Publications by authors named "John A Stauffer"

72 Publications

Surgical Treatment for Intrahepatic, Peri-Hilar, and Distal Cholangiocarcinoma: 20-Single Institutional Year Experience.

Am Surg 2021 Jul 27:31348211034751. Epub 2021 Jul 27.

Department of General Surgery, 156400Mayo Clinic, Jacksonville, FL, USA.

Background: Surgical resection is the curative treatment for all subtypes of cholangiocarcinoma (CCA), including intrahepatic, hilar/peri-hilar, and distal. This study evaluates patients with CCA who underwent surgery and determines factors that impact their survival.

Methods: A retrospective cohort study was performed for patients who underwent surgical resection for CCA at our institution from 1995 to 2016. Demographics, operative variables between CCA tumors, and postoperative complications were analyzed. Predictors of overall and recurrence-free survival were determined via statistical analysis.

Results: A total of 170 patients with a mean age of 61 years old underwent surgical resection of intrahepatic (n = 64, 37.6%), hilar/peri-hilar (n = 75, 44.1%), and distal (n = 31, 18.2%) CCA. Operations performed included liver resections (n = 83, 48.8%), liver transplants (n = 56, 32.9%), and pancreaticoduodenectomies (n = 31, 18.2%). The overall survival rate at 1, 5, and 10 years was 81.1%, 32.4%, and 17.2%, respectively. Low pathological stage and negative resection margins were associated with lower recurrence and higher survival rates. Tumor location and the type of operation performed were not predictive of recurrence or OS in this cohort.

Discussion: This study shows that definitive surgical resection with negative margins can result in long-term survival even at 10 years. Small tumor size and low pathological stage are predictive of higher survival rates post-surgery, emphasizing the importance of early diagnosis and appropriate surgical treatment in achieving positive outcomes.
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http://dx.doi.org/10.1177/00031348211034751DOI Listing
July 2021

Strategies to Develop Potent Oncolytic Viruses and Enhance Their Therapeutic Efficacy.

JCO Precis Oncol 2021 27;5. Epub 2021 Apr 27.

Division of Medical Oncology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ.

Despite advancements in cancer therapy that have occurred over the past several decades, successful treatment of advanced malignancies remains elusive. Substantial resources and significant efforts have been directed toward the development of novel therapeutic modalities to improve patient outcomes. Oncolytic viruses (OVs) are emerging tools with unique characteristics that have attracted great interest in developing effective anticancer treatment. The original attraction was directed toward selective replication and cell-specific toxicity, two unique features that are either inherent to the virus or could be conferred by genetic engineering. However, recent advancements in the knowledge and understanding of OVs are shifting the therapeutic paradigm toward a greater focus on their immunomodulatory role. Nonetheless, there are still significant obstacles that remain to be overcome to enhance the efficiency of OVs as effective therapeutic modalities and potentially establish them as part of standard treatment regimens. In this review, we discuss advances in the design of OVs, strategies to enhance their therapeutic efficacy, functional translation into the clinical settings, and various obstacles that are still encountered in the efforts to establish them as effective anticancer treatments.
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http://dx.doi.org/10.1200/PO.21.00003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232397PMC
April 2021

Evolving Role of Oncolytic Virotherapy: Challenges and Prospects in Clinical Practice.

JCO Precis Oncol 2021 24;5. Epub 2021 Feb 24.

Division of Medical Oncology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ.

Selective oncotropism and cytolytic activity against tumors have made certain viruses subject to investigation as novel treatment modalities. However, monotherapy with oncolytic viruses (OVs) has shown limited success and modest clinical benefit. The capacity to genetically engineer OVs makes them a desirable platform to design complementary treatment modalities to overcome the existing treatment options' shortcomings. In recent years, our knowledge of interactions of the tumors with the immune system has expanded profoundly. There is a growing body of literature supporting immunomodulatory roles for OVs. The concept of bioengineering these platforms to induce the desired immune response and complement the current immunotherapeutic modalities to make immune-resistant tumors responsive to immunotherapy is under investigation in preclinical and early clinical trials. This review provides an overview of attempts to optimize oncolytic virotherapy as essential components of the multimodality anticancer therapeutic approach and discusses the challenges in translation to clinical practice.
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http://dx.doi.org/10.1200/PO.20.00395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232075PMC
February 2021

The use of neoadjuvant lobar radioembolization prior to major hepatic resection for malignancy results in a low rate of post hepatectomy liver failure.

J Gastrointest Oncol 2021 Apr;12(2):751-761

Department of Radiology, Mayo Clinic, Jacksonville, FL, USA.

Background: Neoadjuvant yttrium-90 transarterial radioembolization (TARE) is increasingly being used as a strategy to facilitate resection of otherwise unresectable tumors due to its ability to generate both tumor response and remnant liver hypertrophy. Perioperative outcomes after the use of neoadjuvant lobar TARE remain underinvestigated.

Methods: A single center retrospective review of patients who underwent lobar TARE prior to major hepatectomy for primary or metastatic liver cancer between 2007 and 2018 was conducted. Baseline demographics, radioembolization parameters, pre- and post-radioembolization volumetrics, intra-operative surgical data, adverse events, and post-operative outcomes were analyzed.

