Introduction

Despite improvements in the perioperative care of patients with pancreatic cancer the incidence of postoperative complications following pancreatic resections remains high.

Aims & Methods

The objective of this study was to develop surgical techniques to prevent postoperative complications following pancreatoduodenectomy. A retrospective analysis was conducted on the surgical outcomes of 456 patients with resectable pancreatic and periampullary cancer who underwent pancreatoduodenectomy between 2015 and October 2023. Since November 2018, new surgical tactics have been implemented to prevent the occurrence of postoperative pancreatic fistula (POPF) and other postoperative complications. Preliminary data indicates that the development of postoperative complications after pancreatoduodenectomy correlates with postoperative pancreatic fistula, the presence of sarcopenia has been demonstrated to significantly affect the number of clinically relevant postoperative pancreatic fistula and other postoperative complications.
Since that time, we have used new approaches: our modification of the pancreatic fistula risk score, which assesses pancreatic density according to the degree of pancreatic fibrosis. Depending on the risk, we used our surgical tactics. In cases with a high risk of postoperative pancreatic fistula, during pancreaticojejunostomy we used external pancreatic stent. In patients with intermediate risk we performed invaginated duct to mucosa pancreaticojejunostomy. In low-risk patients, the technique of pancreaticojejunostomous anastomosis was considered by the operating surgeon. We performed early removal of abdominal drains in patients with low risk of pancreatic fistula. Prior to surgery, the presence of sarcopenia was assessed, and nutritional support was provided to patients with sarcopenia.
During the period from November 2018 to October 2023, proposed mitigation strategies were applied to 227 patients in the main group. The comparison group consisted of 229 patients who underwent surgery without the use of the developed surgical strategies between January 2015 and October 2018.

Results

The groups were comparable in terms of sex, age, laboratory results, disease stage, American Society of Anesthesiologists score, and comorbidities. In the main group, 26 patients (11.4%) experienced POPF grade B or C. In the comparison group, 64 out of 229 patients (27.9%) experienced a postoperative pancreatic fistula of grade B or C, which is significantly higher than the main group (c²= 19.5, p = 0.0001). Furthermore, the main group had a significantly lower level of postoperative complications compared to the comparison group. A total of 69 patients (30.1%) in the main group experienced complications, while 94 patients (41.0%) in the comparison group did so (c²=5.6, p=0.02). The mortality rate in the main group was reduced from 2.2% to 1.3% due to the developed tactics (c²=0.49, p=0.5).

Conclusion

The surgical tactics developed to prevent postoperative pancreatic fistula after pancreatoduodenectomy were found to significantly reduce its occurrence from 27.9% to 11.4%, postoperative complications from 41.0% to 30.1%, and mortality from 2.2% to 1.3% (c²= 0.49, p = 0.5).

Introduction

Pancreatic ductal adenocarcinoma (PDAC) remains a challenge in oncology with an overall survival rate remaining about 10%. Surgery and adjuvant chemotherapy stands as only curative treatment options. Only a minority of patients are diagnosed with resectable disease. While traditional diagnostic modalities show limitations in detecting and monitoring pancreatic cancer, liquid biopsies is a relatively new, non-invasive and promising diagnostic method for early detection, molecular profiling, and observation. Despite previous published or ongoing research projects and studies, liquid biopsies and specifically cell-free DNA (cfDNA) alterations role in management of pancreatic cancer remains unverified.

