Extended distal pancreatectomy with thoracic wall resection after neoadjuvant FOLFIRINOX: Is there a limit of resection for pancreatic cancer after downstaging?

Tommaso Giuliani,Maria Lopez Rubio,Eva Montalva Oron,Javier Maupoey Ibanez,Andrea Bosca Robledo,Cecilia Lopez Valdivia,Judith Perez Rojas,Rafael Lopez Andujar 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.1

Indications and outcomes of extended pancreatectomies have been recently appraised by the International Study Group for Pancreatic Surgery. However, no definitive conclusions have been drawn, particularly in the setting of neoadjuvant treatments. We present here a case of 53-year-old man diagnosed with a bulky adenocarcinoma of the tail of the pancreas and infiltrating the adjacent organs and the thoracic wall. The patient was sent to neoadjuvant chemotherapy and he underwent 12 cycles of FOLFIRINOX. Since a significant radiological response was observed after chemotherapy, the patient was scheduled for extended distal pancreatectomy with en bloc resection of the thoracic wall, in order to achieve a radical resection. The surgery is herein described with all technical details. The patient was discharged after an uneventful early post-operative course and subsequently readmitted for a late grade B post-operative pancreatic fistula, which was ultimately treated successfully. Pathology showed complete response. When performed in centers with ample experience in pancreatic surgery, extended pancreatic resections represent a viable curative option with acceptable surgical outcomes. In this setting, challenging tailored resections should be considered to achieve negative margins, particularly following maximized effective downstaging strategies.

Clinical Implications and Risk Factors of Acute Pancreatitis after Cardiac Valve Surgery

정주원,류성호,조정현,박정엽,이삭,박승우,송시영,정재복 연세대학교의과대학 2013 Yonsei medical journal Vol.54 No.1

Purpose: Acute pancreatitis is one of the potentially lethal complications that occurs after cardiac surgery. We tried to identify risk factors for and the prognosis of acute pancreatitis after cardiac valve surgery with cardiopulmonary bypass. Materials and Methods: We retrospectively analyzed a database of consecutive patients who underwent cardiac valve surgery with cardiopulmonary bypass between January 2005 and April 2010 at our institution. Patients were classified as having acute pancreatitis based on serum lipase concentration and clinical symptoms (lipase ≥180 U/L or ≥60 U/L with relevant symptoms). Results: Of the 986 patients who underwent cardiac valve surgery with cardiopulmonary bypass, 58 (5.9%) patients developed post-operative pancreatitis. Post-operative hospital stay was significantly longer (29.7±45.6 days vs. 12.4±10.7 days, p=0.005) and in-hospital mortality rate was higher (15.5% vs. 2.0%, p<0.001) in patients with post-operative pancreatitis than those without. Hypertension, chronic kidney disease, and peri-operative use of norepinephrine were identified as independent risk factors for developing pancreatitis after cardiac valve surgery. Conclusion: We found that acute pancreatitis after cardiac valve surgery requires longer hospitalization and increases the in-hospital mortality rate. Clinicians should be aware that patients could develop pancreatitis after cardiac valve surgery, especially in patients with hypertension and chronic kidney disease treated with norepinephrine.

Bile duct preserving pancreatic head resection (BDPPHR): Can we conclusively define the extent of head resection in surgery for chronic pancreatitis?

Pagadala Naga Balaji Nitesh,Biju Pottakkat 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.3

The role of surgical management for chronic pancreatitis in providing pain relief and improving quality of life is significant. Surgical techniques involving pancreatic head resection scored more over the drainage procedures. Among the resection procedures, Frey’s procedure received widespread acceptance. However, the exact extent of pancreatic head resection to be performed and the limits of the resection are still debatable. The present report of bile duct preserving pancreatic head resection (BDPPHR) describes an innovative approach to the pancreatic head and conclusively defines the extent of head resection. The simplicity, feasibility and easy reproducibility of the BDPPHR is also reiterated.

Is aggressive intravenous fluid prescription the answer to reduce mortality in severe pancreatitis? The FLIP study: Fluid resuscitation in pancreatitis

Julia McGovern,Samuel J Tingle,Northern Surgical Trainees Research Association,Stuart Robinson,John Moir 한국간담췌외과학회 2023 Annals of hepato-biliary-pancreatic surgery Vol.27 No.4