Results: Twenty-six patients underwent major hepatectomy after neoadjuvant lobar TARE. The mean age was 58.3 years (17-88 years). 62% of patients (n=16) had primary liver malignancies while the remainder had metastatic disease. Liver resection included right hepatectomy or trisegmentectomy, left or extended left hepatectomy, and sectorectomy/segmentectomy in 77% (n=20), 8% (n=2), and 15% (n=4) of patients, respectively. The mean length of stay was 8.3 days (range, 3-33 days) and there were no grade IV morbidities or 90-day mortalities. The incidence of post hepatectomy liver failure (PHLF) was 3.8% (n=1). The median time to progression after resection was 4.5 months (range, 3.3-10 months). Twenty-three percent (n=6) of patients had no recurrence. The median survival was 28.9 months (range, 16.9-46.8 months) from major hepatectomy and 37.6 months (range, 25.2-53.1 months) from TARE.

Conclusions: Major hepatectomy after neoadjuvant lobar radioembolization is safe with a low incidence of PHLF.
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http://dx.doi.org/10.21037/jgo-20-507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107583PMC
April 2021

Percutaneous direct pancreatic duct intervention in management of pancreatic fistulas: a primary treatment or temporizing therapy to prepare for elective surgery.

BMC Gastroenterol 2021 Jan 28;21(1):44. Epub 2021 Jan 28.

Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA.

Background: This study evaluates preliminary results of image-guided percutaneous direct pancreatic duct intervention in the management of pancreatic fistula after surgery or pancreatitis when initially ineligible for surgical or endoscopic therapy.

Methods: Between 2001 and 2018 the medical records of all patients that underwent percutaneous pancreatic duct intervention for radiographically confirmed pancreatic fistula initially ineligible for surgical or endoscopic repair were reviewed for demographics, clinical history, procedure details, adverse events, procedure related imaging and laboratory results, ability to directly catheterized the main pancreatic duct, and whether desired clinical objectives were met.

Results: In 10 of 11patients (6 male and 5 female with mean age 60.5, range 39-89) percutaneous pancreatic duct cannulation was possible. The 10 duct interventions included direct ductal suction drainage in 7, percutaneous duct closure in 3 and stent placement in 1. Pancreatic fistulas closed in 7 of 10, 2 were temporized until elective surgery, and 1 palliated until death from malignancy. The single patient with failed duct cannulation resolved the fistula with prolonged catheter drainage of the peri-pancreatic cavity. There were no major adverse events related to intervention.

Conclusion: In patients with pancreatic fistulas initially ineligible for endoscopic therapy or elective surgery, direct percutaneous pancreatic duct interventions are possible, can achieve improvement without major morbidity or mortality, and can improve and maintain the medical condition of patients in preparation for definitive surgery.
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http://dx.doi.org/10.1186/s12876-021-01620-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7844943PMC
January 2021

Surgeon experience contributes to improved outcomes in pancreatoduodenectomies at high risk for fistula development.

Surgery 2021 04 30;169(4):708-720. Epub 2020 Dec 30.

Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Electronic address:

Background: Pancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood.

Methods: The fistula risk score was applied to identify high-risk patients (fistula risk score 7-10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003-2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models.

Results: Eight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (-49.7%) and career length (-41.2%; both P < .001), as did transfusion and reoperation rates, postoperative morbidity index, and duration of stay. Great experience (≥400 pancreatoduodenectomies performed or ≥21-year-long career) was a significant predictor of clinically relevant pancreatic fistula prevention (odds ratio 0.52, 95% confidence interval 0.35-0.76) and was more often associated with pancreatojejunostomy reconstruction and prophylactic octreotide omission, which were both independently associated with clinically relevant pancreatic fistula reduction. A risk-adjusted performance analysis also correlated with experience. Moreover, minimizing blood loss (≤400 mL) significantly contributed to clinically relevant pancreatic fistula prevention (odds ratio 0.40, 95% confidence interval 0.22-0.74).

Conclusion: Surgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.
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http://dx.doi.org/10.1016/j.surg.2020.11.022DOI Listing
April 2021

Outcomes of Minimally Invasive Versus Open Major Hepatic Resection.

J Laparoendosc Adv Surg Tech A 2020 Jul 23;30(7):790-796. Epub 2020 Apr 23.

Department of Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Minimally invasive major hepatic resection (MIMHR) is increasingly being performed in tertiary centers using either hand-assisted laparoscopic surgery (HALS) or totally laparoscopic surgery (TLS). The outcomes data of MIMHR are scarce, especially in comparison to open major hepatic resection (OMHR). Our aim was to compare 90-day outcomes in major hepatic resections when minimally invasive approaches are attempted. At our institution, minimally invasive liver resection was formally introduced in January 2007, initially using the HALS approach. Since then, the use of TLS approach has increased. We collected data on all patients who underwent major liver resection between January 2007 and December 2017 at our institution. In an intention to treat fashion, we then compared MIMHR to OMHR. From January 2007 to December 2017, 669 patients underwent liver resection. Of these, 203 patients (30%) underwent major hepatic resection and MIMHR and OMHR were performed in 68 (33%) and 135 (67%) patients, respectively. The rate of conversion from minimally invasive to open was 30.9%. Overall, there were no significant differences in 90-day mortality (2.9% versus 1.5%;  = .499) or major complications (14.7% versus 14.8%;  = .985). MIMHR was associated with a shorter average postoperative hospital stay (6.2 days versus 7.9 days;  = .0110) and shorter average ICU stay (0.66 days versus 0.90 days;  = .0299) compared with OMHR. The minimally invasive approach to major liver resection is a safe and reasonable alternative to an open approach when performed by a surgeon experienced with the relevant surgical techniques. MIMHR may be associated with similar outcomes and a shorter postoperative hospital stay with no increase in 90-day postoperative complications to OMHR.
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http://dx.doi.org/10.1089/lap.2019.0615DOI Listing
July 2020

Intraoperative Irreversible Electroporation in Locally Advanced Pancreatic Cancer: A Guide for the Interventional Radiologist.

