Hepatic Artery Anomalies in Pancreaticoduodenectomy: Outcomes from a High-Volume Center

Several single-center reports suggest that vascular resection (VR) during pancreaticoduodenectomy (PD) for patients with pancreatic adenocarcinoma is feasible without affecting early postoperative mortality or morbidity. Our objective is to review the outcomes associated with VR during PD using a large multicenter data source. A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005-2009. All patients undergoing PD for a postoperative diagnosis of malignant neoplasm of the pancreas were included. Forward stepwise multivariate regression analysis was used to determine the association between VR during PD and 30-day postoperative mortality and morbidity after adjustment for patient demographics and comorbidities. 3,582 patients were included for analysis, 281 (7.8 %) of whom underwent VR during PD. VR during PD was associated with significantly greater risk-adjusted 30-day postoperative mortality [5.7 % with VR versus 2.9 % without VR, adjusted odds ratio (AOR) 2.1, 95 % confidence interval (CI) 1.22-3.73, P = 0.008] and overall morbidity (39.9 % with VR versus 33.3 % without VR, AOR 1.36, 95 % CI 1.05-1.75, P = 0.02). There was no significant difference in risk-adjusted postoperative mortality or morbidity between those patients undergoing VR by the primary surgical team versus those patients undergoing VR by a vascular surgical team. Contrary to the findings of several previously published single-center analyses, the current study demonstrates increased 30-day postoperative morbidity and mortality in PD with VR when compared with PD alone.

Objective To investigate the association between matrix metallopeptidase-9 (MMP-9) rs3918242 locus single nucleotide polymorphisms and intra-abdominal infection after pancreaticoduodenectomy. Methods 152 patients undergoing pancreaticoduodenectomy were enrolled, and the association between 21 factors including MMP-9 rs3918242 polymorphisms and intra-abdominal infection after pancreaticoduodenectomy was analyzed using Logistic regression method. Postoperative plasma MMP-9 levels were compared between different groups. Results Univariate analysis revealed pancreatic duct diameter ≥3 mm [odds ratio (OR)=0.378, 95% confidence interval (CI): 0.163, 0.874, P=0.023], pancreatic texture (soft, OR=3.414, 95% CI: 1.353, 8.612, P=0.009), operative time ≥6 h (OR=3.018, 95% CI: 1.302, 6.991, P=0.010), pancreatic fistula (OR=6.615, 95% CI: 2.708, 16.161, P=0.000), postoperative intra-abdominal bleeding (OR=8.768, 95% CI: 1.958, 39.264, P=0.005), and rs3918242 polymorphisms CT/TT genotypes (OR=0.211, 95% CI: 0.060, 0.737, P=0.015) were associated with intra-abdominal infection after pancreaticoduodenectomy. Operative time ≥6 h (OR=4.181, 95% CI: 1.535, 11.384, P=0.005), pancreatic fistula (OR=9.713, 95% CI: 3.507, 26.900, P=0.000), and rs3918242 polymorphisms CT/TT genotypes (OR=0.166, 95% CI: 0.042, 0.646, P=0.010) were associated with intra-abdominal infection after pancreaticoduodenectomy in multivariate analysis. The patients carrying rs3918242 CT/TT genotypes [(275.2±103.9) ng/ml] had higher postoperative plasma MMP-9 levels than those carrying CC genotype [(240.1±85.2) ng/ml, P=0.005]. Meanwhile, the patients with intra-abdominal infection [(205.6±83.1) ng/ml] had lower postoperative plasma MMP-9 levels than those without intra-abdominal infection [(258.5±82.4) ng/ml, P=0.000]. Conclusion Operative time, pancreatic fistula, and rs3918242 polymorphisms were the independent influential factors of intra-abdominal infection after pancreaticoduodenectomy. Lower postoperative plasma MMP-9 levels may contribute to the development of intra-abdominal infection. Key words: Matrix metalloproteinase-9; Single nucleotide polymorphisms; Intra-abdominal infection; Pancreaticoduodenectomy; Pancreatic fistula

