n=0.9, P =0.808). Although the rate of all postoperative complications was similar for PSR and oncologic resections (38.5% vs 48.2%, P =0.090), it was higher for central pancreatectomies (38.5% vs 56.6%, P =0.003). Long-term median disease-free survival (190.5 vs 195.2 months, P =0.506) and overall survival (197.9 vs 192.6 months, P =0.372) were comparable. Of the 810 patients 136 (16.7%) had no lymph nodes resected. These patients experienced less blood loss, shorter operations ( P0.001), and lower postoperative complication rates as compared to patients who had lymphadenectomies (39.7% vs 56.9%, P =0.008). Median disease-free survival (197.1 vs 191.9 months, P =0.837) and overall survival (200 vs 195.1 months, P =0.827) were similar for patients with no lymph nodes resected and patients with negative lymph nodes (N0) after lymphadenectomy.In small3 cm nonfunctional PNETs, PSRs and lymph node-sparing resections are associated with lower blood loss, shorter operative times, and lower complication rates when compared to oncologic resections, and have similar long-term oncologic outcomes.

Patient education and resources that address barriers to health literacy to improve understanding in pancreatic cancer are limited. We evaluated the impact and outcomes benefits of Animated Pancreas Patient (APP) cancer educational modules (APP website and YouTube).A retrospective study of APP metrics and utilization data from September 2013 to February 2021 was conducted. We evaluated audience reach and calculated top views by media type (animation/expert video/patient video/slideshow) and top retention videos from the modules.During the study period, APP had 4,551,079 views worldwide of which 2,757,064 unique visitors or 60% were from the United States. Of these, 54% were patients, 17% were family members or caregivers, 16% were health care providers, and 13% were other. The most popular topic viewed among the animations was "Understanding Clinical Trials" (n = 182,217), and the most common expert video viewed was "What are the different stages of pancreatic cancer?" (n = 15,357).Pancreatic cancer patient education using APP's visual formats of learning demonstrated a wide reach and had a significant impact on improved understanding among patients, families, and caregivers. Continued efforts should be made to provide patient resources that address health literacy, better quality of life and improved health outcomes in pancreatic cancer.

A minimally invasive step-up (MIS) approach for management of necrotizing pancreatitis (NP) has been associated with reduced morbidity and mortality compared with open surgical techniques. We sought to evaluate bleeding complications in NP patients treated with a MIS approach and to describe the management and outcomes of these events.An observational, cohort study was performed using a prospectively maintained NP database at a tertiary referral center from 2013 to 2019.Of 119 NP patients, 13% suffering bleeding events, and 18% underwent an intervention. There was a 6-fold higher mortality rate in patients with bleeding events (n = 3; 18.8%) compared with those without (n = 3; 2.9%) ( P = 0.031). The most common intervention for hemorrhage control was endovascular coil embolization (75%), which was successful 88% of the time. Seven patients underwent prophylactic vascular intervention, which was 100% successful in preventing bleeding events from the embolized vessel.Bleeding events in NP patients treated with a MIS approach are associated with a 6-fold increase in mortality. Endovascular intervention is an effective strategy for the management of bleeding events. Prophylactic embolization may be an effective technique for reducing bleeding complications.

The 2017 revised International Association of Pancreatology guidelines for management of intraductal papillary mucinous neoplasm (IPMN) describe worrisome features (WF) and high-risk stigmata (HRS), recommending resection in the latter and further work-up and close surveillance for patients with WF. The effect of multiple WF on the likelihood of malignancy has not been evaluated.Eight hundred ten patients who underwent pancreatic resection for IPMN in 2 tertiary referral centers were identified from prospective institutional databases. Patients were retrospectively categorized into subgroups according to the number of WF or HRS and presence of malignancy, defined as high-grade dysplasia (HGD) or invasive cancer on final pathology.Three hundred seventy-nine (47%) patients had HRS, 370 (46%) had 1 or more WF, and 61 patients (7%) had neither. Malignancy was present in 70% (n = 267) of patients with HRS and in 30% (n = 127) of those with WF. Only 3 of 61 patients without WF/HRS had malignancy, and all only in the form of HGD. The risk of malignancy increased in a stepwise fashion with the number of WF, to 22%, 34%, and 59% with 1, 2, and 3 WF, respectively (p = 0.001), and reached 100% in patients with 4 or more WF. Although the relative risks differed for particular WF, the areas under the curve were not statistically different.We confirm that presence of HRS in IPMN is associated with a very high likelihood of malignancy. The presence of a single WF has a malignancy risk of 22%, and additional WF increase this risk significantly. When 3 or more WF are present, the risk is similar to that of HRS.