Semin Intervent Radiol 2019 Dec 2;36(5):386-391. Epub 2019 Dec 2.

Division of Interventional Radiology, Department of Radiology, Mayo Clinic, Jacksonville, Florida.

Efforts to improve mortality associated with locally advanced pancreatic cancer (LAPC) have shown minimal gains despite advances in surgical technique, systemic treatments, and radiation therapy. Locoregional therapy with ablation has not been routinely adopted due to the high risk of complications associated with thermal destruction of the pancreas. Irreversible electroporation (IRE) is an emerging, nonthermal, ablative technology that has demonstrated the ability to generate controlled ablation of LAPC while preserving pancreatic parenchymal integrity. IRE may be performed percutaneously or via laparotomy and will commonly involve multidisciplinary treatment teams. This article will describe the technical aspects of how multidisciplinary IRE is performed during laparotomy at a single tertiary care institution.
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http://dx.doi.org/10.1055/s-0039-1697640DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887528PMC
December 2019

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection.

Ann Surg 2020 01;271(1):1-14

Department of HPB surgery, Methodist Richardson Medical Center, Richardson, TX.

Objective: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019).

Summary Background Data: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking.

Methods: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology.

Results: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety.

Conclusion: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.
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http://dx.doi.org/10.1097/SLA.0000000000003590DOI Listing
January 2020

Pancreaticoduodenectomy in Patients with Previous Roux-en-Y Gastric Bypass: a Matched Case-Control Study.

Obes Surg 2020 01;30(1):369-373

Department of Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.

Little has been reported regarding outcomes of pancreaticoduodenectomy (PD) in patients with previous Roux-en-Y gastric bypass (RYGB). We performed a retrospective case-control study of patients undergoing PD after RYGB from January 2012 through July 2017 at 2 institutions. Of the 380 patients who underwent PD, 12 (3.2%) had previous RYGB. They were matched (by age, sex, diagnosis, operative approach, and year of surgery) to 36 non-RYGB patients undergoing PD (1:3 ratio). No difference was found between groups in mean operative time, length of hospitalization, or postoperative morbidity. A history of RYGB in patients with pancreatic head pathology did not delay surgical intervention. Outcomes of PD were similar for patients who did or did not have prior RYGB.
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http://dx.doi.org/10.1007/s11695-019-04068-zDOI Listing
January 2020

Technique and audited outcomes of laparoscopic distal pancreatectomy combining the clockwise approach, progressive stepwise compression technique, and staple line reinforcement.

Surg Endosc 2020 01 28;34(1):231-239. Epub 2019 May 28.

General Surgery Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.

Background: Laparoscopic distal pancreatectomy (LDP) has proven advantages over its open counterpart and is becoming more frequently performed around the world. It still remains a difficult operation due to the retroperitoneal location of the pancreas and limited experience and training with the procedure. In addition, complications such as bleeding or postoperative pancreatic fistula (POPF) remain a problem. A standardized approach to LDP with stepwise graded compression technique for pancreatic transection has been utilized at a single center, and we sought to describe the technique and determine the outcomes.

Methods: A review of all patients undergoing LDP by a clockwise approach including the graded compression technique from August 1, 2008 to December 31, 2017 was performed. An external audit was performed by the Dutch Pancreatic Cancer Group.

Results: Overall, 260 patients with a mean age and a BMI of 62.3 and 28, respectively, underwent LDP using this technique. Mean operative time and blood loss were 183 min and 248 mL, respectively,. Hand-assisted method and conversion to open were both 5%. Major morbidity and mortality were 9.2% and 0.4%, respectively,. POPF was noted in 8.1%. The technical steps include (1) mobilization of the splenic flexure of the colon and exposure of the pancreas, (2) dissection along the inferior edge of the pancreas and choosing the site for pancreatic division, (3) pancreatic parenchymal division using a progressive stepwise compression technique with staple line reinforcement, (4) ligation of the splenic vein and artery, (5) dissection along the superior edge of the pancreas and residual posterior attachments, and (6) mobilization of the spleen and specimen removal.

Conclusion: LDP with a clockwise approach for dissection, combined with the progressive stepwise compression technique for pancreatic transection, resulted in excellent outcomes including a very low POPF rate.
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http://dx.doi.org/10.1007/s00464-019-06757-3DOI Listing
January 2020

Minimally Invasive Approaches to Pancreatic Cancer.

Surg Oncol Clin N Am 2019 04 10;28(2):255-272. Epub 2019 Feb 10.

Department of General Surgery, Mayo Clinic, Davis 3N, 4500 San Pablo Road, Jacksonville, FL 32224, USA; Miami Cancer Institute, 8900 North Kendall Drive, Miami, FL 33176, USA; Mayo Clinic College of Medicine and Sciences, 200 First Street South West, Rochester, MN 55905, USA.

In pancreatic cancer, resection combined with neoadjuvant and/or adjuvant therapy remains the only chance for cure and/or prolonged survival. A minimally invasive approach to pancreatic cancer has gained increased acceptance and popularity. The aim of minimally invasive surgery of the pancreas includes limiting trauma, decreasing length of hospitalization, lessening cost, decreasing blood loss, and allowing for a more meticulous oncologic dissection. New advances and routine use in practice have helped progress the field making the minimally invasive approach more feasible. In this article, the minimally invasive surgical approaches to proximal, central, and distal pancreatic cancer are described and literature reviewed.
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http://dx.doi.org/10.1016/j.soc.2018.11.006DOI Listing
April 2019

Postsplenectomy thrombosis of splenic, mesenteric, and portal vein (PST-SMPv): A single institutional series, comprehensive systematic review of a literature and suggested classification.