Purpose: Aberrant hepatic arterial anatomy poses a challenge for surgeon during pancreaticoduodenectomy (PD). These anomalies are best picked up on pre-operative imaging to avoid inadvertent injury to the aberrant vasculature resulting in liver ischaemia or biliary-enteric anastomotic failure. We present our experience of dealing with aberrant hepatic vessels during PD. Methods: Patients with aberrant hepatic vasculature who underwent PD between September 2014 and August 2015 were included in the study. We used artery rst technique for dissection in cases identified on pre operative imaging. Aberrations were classed according to Hiatt classi cation. Results: A total of 23 PD were performed with aberrant arterial anatomy in 10 (43%) cases. These vessels were recognised and preserved in nine cases. In one patient, the replaced right hepatic artery (RRHA) arising from superior mesenteric artery (SMA) was coursing through pancreatic parenchyma needing resection and reconstruction with uneventful post-operative recovery. We also identified one RRHA arising from SMA coursing lateral to common bile duct and entering liver parenchyma in gallbladder fossa. Conclusion: Aberrant hepatic arterial anomalies are common and should ideally be picked up by pre-operative imaging. It is possible to preserve these vessels in most cases with careful surgical dissection using artery first technique. Surgeons performing PD should be well versed with the aberrant vascular anatomy to minimise any inadvertent damage. Key words: Aberrant hepatic artery, artery first technique, pancreaticoduodenectomy

Optimal preoperative biliary drainage for patients with pancreatic cancer before pancreatoduodenectomy remains unclear. This study aimed to investigate the comparison of efficacy and safety between a metallic stent (MS) and a plastic stent (PS). Comparative studies on the use of MS and PS for pancreatic cancer before pancreatoduodenectomy were systematically searched using the MEDLINE and Web of Science databases. Pre- and postoperative data also were extracted. Random-effects meta-analyses were performed to compare post-endoscopic retrograde cholangiopancreatography (ERCP) complications as well as intra- and postoperative outcomes between the two arms of the study, and pooled odds ratios (ORs) or mean differences (MDs) were calculated with 95 percent confidence intervals (CIs). The study analyzed 12 studies involving 683 patients. Insertion of MS was associated with a lower incidence of re-intervention (OR, 0.06; 95% CI 0.03-0.15; P < 0.001), increased post-ERCP adverse events (OR, 2.22; 95% CI 1.13-4.36; P = 0.02), and similar operation time (MD, 18.0 min; 95% CI -29.1 to 65.6 min; P = 0.46), amount of blood loss (MD, 43.0 ml; 95% CI -207.1 to 288.2 ml; P = 0.73), and surgical complication rate (OR, 0.78; 95% CI 0.53-1.15; P = 0.21). The cumulative stent patency rate after 3 months was higher in the MS group than in the PS group (70-100 % vs 30.0-45.0 %). For biliary drainage in patients with pancreatic cancer during this era of multidisciplinary treatment, MS use might be the first choice because MS provides a more durable biliary drainage and a similar risk of postoperative outcomes compared with PS.

Acute pancreatitis (AP) is a rare manifestation of pancreatic cancer (PC). The relationship between AP and PC remains less distinct.From January 2009 to November 2015, 47consecutive patients with PC who presented with AP were reviewed for this study. Clinical features, clinicopathologic variables, postoperative complications, and follow-up evaluations of patients were documented in detail from our database. In order to identify cutoff threshold time for surgery, receiver operating curve (ROC) was built according to patients with or without postoperative complications. Cumulative rate of survival was calculated by using the Kaplan–Meier method. The study was conducted in accordance with the principles of the Declaration of Helsinki and the guidelines of West China Hospital.This study included 35 men (74.5%) and 12 women (25.5%) (mean age: 52 years), with a median follow-up of 40 months. AP was clinically mild in 45 (95.7%) and severe in 2 (4.3%). The diagnosis of PC was delayed by 2 to 660 days (median 101 days). Thirty-nine (83.0%) cases underwent surgery. Eight (17.0%) cases performed biopsies only. Of 39 patients, radical surgery was performed in 32 (82.1%) cases and palliative in 7 (19.9%) cases. Two (8.0%) patients were needed for vascular resection and reconstruction. Postoperative complications occurred in 12 (30.8%) patients. About 24.5 days was the best cutoff point, with an area under curve (AUC) of 0.727 (P = 0.025, 95% confidence interval: 0.555–0.8999). The survival rate of patients at 1 year was 23.4%. The median survival in patients with vascular resection and reconstruction was 18 months, compared with 10 months in patients without vascular resection (P = 0.042). For the primary stage (T), Tix was identified in 3 patients, the survival of whom were 5, 28, 50 months, respectively. And 2 of them were still alive at the follow-up period.The severity of AP was mainly mild. Surgical intervention after 24.5 days may benefit for reducing postoperative complications. Patients with vascular resection and reconstruction, thus achieving tumor-free margins, had a long-time survival.