Aims & Methods

The aim of our study was to evaluate the diagnostic value of liquid biopsies and alterations in cfDNA levels in patients with pancreatic cancer. This study was approved by the Kaunas Regional Bioethics Committee (Approval ID: BE-2-31). Patients with newly diagnosed and histologically confirmed pancreatic cancer and patients with chronic pancreatitis, admitted to the Department of Surgery at Lithuanian University of Health Sciences Hospital, Kaunas Clinics, between September 2022 and December 2023, and healthy volunteers (control group) were included. Blood samples were obtained from the patients before any treatment procedures commenced. cfDNA was extracted from the collected blood using the QIAmp Circulating Nucleic Acid Kit (Qiagen). The concentration and quality of the extracted cfDNA were determined using the Qubit™ 1X dsDNA High Sensitivity (HS) and Broad Range (BR) Assay Kits (ThermoFisher Scientific, Inc., Waltham, MA, USA). Mann-Whitney U-test and Kruskal-Wallis H-test were used to determine the differences in quantitative traits between the comparison groups, with results being presented in median (min – max). The predictive capability (diagnostic performance) of cfDNA to distinguish PDAC and chronic pancreatitis/healthy controls was investigated by means of the area under the ROC (Receiver-Operating Characteristics) curve (AUC).

Results

Sixty-five patients were included (47 patients with PDAC, 10 patients with chronic pancreatitis and 8 healthy controls). Levels of cfDNA were statistically significantly higher in PDAC patients (46.5 (4 - 768) ng/ml) compared to patients with chronic pancreatitis (23.4 (8.56 - 138.4) ng/ml) (p = 0.032) and healthy controls (19.75 (17.6 - 22.8) ng/ml) (p < 0.001). The cfDNA cut-off value distinguishing PDAC from chronic pancreatitis and healthy controls were determined to be 23,65 ng/ml (AUC = 0.716) and 22.9 ng/ml (AUC = 0.915), respectively. There were no differences in cfDNA levels concerning tumor localization, size, differentiation, spread, or survival rates (all p > 0.05).

Conclusion

Liquid biopsies and cfDNA level alterations offer promising opportunities for distinguishing pancreatic cancer from benign inflammatory diseases, such as chronic pancreatitis. However, additional experiments and studies are necessary for more comprehensive validation and clinical use.

Disclosure

This study was partially funded by Lithuanian University of Health Sciences Scientific fund and Lithuanian Future Biomedicine foundation.

Introduction

The prognostic significance of the preoperative C-reactive protein-albumin-lymphocyte (CALLY) index has been reported in various cancer types; however, its role in pancreatic cancer remains unclear.

Aims & Methods

A cohort of 339 patients with resectable pancreatic cancer (RPC) who underwent curative surgery between July 2012 and December 2019 was analyzed. The CALLY　index was defined as (albumin × lymphocytes)/ (C-reactive protein × 10⁴). The cutoff value of the CALLY index was determined according to　receiver operating characteristics analysis using survival status　at the 3-year　follow-up. 　We investigated the association　 between the CALLY index with disease-free survival (DFS) and overall survival (OS) using univariate and multivariate analyses.

Results

The median CALLY index was 4.1, with an interquartile range of 1.4–11.7. The cutoff value of the CALLY index was set at 3.0, dividing the patients into the CALLY-high group (> 3.0; n = 198) and the CALLY-low group (≤ 3.0; n = 141). The DFS and OS in the CALLY-low group were significantly worse than those in the CALLY-high group (p < 0.001 and p < 0.001, respectively). Multivariate analysis, using the preoperative clinicopathological variables, indicated that the CALLY index ≤ 3.0 was an independent prognostic factor for DFS (Hazard Ratio [HR] 1.53, p = 0.008) and for OS (HR 1.69, p = 0.002).

Conclusion

In RPC, survival outcomes were significantly stratified by the CALLY index = 3.0, with < 3 being a significantly poor prognostic factor for DFS and OS. The CALLY index may be useful in predicting the long-term survival of patients with RPC.

Introduction

Until recently, all cystic tumours were treated surgically, including intraductal papillary mucinous neoplasms of the branch type (BD-IPMN). Currently, most patients with BD-IPMN are being followed up.