Am J Surg 2018 12 5;216(6):1192-1204. Epub 2018 Feb 5.

Department of Surgery, Mayo Clinic, Jacksonville, FL, USA. Electronic address:

Objectives: No standard classification exists for post-splenectomy thrombosis of splenic, mesenteric, and portal vein (PST-SMPv). The goal of this study was to review our institution's experience with PST-SMPv and to perform a systematic literature review.

Methods: A retrospective review of all patients undergoing splenectomy from 1995-2016 at our institution was performed. Additionally, six databases and four grey literature websites were systematically searched. Splenectomy for pediatric patients or for trauma or portal hypertension related reasons were excluded.

Results: Between 1995 and 2016, 229 patients (113; 49.3% males) underwent splenectomy for spleen related diseases at our institution. From 1895 to 2016, 1645 unique literature citations were identified. Twenty citations met our inclusion criteria. Data on 1745 splenectomized patients was compiled; PST-SMPv occurred in 141 (8.1%).

Conclusions: In our series, PST-SMPv developed in 6.6% of patients and the incidence of PST-SMPv after splenectomy in the literature ranges from 0.8 - 53.0%. A call for standardized reporting through a proposed classification is made.
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http://dx.doi.org/10.1016/j.amjsurg.2018.01.073DOI Listing
December 2018

Pancreaticoduodenectomy: minimizing the learning curve.

J Vis Surg 2018 30;4:64. Epub 2018 Mar 30.

Department of Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Background: Pancreaticoduodenectomy outcomes improve as surgeon experience increases. We analyzed the outcomes of pancreaticoduodenectomy for any improvements over time to assess the learning curve.

Methods: A retrospective study of patients undergoing consecutive pancreaticoduodenectomy by a single surgeon at the beginning of practice was performed. Operative factors and 90-day outcomes were examined and trends over the course of the 4-year time period were analyzed.

Results: Between July 2011 and June 2015, 124 patients underwent pancreaticoduodenectomy (including total pancreatectomy, n=17) by open (n=93) or a laparoscopic (n=31) approach. The median operative time was 305 minutes which significantly improved over time. The median blood loss and length of stay were 250 mL and 6 days respectively which did not change over time. The pancreatic fistula rate, total morbidity, major morbidity, and mortality, and readmission rate was 7.5%, 41.1%, 14.5%, 1.6%, and 15.3% respectively and did not change over time. Pancreaticoduodenectomy was performed most commonly for pancreatic adenocarcinoma (51.6%) with a negative margin rate of 91.1% which significantly improved over time.

Conclusions: The performance of pancreaticoduodenectomy improves as surgical experience is gained. However, a learning curve that impacts patient outcomes can be considerably diminished by appropriate training, high-volume practice/institution, proficient mentorship and experienced multidisciplinary team.
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http://dx.doi.org/10.21037/jovs.2018.03.07DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5897672PMC
March 2018

Correction to: Endoscopic and surgical management of nonampullary duodenal neoplasms.

Surg Endosc 2018 Jun;32(6):2870

Department of Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.

This article was updated to correct the author listing for Carlos Roberto Simons-Linares.
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http://dx.doi.org/10.1007/s00464-018-6117-0DOI Listing
June 2018

Endoscopic and surgical management of nonampullary duodenal neoplasms.

Surg Endosc 2018 06 1;32(6):2859-2869. Epub 2018 Feb 1.

Department of Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.

Background: Sporadic nonampullary duodenal neoplasms (SNADN) can have malignant potential for which endoscopic and surgical resections are offered. We report combined gastroenterologic and surgical experience for treatment of SNADN, including endoscopic mucosal resection (EMR) and pancreas-preserving partial duodenectomy (PPPD).

Methods: We retrospectively reviewed 121 consecutive patients, who underwent 30 PPPDs and 91 EMRs for mucosal and submucosal SNADN. Decision to undergo EMR or surgical resection was based on expert endoscopist and surgeon discretion including multidisciplinary tumor board review. Main outcomes were recurrence rate of neoplasia and adverse events requiring hospital admission or prolonged care. EMRs were performed with submucosal lifting followed by snare resection. PPPD included total duodenectomy, supra-ampullary PPPD for neoplasms proximal to the ampulla, and infra-ampullary PPPD for lesions distal to the ampulla. Follow-up data were available for 65% of EMR and 73% of surgical patients.

Results: Surgically resected neoplasia was larger with more advanced neoplasia and submucosal lesions. En bloc resection was achieved in all surgical resections and in 53% of EMRs. Post-EMR, mucosal and submucosal neoplasia recurred in 32 and 0%, respectively, including five neoplasms (26%) after an initial negative esophagogastroduodenoscopy. All recurrences were treated endoscopically. Complications occurred in 14 endoscopically and eight surgically treated patients, none requiring surgical intervention.

Conclusions: Post-EMR patients had higher recurrence of mucosal neoplasia, whereas submucosal neoplasms, mainly carcinoid, did not recur. Polyp size and positive resection margin were not associated with neoplasia recurrence. Patients with SNADN could benefit from a multidisciplinary approach to stratify the optimal treatment based on local expertise.
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http://dx.doi.org/10.1007/s00464-017-5994-yDOI Listing
June 2018

Pancreaticoduodenectomy and Outcomes for Groove Pancreatitis.

Dig Surg 2018 18;35(6):475-481. Epub 2018 Jan 18.