A few randomized controlled trials have questioned the justification of pylorus-preserving pancreaticoduodenectomy (PpPD) for pancreatic cancer and periampullary cancer. However, the characteristics of pancreatic cancer are remarkably different from those of other periampullary cancers, so the outcomes of PD and PpPD for pancreatic cancer are being re-evaluated. We studied retrospectively, 55 patients who underwent PpPD at Wakayama Medical University Hospital between 1999 and 2005, when PpPD was available, for pancreatic head adenocarcinoma. The main outcome measures were the postoperative complications, mortality, and survival of the patients who underwent PpPD vs. those who underwent conventional pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma. There were no significant differences between PD and PpPD in postoperative complications; however, the incidences of delayed gastric emptying (DGE) differed significantly according to the type of reconstruction (P < 0.01). The body weight ratio and the incidence of diarrhea 6 months after PpPD and PD were similar. Patients treated with PD had a higher duodenal invasion rate than those treated with PpPD (P < 0.05); therefore, the cause-specific survival of the PpPD patients was better than that of the PD patients (P < 0.05). The surgical outcomes and incidence of postoperative complications in this series suggest that PpPD is an appropriate surgical procedure for pancreatic adenocarcinoma.

Identification of risk categories for in pancreaticoduodenectomy based on diagnosis

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

To determine the prevalence and predictors of adverse postoperative outcomes in older surgical patients undergoing noncardiac surgery. Prospective cohort study of consecutive patients undergoing noncardiac surgery in 1997. A medical school-affiliated teaching community hospital. Patients age 70 and older undergoing noncardiac surgery. Patients presenting for surgery requiring only local anesthesia or monitored anesthesia care were excluded. Potential pre- and intra-operative risk factors were measured and evaluated for their association with the occurrence of predefined in-hospital postoperative adverse outcomes. Univariate predictors of postoperative outcomes were first measured using the chi-square or Fisher's exact tests followed by multivariate logistic regression. Odds ratios (OR) with 95% confidence interval (CI), and two-sided P-values were reported. Five hundred forty-four consecutive patients were studied. Overall, 21% of patients developed one or more postoperative adverse outcomes and 3.7% died during the in-hospital postoperative period. Of all the adverse outcomes, cardiovascular complications (10.3%) were the leading cause of morbidity, followed by neurological (7.7%) and pulmonary complications (5.5%). By multivariate logistic regression analysis, American Society of Anesthesiologists (ASA) classification (OR = 2.7, CI = 1.6-4.4), emergency surgery (OR = 2.0, CI = 1.1-3.4), and intraoperative tachycardia (OR = 3.8, CI = 1.9-7.6) were the most important predictors of postoperative adverse outcomes. Of all the preoperative physical symptoms and signs, decreased functional status (OR = 3.0, CI = 1.4-6.4) and clinical signs of congestive heart failure (OR = 2.1, CI = 1.1-5.1) were the two most important predictors of postoperative adverse neurological and cardiac outcomes, respectively. The median hospital stay was 4 days. The patients who developed postoperative adverse outcomes had significantly longer median hospital stays (9 days) than those without complications (3 days), (P < .0001). Our study demonstrates that the postoperative mortality rate in geriatric surgical patients undergoing noncardiac surgery is low. Despite the prevalence of preoperative chronic medical conditions, most patients do well postoperatively. The ASA classification (a reflection of the severity of preoperative comorbidities), emergency surgery, and intraoperative tachycardia increase the odds of developing any postoperative adverse events. Future studies aimed at modifying some of the potentially reversible risk factors, such as preoperative heart function and intraoperative heart rate are warranted.