The ABO blood type has been associated with risk of development of several malignancies, including pancreatic cancer. Data regarding IPMN is equivocal. To investigate this further, we analyzed the association between the ABO blood group and the presence of malignancy in a large cohort of resected IPMN and its influence in survival.819 patients who underwent pancreatic resection for IPMN in the Massachusetts General Hospital (MGH) and Cambridge University Hospitals NHS Foundation Trust (CUH) from January 1993 to December 2020 were identified from prospective institutional databases. Pathological characteristics and blood type were correlated.The distribution of blood types A, B, AB and O was 384 (47%), 92 (11%), 44 (5%) and 299 (37%), respectively. This blood type distribution was different than the reference population of the MGH and the CUH, which is 55% non-O blood group, and 45% type O. There was a significant predominance of non-O blood types when compared with O-blood type in patients with malignant IPMN (i.e. patients with high-grade dysplasia and invasive cancer) (67% vs 33%, OR 1.31 95%CI: 0.98-1.75, p = 0.069). The association was stronger for IPMN with invasive cancer (OR 1.43 95%CI: 1.01-2.02, p = 0.039). Blood group did not influence survival.Non-O blood type is associated with need for resection in IPMN and with presence of invasive carcinoma.

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OBJECTIVE: To use the concept of benchmarking to establish robust and standardized outcome references after pancreatico-duodenectomy (PD). BACKGROUND: Best achievable results after PD are unknown. Consequently, outcome comparisons among different cohorts, centers or with novel surgical techniques remain speculative. METHODS: This multicenter study analyzes consecutive patients (2012-2015) undergoing PD in 23 international expert centers in pancreas surgery. Outcomes in patients without significant comorbidities and major vascular resection (benchmark cases) were analyzed to establish 20 outcome benchmarks for PD. These benchmarks were tested in a cohort with a poorer preoperative physical status (ASA class ≥3) and a cohort treated by minimally invasive approaches. RESULTS: Two thousand three hundred seventy-five (38%) low-risk cases out of a total of 6186 PDs were analyzed, disclosing low in-hospital mortality (≤1.6%) but high morbidity, with a 73% benchmark morbidity rate cumulated within 6 months following surgery. Benchmark cutoffs for pancreatic fistulas (B-C), severe complications (≥ grade 3), and failure-to-rescue rate were 19%, 30%, and 9%, respectively. The ASA ≥3 cohort showed comparable morbidity but a higher in hospital-mortality (3% vs 1.6%) and failure-to-rescue rate (16% vs 9%) than the benchmarks. The proportion of benchmark cases performed varied greatly across centers and continents for both open (9%-93%) and minimally invasive (11%-62%) PD. Centers operating mostly on complex PD cases disclosed better results than those with a majority of low-risk cases. CONCLUSION: The proposed outcome benchmarks for PD, established in a large-scale international patient cohort and tested in 2 different cohorts, may allow for meaningful comparisons between different patient cohorts, centers, countries, and surgical techniques.