Department of Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Background/aims: The operative management of groove pancreatitis (GP) is still a matter of controversy and pancreaticoduodenectomy (PD) can be a high-risk procedure for patients. The aim of this study was to report our 9-year experience of surgical resection for GP and to review relevant literature.

Methods: A retrospective review of patients undergoing pancreatectomy for GP from August 1, 2008, through May 31, 2017 was performed. Patients with clinical, radiologic, and final pathologic confirmation of GP were included. Literature on the current understanding of GP was reviewed.

Results: Eight patients from total 449 pancreatectomies met inclusion criteria. Four male and 4 female patients (mean age, 51.9 years; mean body mass index, 25.3) underwent pylorus-preserving pancreatoduodenectomy (3 by laparoscopy and 5 by open approach). Mean (range) operative time and blood loss was 343 (167-525) min and 218 (40-500) mL respectively. Pancreatic fistula and delayed gastric emptying were noted in one patient each. No major complications occurred, but minor complications occurred in 5 (62%) patients. Mean hospital stay was 6.1 (range 3-14) days. At median follow-up of 18.15 (interquartile range 7.25-33.8) months, all patients experienced a resolution of pancreatitis and improvement in symptoms.

Conclusions: PD is a safe procedure for GP. Short-term surgical outcomes are acceptable and long-term outcomes are associated with improved symptom control.
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http://dx.doi.org/10.1159/000485849DOI Listing
January 2019

Rare Tumors and Lesions of the Pancreas.

Surg Clin North Am 2018 Feb;98(1):169-188

Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA. Electronic address:

There are a few entities that account for most solid and cystic masses of the pancreas. The pancreas harbors a wide array of diseases, including adenocarcinoma, and its variants, such as anaplastic and adenosquamous carcinoma. Other neoplasms include acinar cell carcinoma, solid pseudopapillary tumor, and sarcomas. Benign lesions include hamartomas, hemangiomas, lymphangioma, and plasmacytoma. Isolated metastases include renal cell carcinoma, melanoma, and other carcinomas. Benign inflammatory conditions, such as autoimmune pancreatitis and groove pancreatitis can also mimic solid neoplasms of the pancreas.
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http://dx.doi.org/10.1016/j.suc.2017.09.013DOI Listing
February 2018

Subcostal Trocar Approach Using Four 5-mm with Exclusive Removal (STAUFFER): An Efficient and Useful Technique for Laparoscopic Cholecystectomy.

J Laparoendosc Adv Surg Tech A 2018 Mar 31;28(3):311-319. Epub 2017 Oct 31.

1 Department of Surgery, Mayo Clinic , Jacksonville, Florida.

Background: Laparoscopic cholecystectomy (LC) is commonly performed in patients who can pose technical challenges, such as obesity, prior surgery, and subsequent incisional hernias. A new technique, the subcostal trocar approach using four 5-mm with exclusive removal (STAUFFER) LC, was developed to diminish these impediments and is highly advantageous.

Methods: A retrospective review was performed of medical records for 389 patients who underwent LC from June 2011 through December 2016. STAUFFER LC involves (1) steep patient positioning, (2) visualized 5-mm trocar entry in the right abdomen, (3) use of three additional right subcostal trocars, and (4) gallbladder extraction from the high right lateral trocar site. Patient characteristics, operative details, and outcomes were analyzed and compared.

Results: STAUFFER LC was used in 255 patients (65.6%), and standard four-trocar LC (SLC) was performed in 134 patients (34.4%). Overall indications for surgery included chronic cholecystitis (71.7%), acute cholecystitis (19.8%), polyp (2.3%), and other (5.9%). No significant differences were detected in comorbidities and American Society of Anesthesiologists classification between the two patient groups. More patients in the STAUFFER LC group had previous midline abdominal surgery (P = .06) and significantly higher body mass index (P = .03), and they required less operative time (P < .001). No patient had an entry site injury. No significant difference was noted in morbidity. One patient required a second laparoscopic operation for bleeding. One patient with Crohn's disease and "hostile abdomen" had an enterocutaneous fistula that closed spontaneously. In the SLC group, trocar site hernia (TSH) developed in 3 patients.

Conclusions: STAUFFER LC is widely applicable and effective, saving operative time and reducing the risk of TSH. It is especially advantageous for obese patients who have had previous surgery.
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http://dx.doi.org/10.1089/lap.2017.0554DOI Listing
March 2018

Laparoscopic Splenectomy for Massive Splenomegaly: Does Size Matter?

J Laparoendosc Adv Surg Tech A 2017 Oct 11;27(10):1009-1014. Epub 2017 Aug 11.

General Surgery, Mayo Clinic , Jacksonville, Florida.

Background: Laparoscopic splenectomy (LS) has become the most common approach for elective splenectomy, but use of LS for patients with massive splenomegaly (MS) remains controversial. By the 2008 European guidelines, LS for MS (spleen size >20 cm) is generally not recommended.

Methods: We performed a retrospective analysis of 229 consecutive patients undergoing LS, hand-assist (HALS), and open splenectomy (OS) at our institution from January 1, 1995 to December 2016. Eighty-six (38%) had MS. Patient demographics, comorbidities, operative details, and outcomes were analyzed.