Association of Complications With Blood Transfusions in Pediatric Cardiac Surgery Patients

Organ/space surgical site infections (OSSI) after pancreaticoduodenectomy (PD) are not rare events. The role of diagnosis and treatment for pancreatic and biliary diseases with an endoscopic retrograde cholangio-pancreatography (ERCP) procedure is currently controversial. However, the ERCP procedure might play a role in surgical outcomes after PD. We conducted a retrospective cohort study for patients who underwent PD in the First Affiliated Hospital with the Nanjing Medical University from 1st September 2012 to 31st January 2018. The relationship between ERCP exposure and OSSI after PD was analyzed by univariate and forward stepwise multivariate logistic regression model. Of the 1,365 patients who underwent PD, 136 developed OSSI (10.0%). We found that ERCP exposure before PD (EEBPD) was significantly associated with an increased incidence rate of post-operative pancreas fistula (POPF) [24.2% (23/95) vs. 14.9% (189/1,270), risk ratio (RR) =1.63, 95% confidence interval (CI), 1.11-2.38, P=0.015]. Hypertension, a higher level of preoperative low-density lipoprotein (LDL) and creatinine (Cr) were associated with elevated risks of post-operative OSSI [adjusted odds ratio (Adj-OR) (95% CI) were 1.59 (1.09-2.32), 1.70 (1.16-2.51), 1.99 (1.36-2.92)], whereas a preoperatively higher level of aspartate aminotransferase (AST) would decrease the risk [Adj-OR (95% CI), 0.62 (0.42-0.91)]. Remarkably, EEBPD would significantly increase and more than double the OSSI risk [Adj-OR (95% CI), 2.56 (1.46-4.47)] especially if it was within 14 days before surgery (Spearman =-0.698, P<0.001). ERCP, as an independent risk factor, significantly increased the risk of post-operative OSSI after PD if it is performed within 14 days prior to surgery. Our findings would assist clinical decision-making, and improve OSSI control and prevention.

While outcomes following pancreaticoduodenectomy (PD) have generally improved, the results of PD with vascular resection (PD-VR) remain inconsistent. The objective of this study was to evaluate short- and long-term outcomes in patients who underwent standard PD (S-PD) or PD-VR. This single-center retrospective cohort study included patients who underwent PD between 2011 and 2023. Histopathological and surgical outcomes were compared between S-PD (n = 173) and PD-VR (n = 30). We looked at short-term morbidity, mortality, and 5-year overall survival (OS). The median age was 60years (range 50-66years), with ampullary adenocarcinoma being the most common tumor type in 79 patients (38.9%). Type 3 and type 4 venous resections were performed in 21/30(70%) patients and 6/30(20%) patients underwent arterial resection. The PD-VR group had longer operative times and higher intra-operative blood loss (P < 0.05). The in-hospital mortality was 1/173 (0.6%) and 1/30 (3.3%) in the S-PD and PD-VR groups (P = 0.274). There was no significant difference in the rates of positive microscopic margins (P > 0.05). For pancreatic cancer, the 5-year OS for S-PD and PD-VR were 20% and 9%, respectively (P = 0.039), while for non-pancreatic periampullary cancers, the 5-year OS for S-PD and PD-VR was 39% and 31%, respectively (P = 0.215). Vascular resections with PD can be performed with comparable short-term and acceptable long-term outcomes.

