In this study, we assessed the prognostic efficacy and feasibility of combined arterial resection (AR) for locally advanced pancreatic cancer (LAPC), and aimed to identify significant prognostic factors for patients who underwent combined AR.Between 1981 and 2018, 733 consecutive patients who underwent pancreatic surgery for PC were identified. The 730 cases with detailed information were enrolled in the analysis.Among 730 resected PC patients, 44 (6%) underwent AR including 21 hepatic (48%), 12 celiac (27%), five splenic (12%), four superior mesenteric (9%), and two other arteries (4%). The combined AR surgery showed significantly longer operative time (median, 608 vs 451 min, P < 0.0001), and the incidence of intraoperative blood transfusion was significantly higher in AR than surgery without AR (P = 0.0002), whereas there was no significant difference in the intraoperative blood loss (970 vs 1200 mL, P = 0.2) and occurrence of major complications (P = 0.5). In prognostic analysis of AR cases, multivariate Cox proportional hazard models revealed preoperative and postoperative therapy were the independent factors for both recurrence-free survival (RFS) and overall survival (OS) (preoperative therapy: RFS, HR = 0.21, P = 0.007; OS, HR = 0.18, P = 0.01; postoperative therapy: RFS, HR = 0.31, P = 0.003; OS, HR = 0.19, P = 0.002).This study showed the feasibility of combined AR for LAPC and robust association of pre- and postoperative therapy and survival after AR surgery. Preoperative therapy following combined AR surgery is potentially powerful strategy for LAPC.Copyright © 2019 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

The aim of this study was to achieve radical resection of locally advanced pancreatic ductal adenocarcinoma (PDAC), and tested the safety and benefits of intestinal autotransplantation in pancreatic surgery.PDAC has extremely dismal prognosis. Radical resection was proved to improve prognosis of patients with PDAC; however, locally advanced disease had a very low resection rate currently. We explored and evaluated whether the combination of modern advances in systemic treatment and this microinvasive surgery was feasible in clinical practice.Patients diagnosed as PDAC with superior mesenteric artery (SMA) involvement and with or without coeliac trunk involvement were included. Patients were treated with modified-FOLFIRINOX chemotherapy with or without anti-PD-1 antibodies, and were applied to tumor resection combined with intestinal autotransplantation. Data of operative parameters, pathological results, mortality, morbidity, and survival were analyzed.A total of 36 consecutive cases were applied to this strategy and underwent radical resection combined with intestinal autotransplantation. Among these patients, 24 of them received Whipple procedure, eleven patients received total pancreatectomy, and the other one patient received distal pancreatectomy. The median operation time was 539 minutes. Postoperative pathology showed R0 resection rate of 94.4%, and tumor invasion of SMA or SMV was confirmed in 32 patients. The median number of dissected lymph nodes was 43, and 25 patients were positive for lymph nodes metastasis. The median time of Intensive Care Unit stay was four days. Two patients died within 30 days after surgery due to multi-organ failure. The severe postoperative adverse events (equal or higher than grade 3) was observed in 12 out of 36 patients, and diarrhea, gastroparesis, and abdominal infection were the most frequent adverse events. Postoperative hospital stay was averagely 34 days. The recurrence-free survival is 13.6 months. The median overall survival of patients after diagnosis and after surgery were 21.4 months and 14.5 months, respectively.Our attempt suggests safety of this modality and may be clinically beneficial for highly-selected patients with PDAC. However, experience of multidisciplinary pancreatic cancer care and intestinal transplantation is warranted.Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

To identify predictive factors associated with operative morbidity, mortality, and survival outcomes in patients with borderline resectable (BR) or locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) undergoing total neoadjuvant therapy (TNT).

Carbohydrate antigen 19-9 (CA19-9) is a prognostic marker for patients with pancreatic cancer (PC), but its value as a treatment biomarker is unclear.Although CA19-9 is an established prognostic marker for patients with PC, it is unclear how CA19-9 monitoring should be used to guide multimodality treatment and what level of change in CA19-9 constitutes a meaningful treatment response.CA19-9 measurements at diagnosis (pretx), after completion of all planned neoadjuvant therapy (preop), and after surgery (postop) were analyzed in patients with localized PC who had an elevated CA19-9 (≥35 U/dL) at diagnosis. Patients were classified by: 1) quartiles of pretx CA19-9 (Q1-4); 2) proportional changes in CA19-9 (ΔCA19-9) after the completion of neoadjuvant therapy; 3) normalization (CA19-9 <35 U/dL) of preop CA19-9; and 4) normalization of postop CA19-9.Among 131 patients, the median overall survival (OS) was 30 months; 68 months for the 33 patients in Q1 of pretx CA19-9 (<80 U/dL) compared with 25 months for the 98 patients in Q2-4 (P = 0.03). For the 98 patients in Q2-4, preop CA19-9 declined (from pretx) in 86 (88%), but there was no association between the magnitude of ΔCA19-9 and OS (P = 0.77). Median OS of the 98 patients who did (n = 29) or did not (n = 69) normalize their preop CA19-9 were 46 and 23 months, respectively (P = 0.02). Of the 69 patients with an elevated preop CA19-9, 32 (46%) normalized their postop CA19-9. Failure to normalize preop or postop CA19-9 was associated with a 2.77-fold and 4.03-fold increased risk of death, respectively (P < 0.003) as compared with patients with normal preop CA19-9.Following neoadjuvant therapy, normalization of CA19-9, rather than the magnitude of change, is the strongest prognostic marker for long-term survival.

