3,436 research outputs found
STUDIO PROSPETTICO MULTICENTRICO SULLA GESTIONE DEI DRENAGGI DOPO DUODENOCEFALOPANCREASECTOMIA UTILIZZANDO UN SISTEMA DI STRATIFICAZIONE DEL RISCHIO
No full textObiettivo: Questo studio multicentrico ha valutato prospetticamente un protocollo di gestione dei drenaggi chirurgici dopo duodenocefalopancreasectomia (DCP) basato sulla combinazione del concetto di drenaggio selettivo (in base a stratificazione del rischio) e di rimozione precoce dei drenaggi stessi.
Background: Recenti evidenze scientifiche suggeriscono che sia il posizionamento selettivo di drenaggi sia la loro rimozione precoce risultino applicabili nella DCP. Entrambe le strategie, prese singolarmente, sono state associate a una diminuzione dell'incidenza di fistola pancreatica clinicamente rilevante, la complicanza più comune e allo stesso tempo più critica dopo DCP.
Metodi: Il protocollo è stato applicato a 260 pazienti consecutivi operati in un periodo di 17 mesi nelle due istituzioni partecipanti. Il rischio di sviluppare fistola pancreatic clinicamente rilevante è stato stimato attraverso il calcolo intraoperatorio del fistula risk score (FRS). I drenaggi non sono stati posizionati nei pazienti con FRS 0-2, mentre sono stati posizionati per FRS >=3. Nei pazienti con drenaggio, è stato ottenuto in prima giornata postoperatoria ll valore di amilasi dal liquido del drenaggio stesso, che è stato successivamente rimosso in terza giornata se il valore era 5000 U/L sono stati gestiti a discrezione del chirurgo che aveva il paziente in carico. I risultati sono stati comparati con una coorte storica (N=557; 2011-2014).
Risultati: il FRS non è risultato diverso tra le due coorti (Mediana: 4 vs. 4; p=0.933). Non si è sviluppata alcuna fistola clinicamente rilevante nei 70 pazienti con FRS=0-2, nei quali i drenaggi non erano stati posizionati. L'incidenza di fistola clinicamente rilevante è risultata significativamente minore dopo l'implementazione del protocollo (11.2 vs 20.6%, p=0.001). Nella coorte sperimentale è anche stata osservata minore incidenza di complicanze severe, reinterventi, e posizionamento di drenaggi percutanei (tutte le p<0.05). Anche la degenza mediana è stata minore nella coorte sperimentale (8 vs. 9 giorni, p=0.001). Non c'è stata differenza nell'incidenza di fistole biliari e chilose.
Conclusione: Il posizionamento di drenaggi può essere evitato in un quarto dei pazienti sottoposti a DCP. Nei pazienti in cui il drenaggio è posizionato, Il dosaggio delle amilasi in prima giornata postoperatoria identifica in quali la rimozione precoce del drenaggio stesso è appropriata. Questo approccio stratificato per rischio ha ridotto significativamente l'incidenza di fistola pancreatica.Objective: This multicenter study sought to prospectively evaluate a drain management protocol for pancreatoduodenectomy (PD).
Background: Recent evidence suggests value for both selective drain placement and early drain removal for PD. Both strategies have been associated with reduced rates of clinically relevant pancreatic fistula (CR-POPF) – the most common and morbid complication following PD.
Methods: The protocol was applied to 260 consecutive PDs performed at two institutions over 17 months. Risk for ISGPF CR-POPF was determined intra-operatively using the Fistula Risk Score (FRS); drains were omitted in negligible/low risk patients and drain fluid amylase (DFA) was measured on POD1 for moderate/high risk patients. Early drain removal (POD3) occurred for patients with POD1 DFA ≤5000 U/L, while patients with POD1 DFA >5000 U/L were managed by clinical discretion. Outcomes were compared with a historical cohort (N=557; 2011-2014).
Results: Fistula risk did not differ between cohorts (Median FRS: 4 vs. 4; p=0.933). No CR-POPFs developed in the 70 (29.4%) negligible/low risk patients. Overall CR-POPF rates were significantly lower following protocol implementation (11.2 vs 20.6%, p=0.001). The protocol cohort also demonstrated lower rates of severe complications, any complication, reoperation, and percutaneous drainage (all p<0.05). These patients also experienced reduced hospital stay (8 vs. 9 days, p=0.001). There were no differences between cohorts in bile or chyle leaks.