Results: Of 86 patients with MS, 27 (31%) underwent LS, 12 (14%) HALS, and 47 (55%) OS. No significant difference was revealed in patient demographics, comorbidities, American Society of Anesthesiologists class, and spleen size (24.2 cm vs. 23.7 cm vs. 26.6 cm, P = .06). Benign spleen diseases (23), malignancy (57%), and miscellaneous (20%) were indications for surgery. The mean operative time and estimated blood loss in LS, HALS, and OS were 153, 168, and 131 minutes (P = .17) and 100, 162, and 278 mL (P = .24), respectively. Three patients (11.1%) with LS and 1 (8.3%) with HALS required conversion to OS for different reasons (spleen size, technical difficulties, bleeding). Morbidity was similar in all three groups (P = .99). One mortality (1.1%) was noted after OS. Six (7%) patients in the LS group and three (3.5%) in the OS group developed postsplenectomy thrombosis of splenic, mesenteric, and portal veins. Length of stay was shorter in patients with LS and almost reached clinical significance (3.2 vs. 4.9 vs. 5.2 days; P = .06).

Conclusion: LS is safe, feasible, and associated with shorter hospital stay than HALS and OS for MS.
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http://dx.doi.org/10.1089/lap.2017.0384DOI Listing
October 2017

Laparoscopic Sleeve Gastrectomy for Morbid Obesity in Patients After Orthotopic Liver Transplant: a Matched Case-Control Study.

Obes Surg 2018 02;28(2):444-450

Department of Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.

Introduction: Obesity is frequently encountered in patients with orthotopic liver transplant (OLT). The role of bariatric surgery is still unclear for this specific population. The aim of this study was to review our experience with laparoscopic sleeve gastrectomy (LSG) after OLT.

Material And Methods: We performed a retrospective case-control study of patients undergoing LSG after OLT from 2010 to 2016. OLT-LSG patients were matched by age, sex, body mass index (BMI), and year to non-OLT patients undergoing LSG. Demographics, operative variables, postoperative events, and long-term weight loss with comorbidity resolution were collected and compared between cases and controls.

Results: Of 303 patients undergoing LSG, 12 (4%) had previous OLT. They were matched to 36 non-OLT patients. No difference was found between groups in the American Society of Anesthesiologists class, mean operative time, or postoperative morbidity. The non-OLT group, however, had a significantly shorter mean hospital stay than the OLT group (1.7 vs 3.1 days; P < .001). There were no conversions to open procedures. For patients with long-term follow-up, change in BMI after LSG was similar between the groups, but the non-OLT patients had significantly more excess body weight loss at 2 years (53.7 vs 45.2%; P < .001). Similar resolution of comorbid conditions was noted in both groups. LSG caused no changes in dosage of immunosuppressive medications, and no liver complications occurred.

Conclusion: LSG after OLT in appropriately selected patients appears to have similar outcomes to LSG in non-OLT patients.
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http://dx.doi.org/10.1007/s11695-017-2847-7DOI Listing
February 2018

Late onset asymptomatic pancreatic neuroendocrine tumor - A case report on the phenotypic expansion for MEN1.

Hered Cancer Clin Pract 2017 21;15:10. Epub 2017 Jul 21.

Department of Clinical Genomics, Mayo Clinic, Jacksonville, FL 32224 USA.

Background: Multiple endocrine neoplasia type 1 (MEN1) is a hereditary cancer syndrome associated with several endocrine as well as non-endocrine tumors and is caused by mutations in the gene. Primary hyperparathyroidism affects the majority of MEN1 individuals by age 50 years. Additionally, mutations trigger familial isolated hyperparathyroidism. We describe a seemingly unaffected 76-year-old female who presented to our Genetics Clinic with a family history of primary hyperparathyroidism and the identification of a pathogenic variant.

Case Presentation: The patient was a 76 year-old woman who appeared to be unaffected. She had a family history of a known pathogenic variant. Molecular testing for the known mutation c.1A > G, as well as, biochemical testing, MRI of the brain and abdomen were all performed using standard methods. Molecular testing revealed our patient possessed the pathogenic variant previously identified in her two offspring. Physical exam revealed red facial papules with onset in her seventies, involving her cheeks, nose and upper lip. Formerly, she was diagnosed with rosacea by a dermatologist and noted no improvement with treatment. Clinically, these lesions appeared to be facial angiofibromas. Brain MRI was normal. However, an MRI of her abdomen revealed a 1.5 cm lesion at the tail of the pancreas with normal adrenal glands. Glucagon was mildly elevated and pancreatic polypeptide was nearly seven times the upper limit of the normal range. The patient underwent spleen sparing distal pancreatectomy and subsequent pathology was consistent with a well-differentiated pancreatic neuroendocrine tumor (pNET).

Conclusions: Age-related penetrance and variable expressivity are well documented in families with MEN1. It is thought that nearly all individuals with MEN1 manifest disease by age 40. We present a case of late-onset MEN1 in the absence of the most common feature, primary hyperparathyroidism, but with the presence of a pNET and cutaneous findings. This family expands the phenotype associated with the c.1A > G pathogenic variant and highlights the importance of providing comprehensive assessment of mutation carriers in families that at first blush may appear to have isolated hyperparathyroidism.
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http://dx.doi.org/10.1186/s13053-017-0070-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5521080PMC
July 2017

The Feasibility and Safety of Surgery in Patients Receiving Immune Checkpoint Inhibitors: A Retrospective Study.

Front Oncol 2017 12;7:121. Epub 2017 Jun 12.

Department of Surgery, Mayo Clinic, Jacksonville, FL, United States.