Aims & Methods

The aims of this study was to estimate the results of treatment of patients with IPMN.
A total of 228 patients with cystic pancreatic tumours who were treated at our department between 2012 and 2023 were included in the analysis. IPMN was diagnosed in 78 (34.2%) patients. All patients with IPMN were divided into two groups. The primary group included 56 patients who underwent surgery between 2018 and 2023 in accordance with the proposed algorithms. The comparison group comprised 22 patients who underwent surgery between 2012 and 2017. The two groups demonstrated comparable demographic characteristics, including age, gender distribution, and pathological structure.
In the diagnostic algorithm, we always perform MRI with the DWI and with magnetic resonance cholangiopancreatography. We also perform endoscopic ultrasound with fine-needle aspiration if required.
Until 2018, all types of IPMN were operated. Since 2018, we have revised our tactics. Indications for surgery were considered to be the presence of central and mixed type of IPMN or branch duct of IPMN with the presence of HRS and WF.
Of the 22 patients in the control group, central type IPMN was diagnosed in 10 patients (adenocarcinoma was diagnosed in 9, 1 patient was unresectable at the time of diagnosis), mixed type in 4 (2 patients had malignant tumours, 1 patient was unresectable at the time of diagnosis, 1 patient did not undergo surgery), and branch type in 8 (4 patients had malignant tumours, 2 patients - benign and in 2 patients we did not perform surgery). 17 patients with IPMN underwent surgery. Pancreatoduodenectomy (PDE) was performed in 9 patients, total pancreatectomy (TPE) in 1, distal pancreatectomy (DPE) in 7. Five patients were not operated: 2 patients had unresectable tumours diagnosed preoperatively, 2 patients with BD-IPMN were offered observation, 1 patient with mixed type IPMN refused surgery.
IPMN was diagnosed in 56 (40.6%) patients in the main group. Adenocarcinoma on the background of IPMN was diagnosed in 21 (37.5%) patients, all patients with central or mixed type of IPMN, of which PDE was performed in 12 patients, DPE with splenectomy in 8 patients, TPE - in 1 patient. IPMN with mild or severe dysplasia was diagnosed in 20 (35.7%) patients. Of these, PDE was performed in 13 patients, TPE in 1 patient and DPE in 6 patients. In 15 (26.8%) patients BD-IPMN without HGD and WF was diagnosed.

Results

In the comparison group, 17 (77.3%) patients underwent resection. Complications occurred in 6 (35.3%) patients, 3 of which were pancreatogenic complications (17.6%). In the main group, 41 (73.2%) patients underwent surgery. Complications occurred in 11 patients (26.8%). There was no mortality among these patients in either group. Of the 2 patients in the comparison group who were followed up, 1 patient had no progression of the disease, 1 patient was lost to follow-up, the outcome is unknown. Of the 15 patients in the main group with BD IPMN who were followed, none had disease progression.

Conclusion

The treatment of IPMN of the pancreas requires an individualized approach. In select patients, surveillance of presumed BD-IPMN can be safely discontinued. When choosing a wait-and-see approach in patients with BD-IPMN, it is imperative that the diagnosis not raise doubts.

Introduction

Defining pancreatic steatosis (PS) and establishing its association with pancreatic cancer has been a discussed theme in the last decade. However, no consensus guidelines have yet been published on the clinical relevance and management of PS. In this systematic review and meta-analysis, we investigated the association between PS and pancreatic ductal adenocarcinoma (PDAC).

Aims & Methods

Medical literature between 2007 and 2023 was reviewed for eligible trials investigating the prevalence of PS in patients with PDAC. Eligible studies reporting on PS, assessed via imaging or histology, were included. Our primary objective was to determine the association between PDAC and PS by comparing the prevalence of PS in individuals with- and without PDAC. Subsequently, an evaluation was conducted to determine whether the method of assessment (CT, MRI, EUS or histology) and study country was correlated with the association between PS and PDAC. Measures of effect size were determined using odds ratios (ORs) and corresponding 95% confidence intervals (95% CI).