Conclusion: Drains can be safely obviated for one-quarter of PDs. Drain amylase analysis identifies which moderate/high risk patients benefit from early drain removal. This data-driven, risk-stratified approach has significantly decreased the occurrence of clinically relevant pancreatic fistula
Dynamic Behavior of Ca 19-9 and Pancreatic Cancer Recurrence: Enough Data to Drive Salvage Therapy?
No full textthis is an editorial on the role of Ca 19.9 in the post-pancreatectomy follow-up proces
ASO Author Reflections: Long-Term Outcomes After Surgical Resection of Pancreatic Metastases from Renal Clear-Cell Carcinoma
No full textAuthor reflection on the companion paper "long term results of pancreatectomy for metastatic RCC
The unsolved mystery of Johann Georg Wirsung and of (his?) pancreatic duct
No full textThe discovery of the pancreatic duct occurred on March 2, 1642, at San Francesco Hospital during the autopsy of Zuane Viaro Della Badia, a 30 year-old man who had been hanged the day before.1 Wirsung was assisted—perhaps fatefully—by 2 students, Thomas Bartholin of Denmark and Moritz Hoffmann of Germany. Wirsung recognized that his finding was important, but had no idea about the possible function of the duct itsel
Pancreas: Postoperative pancreatic fistula: use of enteral nutrition
No full textThe most common cause of external pancreatic fistulas is pancreatic surgery. Once a postoperative pancreatic fistula (POPF) has developed, about 95–98% of patients are treated with conservative therapy, which includes adequate drainage of exocrine secretions and/or peripancreatic fluid collections, with restriction of oral intake
Postpancreatectomy Complications and Management
No full textAlthough mortality rates after pancreatectomy have decreased, the incidence of postoperative morbidity remains high. The major procedure-related complications are pancreatic fistula, delayed gastric emptying, and postpancreatectomy hemorrhage. The International Study Group of Pancreatic Surgery defined leading complications in a standardized fashion, allowing unbiased comparison of operative results and management strategies. Risk factors for postoperative complications have been investigated and quantitative scoring systems established to estimate patient-specific risks. Management of postpancreatectomy complications has shifted from an operative to a conservative approach. Nevertheless, postoperative morbidities may have a profound impact on patient recovery and length of hospital stay and are associated with increased hospital costs
ASO Author Reflections: Recurrence Following Post-neoadjuvant Pancreatectomy: How Can We Do Better?
No full textN/
ASO Author Reflection: Location of Nodal Metastases in Pancreatoduodenectomy for Cancer: Which Station Matters?
No full textNo abstract availabl
ASO Author Reflections: Adjuvant Therapy for Resectable Pancreatic Cancer in the Real World-Not as Common as One Might Think
No full textN
Surgical Management of Serous Cystic Neoplasms of the Pancreas
No full textSerous cystic neoplasms (SCNs) account for 30% of all pancreatic cystic neoplasms, occur in middle‐aged women, and are mostly diagnosed incidentally on cross‐sectional imaging performed for other complaints. When present, symptoms (the most common of which is abdominal pain) may be nonspecific. The generally benign nature of SCNs, combined with the substantial morbidity and potential mortality of pancreatic resections, led to a management strategy weighted toward surveillance. However, an initial operative approach is indicated in symptomatic patients or when the diagnosis is uncertain. Despite technical advances, differentiation on imaging between the macrocystic variant of SCNs and mucinous lesions is often difficult, because of a certain degree of morphologic overlap. Endoscopic ultrasound with measurement of carcinoembryonic antigen in the cyst fluid may help to improve the diagnostic accuracy. Giant neoplasms (>10 cm) in the pancreatic head are more likely to exhibit a locally aggressive behavior and also should be resected. Asymptomatic SCNs have been shown to grow very slowly over time (less than 0.3 cm/year) and can be initially managed nonoperatively. In a model assessing predictors of growth, the macrocystic variant and a personal history of other nonpancreatic neoplasms were found to be significant factors, and patients presenting with these two features should be informed about an increased likelihood of resection in the long term. Indications for crossover to surgery during the follow‐up period include the development of symptoms and an unexpected acceleration of growth. The surgical approach has to be tailored according to the location and size of the lesion; atypical and minimally invasive resections can be proposed when feasible. In patients who are poor candidates for surgery, imaging‐guided cyst ablation with ethanol and paclitaxel have shown promising results, despite this approach still being under investigation
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