Immune checkpoint inhibitors (ICI) are revolutionizing care for cancer patients. The list of malignancies for which the Food and Drug Administration is granting approval is rapidly increasing. Furthermore, there is a concomitant increase in clinical trials incorporating ICI. However, the safety of ICI in patients undergoing surgery remains unclear. Herein, we assessed the safety of ICI in the perioperative setting at a single center. We conducted a retrospective review of patients who underwent planned surgery while receiving ICI in the perioperative setting from 2012 to 2016. We collected 30-day postoperative morbidity and mortality utilizing the Clavien-Dindo classification system. We identified 17 patients who received perioperative ICI in 22 operations. Patients were diagnosed with melanoma ( = 14), renal cell carcinoma ( = 2), and urothelial carcinoma ( = 1). Therapies included pembrolizumab ( = 10), ipilimumab ( = 5), atezolizumab ( = 5), and ipilimumab/nivolumab ( = 2). Procedures included cutaneous/subcutaneous resection ( = 6), lymph node resection ( = 5), small bowel resection ( = 5), abdominal wall resection ( = 3), other abdominal surgery ( = 3), orthopedic surgery ( = 1), hepatic resection ( = 1), and neurosurgery ( = 2). There were no Grade III-IV Clavien-Dindo complications. There was one death secondary to ventricular fibrillation in the setting of coronary artery disease. ICI appear safe in the perioperative setting, involving multiple different types of surgery, and likely do not need to be stopped in the perioperative setting. Further studies are warranted to confirm these findings.
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http://dx.doi.org/10.3389/fonc.2017.00121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466999PMC
June 2017

Characterization and Optimal Management of High-risk Pancreatic Anastomoses During Pancreatoduodenectomy.

Ann Surg 2018 04;267(4):608-616

The Ohio State University Wexner Medical Center, Columbus, OH.

Objective: The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy.

Background: The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circumstances of the anastomosis. The Fistula Risk Score (FRS) identifies a distinct high-risk cohort (FRS 7 to 10) that demonstrates substantially worse clinical outcomes. The value of various fistula mitigation strategies in these particular high-stakes cases has not been previously explored.

Methods: This multinational study included 5323 PDs performed by 62 surgeons at 17 institutions. Mitigation strategies, including both technique related (ie, pancreatogastrostomy reconstruction; dunking; tissue patches) and the use of adjuvant strategies (ie, intraperitoneal drains; anastomotic stents; prophylactic octreotide; tissue sealants), were evaluated using multivariable regression analysis and propensity score matching.

Results: A total of 522 (9.8%) PDs met high-risk FRS criteria, with an observed CR-POPF rate of 29.1%. Pancreatogastrostomy, prophylactic octreotide, and omission of externalized stents were each associated with an increased rate of CR-POPF (all P < 0.001). In a multivariable model accounting for patient, surgeon, and institutional characteristics, the use of external stents [odds ratio (OR) 0.45, 95% confidence interval (95% CI) 0.25-0.81] and the omission of prophylactic octreotide (OR 0.49, 95% CI 0.30-0.78) were independently associated with decreased CR-POPF occurrence. In the propensity score matched cohort, an "optimal" mitigation strategy (ie, externalized stent and no prophylactic octreotide) was associated with a reduced rate of CR-POPF (13.2% vs 33.5%, P < 0.001).

Conclusions: The scenarios identified by the high-risk FRS zone represent challenging anastomoses associated with markedly elevated rates of fistula. Externalized stents and omission of prophylactic octreotide, in the setting of intraperitoneal drainage and pancreaticojejunostomy reconstruction, provides optimal outcomes.
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http://dx.doi.org/10.1097/SLA.0000000000002327DOI Listing
April 2018

Feasibility of pancreatectomy following high-dose proton therapy for unresectable pancreatic cancer.

World J Gastrointest Surg 2017 Apr;9(4):103-108

Kathryn E Hitchcock, R Charles Nichols, Christopher G Morris, Nancy P Mendenhall, Michael S Rutenberg, Department of Radiation Oncology, University of Florida, Jacksonville, FL 32206, United States.

Aim: To review surgical outcomes for patients undergoing pancreatectomy after proton therapy with concomitant capecitabine for initially unresectable pancreatic adenocarcinoma.

Methods: From April 2010 to September 2013, 15 patients with initially unresectable pancreatic cancer were treated with proton therapy with concomitant capecitabine at 1000 mg orally twice daily. All patients received 59.40 Gy (RBE) to the gross disease and 1 patient received 50.40 Gy (RBE) to high-risk nodal targets. There were no treatment interruptions and no chemotherapy dose reductions. Six patients achieved a radiographic response sufficient to justify surgical exploration, of whom 1 was identified as having intraperitoneal dissemination at the time of surgery and the planned pancreatectomy was aborted. Five patients underwent resection. Procedures included: Laparoscopic standard pancreaticoduodenectomy ( = 3), open pyloris-sparing pancreaticoduodenectomy ( = 1), and open distal pancreatectomy with irreversible electroporation (IRE) of a pancreatic head mass ( = 1).

Results: The median patient age was 60 years (range, 51-67). The median duration of surgery was 419 min (range, 290-484), with a median estimated blood loss of 850 cm (range, 300-2000), median ICU stay of 1 d (range, 0-2), and median hospital stay of 10 d (range, 5-14). Three patients were re-admitted to a hospital within 30 d after discharge for wound infection ( = 1), delayed gastric emptying ( = 1), and ischemic gastritis ( = 1). Two patients underwent R0 resections and demonstrated minimal residual disease in the final pathology specimen. One patient, after negative pancreatic head biopsies, underwent IRE followed by distal pancreatectomy with no tumor seen in the specimen. Two patients underwent R2 resections. Only 1 patient demonstrated ultimate local progression at the primary site. Median survival for the 5 resected patients was 24 mo (range, 10-30).