Dynamic survival data based on time already survived are lacking for resected borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC) patients who received total neoadjuvant therapy (TNT) with FOLFIRINOX followed by chemoradiation. Conditional survival, i.e., the probability of surviving an additional length of time after having already survived an amount of time, offers such information. We aimed to determine actuarial and conditional overall (OS, COS) and disease-free survival (DFS, CDFS) among this cohort.Clinicopathologic data were retrospectively collected for resected BR/LA PDAC patients who received TNT (2011-2019). COS and CDFS rates were calculated for patients being event (death/recurrence)-free at multiple intervals and by recurrence status.After a median follow-up of 32.1 months, the 183 patients had a median OS and DFS of 39.1 months and 16.8 months, respectively. COS and CDFS increased as a function of time already survived. The probability of surviving an additional 24 months if a patient survived 2 years post-operatively was 70%, whereas the 4-year actuarial OS was 47%. Similarly, the probability of surviving disease-free an additional 24 months after 2 years was 66%, while actuarial 48-month DFS was 27%. COS for disease-free patients increased further over time. For patients remaining disease-free 12 months post-operatively, BR vs. LA status at diagnosis, tumor ≤ 4 cm at diagnosis, and R0 resection were independent predictors of favorable additional OS and DFS.For resected TNT-treated BR/LA PDAC patients, the probability of surviving an additional length of time increases as a function of survival already accrued. Dynamic survival estimates may allow personalized follow-up and counseling.

FOLFIRINOX [fluorouracil (5-FU), irinotecan, oxaliplatin] and gemcitabine plus nab-paclitaxel are standard treatments for patients with pancreatic ductal adenocarcinoma (PDAC). Despite efficacy rates of less than 32%, evidence is lacking to guide the use of one drug over the other. Herein, we compared the sensitivity of patient-derived PDAC cell lines to each of these regimens.Changes in the growth of 19 low-passage patient-derived PDAC cell lines were evaluated in response to treatment with FOLFIRINOX and gemcitabine plus paclitaxel (Gem-Pac).Six cell lines exhibited optimal sensitivity (high EFurther characterization of cancer cells exhibiting preferential sensitivity to each of these regimens may allow the identification of biomarkers to guide the selection of appropriate chemotherapy for a given patient.

Diagnosis of depression may be associated with adverse outcomes following surgery. The aim of this study is to investigate whether depression is associated with an increased readmission rate following elective pancreatectomy, which is currently unknown.The 2014 Nationwide Readmissions Database was used to evaluate whether diagnosis of depression was associated with 30-day readmission following elective pancreatectomy in adult patients. Univariate and multivariate logistic regression models were adjusted for clustering by facility. A secondary analysis was performed to evaluate whether the risk of diagnosis of depression on 30-day readmission rates was modified by length of stay (median 8 days). All multivariate models were adjusted for patient-level characteristics.There were an estimated 11,992 patients who underwent elective pancreatectomy. Mean age was 63 years, and 48.9% were male. Approximately 10.2% (n = 1223) had diagnosis of depression. Depression was associated with higher odds of 30-day readmission following elective pancreatectomy on univariate [odds ratio (OR) 1.26, 95% confidence interval (CI) 1.01-1.59; P = 0.043] and multivariate analyses (OR 1.29, 95% CI 1.01-1.65; P = 0.039). Although length of stay 8 days was independently associated with higher odds of 30-day readmission (P = 0.005), length of stay did not alter the association between diagnosis of depression and odds of readmission (P = 0.90).Diagnosis of depression was associated with higher odds of 30-day readmission following pancreatectomy, regardless of length of stay. Enhanced focus on evaluation and optimization of perioperative mental health is warranted to identify patients at high risk for readmission and reduce the burden related to readmission following pancreatic surgery.