Association of health literacy with short-term postoperative outcomes in older adult patients with abdominal tumors undergoing surgery and perioperative rehabilitation program: A prospective cohort study

ObjectiveThe aim of this study was to present the therapeutic outcome of patients with locally advanced pancreatic cancer treated with pancreatoduodenectomy combined with vascular resection and reconstruction in addition to highlighting the mortality/morbidity and main prognostic factors associated with this treatment.Materials and MethodsWe retrospectively analyzed the clinical and pathological data of a total of 566 pancreatic cancer patients who were treated with PD from five teaching hospitals during the period of December 2006–December 2011. This study included 119 (21.0%) patients treated with PD combined with vascular resection and reconstruction. We performed a detailed statistical analysis of various factors, including postoperative complications, operative mortality, survival rate, operative time, pathological type, and lymph node metastasis.ResultsThe median survival time of the 119 cases that received PD combined with vascular resection was 13.3 months, and the 1-, 2-, and 3-year survival rates were 30.3%, 14.1%, and 8.1%, respectively. The postoperative complication incidence was 23.5%, and the mortality rate was 6.7%. For the combined vascular resection group, complications occurred in 28 cases (23.5%). For the group without vascular resection, complications occurred in 37 cases (8.2%). There was significant difference between the two groups (p = 0.001). The degree of tumor differentiation and the occurrence of complications after surgery were independent prognostic factors that determined the patients’ long-term survival.ConclusionsCompared with PD without vascular resection, PD combined with vascular resection and reconstruction increased the incidence of postoperative complications. However, PD combined with vascular resection and reconstruction could achieve the complete removal of tumors without significantly increasing the mortality rate, and the median survival time was higher than that of patients who underwent palliative treatment. In addition, the two independent factors affecting the postoperative survival time were the degree of tumor differentiation and the presence or absence of postoperative complications.

Introduction: ABO blood type has long been implicated in disease susceptibility, including cancer. However, evidence for associations with many malignancies is mixed. We applied a novel phenome approach to test to cancer codes from electronic medical records (EMR) in relation to ABO blood type in a large predominantly Caucasian study population. Approach: Among adults aged 18-100, cancer case and control status were assigned using 58 general neoplasm related phenome codes to de-identified EMR at the Vanderbilt University Medical Center. Blood type from serologic assays was ascertained from EMR-linked laboratory reports. Associations between blood type and cancer phenomes were quantified with Odds Ratios (OR) and corresponding 95% Confidence Intervals (CI) from logistic regression in models adjusted for sex and stratified by race/ethnicity. Only analyses with at least 100 cases per strata were conducted. Results: Among 221,015 Non-Hispanic Caucasians, 37,841 Blacks, 7,714 Hispanic Caucasians, and 3,616 Asian subjects with ABO blood type available in linked EMR, we evaluated 56, 37, 4, and 3 general cancer phenome codes, respectively. After employing Bonferroni corrections, ABO blood type was significantly associated with cancers of the pancreas, ovary, cervix, skin, and hematopoietic system. Caucasians with blood type O were less likely to have ovarian cancer (OR: 0.82, 95% CI 0.73-0.91) and pancreatic cancer (OR: 0.83, 95% CI: 0.74-0.92), and more likely to have squamous cell or other skin cancer (OR: 1.08, 95% CI: 1.04-1.13) and myeloid leukemia (OR: 1.15, 95% CI: 1.06-1.25) than those with other blood types (A, B, or AB). Hispanic Caucasians with blood type O were less likely to have cervical cancer (OR: 0.56, 95% CI: 0.38-0.82) than those with other blood types. No associations surpassed correction for multiple comparisons among Blacks or Asians. Conclusions: Our phenome approach confirmed known associations between blood type and risk of pancreatic and ovarian cancer, and adds to accumulating evidence supporting associations with skin cancer and leukemia. Our novel cervical cancer association among Hispanic Caucasians and other nominally significant findings, especially in understudied non-Caucasians, should be further evaluated in large and diverse populations. In addition, research to determine how ABO blood type may influence cancer development and progression, and if such associations can be exploited for risk prediction or cancer prevention is warranted. Citation Format: Alicia Beeghly-Fadiel, Ayush Giri, Lisa Bastarache, Jill Pulley, Jeremy Warner, Josh Denny. ABO blood type and cancer risk: preliminary findings from a phenome analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1293. doi:10.1158/1538-7445.AM2017-1293