Intraoperative ultrasound (IOUS) allows confirming and verifying the preoperative diagnosis. In many cases it allows correct determination of the severity of the disease, safe surgery performance and shortening its duration. Proper assessment of anatomic structures during the surgery and evaluation of the operating field after the treatment termination, in combination with their ultrasound evaluation that permits more complete assessment of radical treatment. The aim of the study was to define current indications for the use of intraoperative ultrasound in the treatment of pancreatic lesions, based on our own experience and the cited literature.The Clinic, where the authors work, uses intraoperative ultrasound in everyday practice. In this paper we try to share our experience in this imaging technique. Studies were compared before the procedure both in the ultrasound and CT examination rooms with the images obtained intraoperatively. Intraoperative examination was performed by the surgeon who performed assessment before the procedure, what enabled verification of diagnoses. Presented material refers to 102 IOUS procedures performed during laparotomy due to pancreatic lesions.IOUS is a reliable test for the evaluation of both inflammatory and acute lesions in the pancreas during the surgery of chronic, symptomatic pancreatitis. It correctly determines the extent of the planned surgery. In the case of pancreatic cancer it verifies local severity of the tumour lesions, assessing involving of the peripancreatic vessels, lymph nodes and the presence of local and distant metastases, including those in the liver. IOUS proved highly effective in the evaluation of endocrine and cystic pancreatic tumours. The study significantly improves the effectiveness of intraoperative BAC and aspiration or drainage of fluid reservoirs.

Determining the resectability of pancreatic cancer with vascular involvement on preoperative computed tomography imaging remains challenging, especially following preoperative chemotherapy and chemoradiotherapy. Intraoperative ultrasound (IOUS) may provide real-time additional information, but prospective multicenter series confirming its value are lacking.This prospective multicenter study included patients undergoing surgical exploration for pancreatic cancer with vascular involvement. All patients underwent IOUS at the start of explorative laparotomy. Primary outcomes were resectability status as defined by the National Comprehensive Cancer Network and the extent of vascular involvement.Overall, 85 patients were included, of whom 74 (87%) were post preoperative chemotherapy, and mostly following FOLFIRINOX regimen (n = 57; 76%). On the basis of preoperative imaging, 34 (40%) patients were staged as resectable (RPC), 32 (38%) borderline resectable (BRPC), and 19 (22%) locally advanced pancreatic cancer (LAPC). IOUS changed the resectability status in 32/85 (38%) patients (p < 0.001), including 8/19 (42%) patients with LAPC who were downstaged (4 to BRPC, 4 to RPC), and 22/32 (69%) patients with BRPC who were downstaged to RPC. Among patients with presumed superior mesenteric artery (SMA) involvement, 20/28 (71%) had no SMA involvement on IOUS. In 15 of these 20 patients a pancreatic resection was performed, all with R0 SMA margin.IOUS during surgical exploration for pancreatic cancer and vascular involvement downstaged the resectability status in over one-third of patients, which could facilitate progress during surgical exploration. This finding should be confirmed by larger studies, including detailed pathology assessment. Trial Registration www.trialregister.nl (NL7621).© 2023. The Author(s).

To investigate the perioperative and oncologic long-term outcomes of patients with LAPC after surgical resection at a high-volume center for pancreatic surgery.

Few studies have compared patency rates of the different methods of venous reconstruction (VR) during a pancreatectomy. This study aimed to evaluate the patency rates and the clinical impact of various reconstruction methods.For the meta-analysis, databases were systematically searched to identify studies reporting the outcomes of patients who underwent PVR/SMVR. For the retrospective study, clinical data were retrospectively analyzed from patients who underwent a pancreatectomy and VR between Feb. 2009 and Oct. 2015. Patency was assessed by CT and/or ultrasound.For the meta-analysis, the long-term patency rates of the primary repair group and the autologous graft group were significantly higher than that of the synthetic graft group. For the retrospective study, the reconstruction consisted of primary repair in 62 cases (89.8%) and synthetic grafting in 7 cases (10.1%). Synthetic grafting was more likely to cause acute thrombosis compared with primary repair for PVR/SMVR (85.7% versus 16.7%). Acute thrombosis was associated with decreased median survival (12 versus 6 months) and increased hazard of death. Late thrombosis and stenosis were not associated with survival or serious clinical impact. Median survival for the primary repair group and the synthetic grafting group was 12 and 7 months, respectively.Primary repair following PVR/SMVR is preferred and can be achieved in most situations. Stenosis should be noted when with risk factors (long segmental and tension), but it produced little clinical impact. Synthetic grafting was associated with a higher thrombosis rate. Acute thrombosis is associated with increased mortality and decreased survival.Copyright © 2016 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest malignancies due to late diagnosis and limited treatment options. Circulating tumor DNA (ctDNA) is a promising, minimally invasive biomarker that could improve the clinical outcomes of patients with PDAC by enabling early disease detection, minimal residual disease (MRD) assessment, precise prognostication, and accurate treatment monitoring. CtDNA has prognostic as well as predictive value in both resectable and metastatic settings, with serial measurements enhancing risk stratification and recurrence prediction beyond CA19-9. However, despite the promise, the true potential of ctDNA has not yet been fulfilled in patients with PDAC. The current limitations include a low sensitivity of ctDNA assays in early stage PDAC, challenges in the assay interpretation due to the specific nature of ctDNA shedding in PDAC, inter-patient heterogeneity, and technical variability. As precision oncology advances, ctDNA will be a powerful tool for personalized care in PDAC, but rigorous validation of its use within specific clinical contexts is still needed before the true potential of ctDNA is realized for patients with PDAC.

Cancer antigen 19-9 (CA19-9) is used to assess treatment response among patients with pancreatic ductal adenocarcinoma (PDAC); however, nearly 30% of patients with PDAC do not produce elevated CA19-9.