Objective To report a rare case of gonadal agenesis with rudimentary paramesonephric ducts derivatives in a female with a 46,XX normal karyotype. Design Case study. Setting National Institute of Health. Patient(s) An 18-year-old female with primary amenorrhea and lack of secondary sexual development. Intervention(s) Clinical, gynecological, endocrine, and genetic evaluation. Laboratory studies conducted included measurement of pituitary, ovary, and thyroid hormones; analyses of G-banded chromosomes in peripheral blood and fibroblast cultures; search for genomic Y-chromosome DNA by fluorescence in situ hybridization and molecular biology techniques; X-ray, ultrasonography, echocardiographic and laparoscopic studies for the assessment of bone age, and genitourinary and other associated malformations. Main outcome measure(s) Clinical, hormonal, anatomical, and genetic characteristics of the patient. Result(s) The studies performed confirmed a prepubertal female with hypergonadotrophic hypogonadism, bilateral gonadal agenesis, a rudimentary uterus and fallopian tubes, a normal vagina, kidney, and urinary tract structures, and a 46,XX normal karyotype. The search for centromeric Y-chromosome DNA and SRY and ZFY genes was negative. Conclusion(s) A primary deficiency confined to the gonadal blastema and the nearby coelomic epithelium is proposed as an alternative embryologic mechanism to explain the occurrence of this singular sexual developmental defect.

Urinalysis is one of the most common studies performed on the diabetic patient at every visit. The presence of leukocyturia is relatively common but it is not clear what the attitude of the physician toward this particular finding should be. The main objective of the present study was to investigate the clinical significance of leukocyturia in diabetic women.Ninety-eight diabetic women (84.7% type 2) aged 57 +/- 13 years who were being seen at the diabetic out-patient clinic were randomly selected. All patients underwent a clinical and gynecologic examination and a urinalysis. A Papanicolaou smear and a urine culture were also obtained.The overall prevalence of leukocyturia (5 cells/high power field (hpf)) was 46.5%. Patients with urinary tract infections (UTI) were 7.5 times more likely to have leukocyturia, while a leukocyte count5cells/hpf predicted the absence of UTI in 96% of the women. In the comparison of patients with and without leukocyturia, we found that proteinuria (p = 0.06) and bacteriuria (p0.002) were more common in the women with leukocyturia. A significant association with leukorrhea was not demonstrated. The empirical use of antibiotics was 12 times more frequent in the patients with leukocyturia.A urinary culture should be requested in all diabetic patients with leukocyturia. The possibility of a UTI is remote when leukocyturia is absent.

Cystic pancreatic neuroendocrine tumors (cPanNETs) account for 13% to 17% of PanNETs. Although the value of endoscopic ultrasound (EUS) imaging and cyst fluid analysis (CFA) in their preoperative diagnosis has been well described, limited information is available about the diagnostic role of cytology samples obtained from fine-needle aspiration (FNA).Cytopathology records between 1992 and 2013 were searched for all reports of cysts interpreted as PanNET. Patient demographics, clinical and radiologic information, CFA, histopathology, and cytopathology findings were recorded. Performance characteristics of cytology and EUS for the accurate diagnosis of cPanNET were calculated.In total, 35 FNAs from 33 patients with cPanNETs were identified, and 34 EUS were performed. Cytology made a specific diagnosis of a cPanNET in 71% of the biopsies compared with a specific diagnosis by EUS in 38% of cases. An interpretation of suspicious for cPanNET was given in 77% of cases by cytology and in 47% by EUS. Cytology identified 86% of the lesions as high-risk pancreatic cysts compared with 56% by EUS. Diagnostic morphology was present on both cytology and cell block preparations in 60% of aspirates, on cytology only in 20%, and on cell block only in 20%. CFA was performed on 51% cyst fluids. All cysts but 1 revealed low carcinoembryonic antigen levels (range, 0.2 to500 ng/mL; mean, 29.5 ng/mL), and amylase levels were500 U/L in all but 2 cases (range, 16-1493 U/L; mean, 205 U/L).Cytology is the most accurate test for preoperative diagnosis of cPanNETs. EUS is insufficiently accurate for independent diagnosis, and carcinoembryonic antigen and amylase analyses are noncontributory.