Backgrounds/Aims: Acute pancreatitis is an emergency presentation, which can range from mild to life threatening. Intravenous fluids are the cornerstone of management. Although the WATERFALL trial described the optimal fluid rate in mild/moderate pancreatitis, this trial excluded patients with moderate-severe/severe pancreatitis. The aim of this study was to establish clinical practice regarding intravenous fluid administration in acute pancreatitis and assess its effect on mortality. Methods: Prospective multi-centre audit of patients with acute pancreatitis was conducted. Data were collected regarding intravenous fluid administration within 72 hours of admission. The primary outcome was 30-day mortality. Multivariable logistic regression was used to identify predictors of 30-day mortality. Results: Those with severe pancreatitis received more fluid; median 5.7 L versus 4 L in 72 hours (p = 0.003). Participants with severe pancreatitis who died within 30 days received a median of 2,750 mL in the first 24 hours, compared to 4,000 mL in those who survived. The following factors were significant predictors of 30-day mortality: age, Glasgow score, C-reactive protein, ischaemic heart disease, and pancreatitis aetiology. Overall, volume of intravenous fluid was not associated with mortality. However, the effect of intravenous fluid volume on mortality differed significantly depending on pancreatitis severity. In severe pancreatitis, increased volume of intravenous fluid was associated with significant reductions in mortality (odds ratio = 0.655; 0.459–0.936; p = 0.020). Conclusions: In severe pancreatitis, more aggressive fluid prescription was associated with decreased mortality; however, this was not the case in milder disease. Further prospective trials guiding fluid resuscitation in severe pancreatitis are needed, as the impact of fluid on this population appears to differ from that in those with milder disease.

Update on endoscopic Management of Main Pancreatic Duct Stones in Chronic Calcific Pancreatitis

( Eun Kwang Choi ),( Glen A. Lehman ) 대한내과학회 2012 The Korean Journal of Internal Medicine Vol.27 No.1

Pancreatic duct stones are a common complication during the natural course of chronic pancreatitis and often contribute to additional pain and pancreatitis. Abdominal pain, one of the major symptoms of chronic pancreatitis, is believed to be caused in part by obstruction of the pancreatic duct system (by stones or strictures) resulting in increasing intraductal pressure and parenchymal ischemia. Pancreatic stones can be managed by surgery, endoscopy, or extracorporeal shock wave lithotripsy. In this review, updated management of pancreatic duct stones is discussed.

A Study on the Dietary Intake and the Nutritional Status among the Pancreatic Cancer Surgical Patients

( Jimin Kang ),( Joon Seong Park ),( Dong Sup Yoon ),( Woo Jeong Kim ),( Hae-yun Chung ),( Song Mi Lee ),( Namsoo Chang ) 한국임상영양학회 2016 Clinical Nutrition Research Vol.5 No.4

The adequate dietary intake is important to maintain the nutritional status of the patients after pancreatic cancer surgery. This prospective study was designed to investigate the dietary intake and the nutritional status of the patients who had pancreatic cancer surgery. Thirty-one patients (15 men, 16 women) were enrolled and measured body weight, body mass index (BMI), nutritional risk index (NRI), and Malnutrition Universal Screening Tool (MUST). Actual oral intake with nutritional impact symptoms recorded on the clinical research foam at every meal and medical information were collected from electronic medical charts. The rates of malnutrition at admission were 45.1% (14/31) and 28.9% (9/31) by NRI and MUST method, respectively, but those were increased to 87% (27/31) and 86.6% (26/31) after operation on discharge. The median values of daily intake of energy, carbohydrates, fat, and protein were 588.1 kcal, 96.0 g, 11.8 g, and 27.0 g, respectively. Most patients (n = 20, 64.5%) experienced two or more symptoms such as anorexia, abdominal bloating and early satiety. There were negative correlations between C-reactive protein (CRP) levels and the intake of total energy, protein, fat, and zinc. The rates of malnutrition were increased sharply after surgery and the dietary intake also influenced the inflammatory indicators. The results suggested that need of considering special therapeutic diets for the patients who received pancreatic surgery.

유전성 췌장염 - 1가계보고 -

김형란,정재희,송영택,윤원재,류지곤,김용태,Kim, Hyoung-Ran,Chung, Jae-Hee,Song, Young-Tack,Yoon, Won-Jae,Ryu, Ji-Kon,Kim, Yong-Tae 대한소아외과학회 2006 소아외과 Vol.12 No.1