Results

The systematic review identified a total of 23 studies, of which seventeen studies examined PS prevalence among PDAC patients. Overall, the pooled prevalence of PS in patients with PDAC. was 53.6% (95% CI 40.9-66.2). No significant difference in PS prevalence was observed across various diagnostic methods or geographical regions (p= 0.71 and p= 0.50, respectively). Overall, the pooled OR for PS in in patients with PDAC compared to controls was 3.23 (95% CI 1.86-5.60, Figure 1). Subgroup analysis did not reveal any difference according to country (p= 0.52), but higher OR was observed in studies using EUS for the assessment of PS (pooled OR=6.26, 95% CI 1.23-31.8) compared to studies using CT (pooled OR=3.31, 95% CI 1.93-5.68), histology (pooled OR=1.76, 95% CI 1.22-2.54) or MRI (pooled OR=1.19, 95% CI 1.06-1.33).

Conclusion

Patients with PDAC have notable prevalence of pancreatic steatosis (53.6%). Furthermore, PDAC patients are significantly more likely to have PS (OR 3.23). These findings underscore the importance of prioritizing a standardized approach to the diagnosis, follow-up, and treatment of PS. Future studies should prioritize the identification of patients with PS who will benefit from PDAC surveillance programs.

Introduction

Necrotizing pancreatitis with walled-off necrosis (WON) is associated with severe morbidity and substantial mortality. Vascular complications such as pseudoaneurysm, arterial erosion, and especially thrombosis of the splanchnic veins are all associated with acute pancreatitis (AP). However, the occurrence and clinical outcome of vascular manifestations in patients developing WON are poorly described. We aimed to describe vascular complications in a well-defined cohort of consecutive patients endoscopically treated for symptomatic WON.

Aims & Methods

Four hundred and nine patients treated endoscopically for their pancreatic fluid collection during a 10-year period were assessed for inclusion. Patients with pseudocysts, < 18 years, concomitant malignant disease and/or procedure-related bleeding were excluded. A total of 290 patients were eligible for analysis.
Vascular complications included bleeding and thromboembolic events. Thromboembolic complications were defined as confirmation of thrombus in one of the splanchnic veins on contrast-enhanced computed tomography scan (CECT). Bleeding complications were defined as clinical bleeding necessitating intervention, including embolization, surgery or transfusion.

Results

The median age was 59 years (range 18-84), and 57% were males. Gallstones were the etiology in 47%, alcohol in 20%, and post-ERCP pancreatitis in 14%. In 14% of the cases, the etiology was unknown. Infection was the main indication for intervention (92%), followed by gastric outlet obstruction (6%) and pain (2%). The average time from debut of symptoms to index procedure was 35 days (range 6-89). The average duration of hospital admission was 89 days (range 21-286). The overall in-hospital mortality was 14%, and need for admission to intensive care unit (ICU) was 35%.
In total, 87 (30%) patients developed vascular complications of which 53 (18%) were thromboembolic, 34 (12%) bleeding, and nine patients (3%) developed both thromboembolic and bleeding complications.
The portal vein was most affected (34%), followed by the splenic vein (28%) and the superior mesenteric vein (23%). Two or all three splanchnic veins were affected in 15%. The majority (81%) of thromboembolic complications occurred before the index procedure. Development of splanchnic venous thrombosis was not associated with in-hospital mortality (13% vs. 14%, p=1.0) or need for ICU admission (38% vs. 34%, p=0.64). None of the patients with splanchnic vein thrombosis developed variceal bleeding during follow-up.
The splenic artery was the most common cause of bleeding (32%), followed by the gastroduodenal artery (24%) and the left gastric artery (12%). In five cases, the source of the bleeding could not be identified. All patients received blood products, 23 patients were treated with arterial embolization and 4 patients with surgery. Seventy seven percent of the bleeding complications occurred after the index procedure. The need for ICU (59% vs. 32%, p=0.003) and in-hospital mortality (38% vs. 11%, p<0.0001) were significantly higher in patients with arterial bleedings as compared to patients without.

Conclusion

Vascular complications are common in WON patients. The timing of occurrence seems distinct, as the vast majority of thromboembolic complications occur before index endoscopic intervention, while bleeding complications mainly occur after. While arterial bleedings are linked to increased morbidity and in-hospital mortality, thromboembolic complications are not associated with a poor short- or long-term clinical outcome.