Our vocation has called us to become physicians and we have learned and practiced surgery as part of our medical training and knowledge. Surgery is an art expressed during each intervention carried out with effectiveness and devotion; enjoying the pleasure to perform it without hurry, with harmony, fluency and cleanness. Therefore, medicine and surgery belong to the same vocation being at service of people with the clear mission to heal patients and if we favor it, this activity will get our attention firmly and forever. A physician is a sensitive person that understands the sadness and happiness consequence of his actions at the office, operating room, research and relationships with colleagues. This provides him a pleasant experience of practicing medicine and especially surgery. Medical and surgical professions produce an irresistible attraction and they are very rewarding experiences; however, as time goes by there are effects over physician's health. Surgeons will switch from an active professional role into a passive agent and will need to assess himself and answer if he is still in optimal conditions to practice medicine. Therefore, every surgeon must be prepared to grow old from the start and preserve his Faith once retirement has been accepted as the next step in his career.

The differential diagnosis of a pancreatic head mass encompasses a wide range of clinical entities that include both solid and cystic lesions. This chapter focuses on our approach to the patient presenting with a newly found pancreatic head mass with the main goals of determining the risk of the lesion being malignant or premalignant, resectability if the patient is appropriate for surgical intervention, assessment of need for multimodality treatment and determination the patient's surgical risk.

Complaints related to uterine myomatosis treatments received by the National Commission of Medical Arbitration (Conamed) between 2001 and 2005 were analyzed. Complaints were from patients affiliated to social security institutions (51.7 %), private providers (34.5 %) and public health care services (13.8 %). A medical doctor suggested to fill in the complaint in 10.3 % of cases. Perception of inadequate treatment was the most frequent cause (69 %), incomplete medical charts were 60.3 % and only 24 % included the informed consent form. Medical information given to patients and relatives was inadequate (48.2 %). Hysterectomy was performed to 84.5 % of patients. The most frequent surgical complications were hemorrhage (25.7 %), urologic injuries (25.7 %) and surgical infections (12.7 %). 36.4 % of cases had no surgical complication. Main sequelae were: elapsed length of hospital stay (15 %) and loss of an organ (other than uterus) or function (not reproductive) (13.8 %). There was one death (1.7 %). Medical malpractice was found in 29.3 % of cases. Principal deviations: communication problems (29.6 %), unjustified delayed surgery (29.4 %) and delayed diagnosis of complications due to poor post-surgical care or premature hospital discharge (29.4 %).

In contrast to cancers of the head of the pancreas (jaundice), cancers of the pancreatic body and tail do not have heralding signs. The principal clinical features are pain and weight loss. Although the diagnosis of pancreatic cancer carries a grave prognosis, it is not a uniformly fatal disease, even when located in the body and tail. Resection offers the best chance for cure; resectability can be determined preoperatively using CT and laparoscopy. Metastatic disease to the liver, peritoneal surfaces, and omentum and peritoneal washings are contraindications to pancreatectomy. For localized unresectable disease, symptoms can be palliated and survival prolonged with combined irradiation (external beam or intraoperative) and chemotherapy.

Background: Patients with potentially resectable pancreatic masses, without evidence of metastatic disease, require surgical exploration. We assessed the reliability of frozen section diagnosis of pancreatic malignancy. Methods: We analysed data from 120 patients who underwent pancreatic exploration, including frozen section assessment, over a period of 41 months. Results: A total of 310 pancreatic biopsies were sent for frozen section analysis. The frozen section result concurred with the final histological diagnosis in 98.1% of biopsies. The false-negative rate was 1.9%, with the correct diagnosis being established on subsequent frozen section in half of these cases. Only 3 patients were not correctly diagnosed intra-operatively by frozen section. The majority of tumours identified were pancreatic ductal adenocarcinomas, but endocrine tumours and lymphoma were also detected. 15 (12.5%) patients required more than one set of biopsies in order to establish a diagnosis of malignancy. 19 (15.8%) patients had malignant disease outside the pancreas, making their tumours unsuitable for curative resection. Conclusions: Frozen section diagnosis is very reliable in the assessment of pancreatic masses and accurately differentiates between benign and malignant disease. More than one biopsy is needed to make a diagnosis, and if clinically suspicious, successive sets of biopsies may be required.