저자들은 만성췌장염으로 췌관결석이 합병되어 Puestow-Gillesby 췌관 공장 측측변형 문합술을 시행 받은 14 세 환아와 합병증이 발생하지 않은 만성췌장염을 앓고 있는 13세의 환아의 여자형제, 췌장암으로 사망한 외삼촌과 만성췌장염으로 배액술을 받은 26세 사촌언니를 가진 유전성 췌장염한 가계를 경험하였다. 또한 이들을 대상으로 유전자를 검사하여 R122H 변이를 관찰하였기에 보고하는 바이다. Hereditary pancreatitis (HP) appears as an autosomal dominant trait. If the patient has (1) more than 2 affected relatives in different generations and (2) no known etiological factors such as alcohol or gallstones, or has R122H or N29I mutation in the cationic trypsinogen (CT) gene, the diagnosis of HP can be applied. Risk of pancreatic cancer is estimated to be 53-fold higher than in a general population after the age of 50 years. We report a kindredof HP, involving three of its family together; two siblings (14 years old, 13 years old) and cousin (26 years old). The patient had complicating chronic pancreatitis and pancreatic stone, and was treated with amodified Puestow-Gillesby procedure. Her sisters showed chronic pancreatitis. Her cousin underwent a drainage procedure of the pancreatic duct for chronic pancreatitis during the high school period. All the three members showed the R122H mutation of the CT gene.

Assessment of functional outcome of patients undergoing surgery for chronic pancreatitis: A prospective study

Pagadala Naga Balaji Nitesh,Vutukuru Venkatarami Reddy,Sivarama Krishna Gavini,Suresh Vaikkakara,Chandramaliteeswaran Chandraha,Musunuru Bramheswara Rao,Dasari Varun 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.2

Backgrounds/Aims: This study was done with the aim of assessing impact of surgery for chronic pancreatitis on exocrine and endocrine functions, quality of life and pain relief of patients. Methods: 35 patients of chronic pancreatitis who underwent surgery were included. Exocrine function assessed with fecal fat globule estimation and endocrine function assessed with glycated haemoglobin (HbA1C), fasting plasma glucose (FPG), Insulin and C-peptide levels. Percentage (%) beta cell function by homeostatic model assessment (HOMA) was determined using web-based calculator. Quality of life (QOL) and pain assessment was done using Short form survey (SF-36) questionnaire and Izbicki scores respectively. Follow up done till 3 months following surgery. Results: Endocrine insufficiency was noted in 13 (37%) patients in the postoperative period compared to 17 (49%) patients preoperatively (p=0.74). Exocrine insufficiency was detected in 11 (32%) patients postoperatively compared to 8 (23%) patients preoperatively, with denovo insufficiency noted in 3 (8%) patients (p<0.05). The mean Izbicki score at 3 months postoperatively was remarkably lower compared to preoperative score (29.3±14.3 vs. 60.6±12.06; p<0.05). QOL at 3 months following surgery for chronic pancreatitis was significantly better than preoperative QOL (50.24±22.16 vs. 69.48±20.81; p<0.05). Conclusions: Significant pain relief and improvement in quality of life among patients of chronic pancreatitis following surgery. However, worsening of exocrine function with only clinical improvement of endocrine function was also noted.

Giant solitary pancreatic stone in a chronic pancreatitis patient

Osman Cagin Buldukoglu,Serkan Ocal,Tugrul Cakir,Ahmet Sukru Alparslan,Ayhan Hilmi Cekin 소화기인터벤션의학회 2023 International journal of gastrointestinal interven Vol.12 No.3

Chronic pancreatitis (CP) is a chronic, progressive, inflammatory disease of the pancreas. Pancreatolithiasis is a complication of CP. In this case report, we present a patient with a giant solitary pancreatic stone that necessitated surgery. A 34-year-old patient with CP presented to our outpatient clinic with abdominal pain. Computed tomography revealed near-total atrophy of the pancreatic parenchyma and an 85-mm-long stone within the main pancreatic duct. Due to abdominal pain refractory to medical treatment and the long-term malignancy risk in the near-totally atrophic pancreas, the decision was made to perform surgery based on a multidisciplinary team meeting. Total pancreatectomy was carried out and a 30 × 85 mm pancreatic stone filling the main pancreatic duct was found in the specimen. Intractable pain, local complications of adjacent organs, and suspicion of a malignant lesion are indications for surgery in patients with CP. A case-based clinical approach is necessary for the management of pancreatic stones.

Port-site metastasis after laparoscopic radical pancreatosplenectomy in left-sided pancreatic cancer

Su Hyeong Park,Zhanay Zhassanov,Chang Moo Kang 한국간담췌외과학회 2024 Annals of hepato-biliary-pancreatic surgery Vol.28 No.1

Despite debates regarding the safety of well-selected left-sided pancreatic cancer, minimally invasive distal pancreatosplenectomy is considered safer and more effective than open distal pancreatosplenectomy in well-selected patients. Previous studies have shown that minimally invasive surgery yields comparable oncologic outcomes to open surgery. While patients who undergo minimally invasive distal pancreatosplenectomy also experience recurrences and metastases after surgery, port-site metastasis is particularly rare. In this report, we report an extremely rare case of port-site metastasis following minimally invasive distal pancreatosplenectomy for left-sided pancreatic cancer.