Conclusion: Pancreatic resection for patients with initially unresectable cancers is feasible after high-dose [59.4 Gy (RBE)] proton radiotherapy with a high rate of local control, acceptable surgical morbidity, and a median survival of 24 mo.
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http://dx.doi.org/10.4240/wjgs.v9.i4.103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5406731PMC
April 2017

Standardization and streamlining of a pancreas surgery practice improves outcomes and resource utilization: A single institution's 20-year experience.

Am J Surg 2017 Sep 30;214(3):450-455. Epub 2017 Jan 30.

Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.

Background: In the past two decades, pancreas surgery (PS) has undergone significant advances in operative techniques and with a focus on multidisciplinary high-volume practices.

Methods: A review of patients undergoing PS from 3/1995-2/2015 was conducted; dividing patients into group A (1995-2005) and group B (2005-2015) for a detailed comparison. Effect of surgeon volume in group B was determined.

Results: A total of 1001 patients underwent PS (group A: 259; group B: 742). The mean age was 62.7 years and 52.8% were female. Group B patients were associated with a higher rate of pylorus preservation and minimally invasive resection and a lower rate of morbidity, pancreas fistula (PF), and delayed gastric emptying (DGE) than group A. High-volume surgeons (HVS) had lower operative blood loss (300 mL vs 600 mL), transfusion requirements, PF (14% vs 20%), DGE, surgical site infections, reoperations, and major morbidity rate (15.5 vs 39%) than low-volume surgeons.

Conclusions: This study demonstrates improved patient outcomes and hospital resource utilization over the past 20 years. Concentration of PS to HVS results in superior results.
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http://dx.doi.org/10.1016/j.amjsurg.2017.01.033DOI Listing
September 2017

Pancreatic Surgery in the Older Population: A Single Institution's Experience over Two Decades.

Curr Gerontol Geriatr Res 2016 27;2016:8052175. Epub 2016 Nov 27.

Division of General Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.

. Surgery is the most effective treatment for pancreatic cancer. However, present literature varies on outcomes of curative pancreatic resection in the elderly. The objective of the study was to evaluate age as an independent risk factor for 90-day mortality and complications after pancreatic resection. . Nine hundred twenty-nine consecutive patients underwent 934 pancreatic resections between March 1995 and July 2014 in a tertiary care center. Primary analyses focused on outcomes in terms of 90-day mortality and postoperative complications after pancreatic resection in these two age groups. . Even though patients aged 75 years or older had significantly more postoperative morbidities compared with the younger patient group, the age group was not associated with increased risk of 90-day mortality after pancreatic resection. . The study suggests that age alone should not preclude patients from undergoing curative pancreatic resection.
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http://dx.doi.org/10.1155/2016/8052175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5149609PMC
November 2016

Laparoscopic pancreatoduodenectomy: current status and future directions.

Updates Surg 2016 Sep 4;68(3):217-224. Epub 2016 Nov 4.

Division of General Surgery, Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.

In recent years, laparoscopic pancreatoduodenectomy (LPD) has been gaining a favorable position in the field of pancreatic surgery. However, its role still remains unclear. This review investigates the current status of LPD in high-volume centers. A literature search was conducted in PubMed, and only papers written in English containing more than 30 cases of LPD were selected. Papers with "hybrid" or robotic technique were not included in the analysis. Out of a total of 728 LPD publications, 7 publications matched the review criteria. The total number of patients analyzed was 516, and the largest series included 130 patients. Four of these studies come from the United States, 1 from France, 1 from South Korea, and 1 from India. In 6 reports, LPDs were performed only for malignant disease. The overall pancreatic fistula rate grades B-C were 12.7%. The overall conversion rate was 6.9%. LPD seems to be a valid alternative to the standard open approach with similar technical and oncological results. However, the lack of many large series, multi-institutional data, and randomized trials does not allow the clarification of the exact role of LPD.
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http://dx.doi.org/10.1007/s13304-016-0402-zDOI Listing
September 2016

Total pancreatectomy: Short- and long-term outcomes at a high-volume pancreas center.

World J Gastrointest Surg 2016 Sep;8(9):634-642

Hazem M Zakaria, Department of Hepatopancreatobiliary and Liver Transplantation Surgery, National Liver Institute, Menoufia University, Al-Minufya 22732, Egypt.

Aim: To identify the current indications and outcomes of total pancreatectomy at a high-volume center.

Methods: A single institutional retrospective study of patients undergoing total pancreatectomy from 1995 to 2014 was performed.

Results: One hundred and three patients underwent total pancreatectomy for indications including: Pancreatic ductal adenocarcinoma ( = 42, 40.8%), intraductal papillary mucinous neoplasms ( = 40, 38.8%), chronic pancreatitis ( = 8, 7.8%), pancreatic neuroendocrine tumors ( = 7, 6.8%), and miscellaneous ( = 6, 5.8%). The mean age was 66.2 years, and 59 (57.3%) were female. Twenty-four patients (23.3%) underwent a laparoscopic total pancreatectomy. Splenic preservation and portal vein resection and reconstruction were performed in 24 (23.3%) and 18 patients (17.5%), respectively. The 90 d major complications, readmission, and mortality rates were 32%, 17.5%, and 6.8% respectively. The 1-, 3-, 5-, and 7-year survival for patients with benign indications were 84%, 82%, 79.5%, and 75.9%, and for malignant indications were 64%, 40.4%, 34.7% and 30.9%, respectively.

Conclusion: Total pancreatectomy, including laparoscopic total pancreatectomy, appears to be an appropriate option for selected patients when treated at a high-volume pancreatic center and through a multispecialty approach.
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http://dx.doi.org/10.4240/wjgs.v8.i9.634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5037337PMC
September 2016
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