Predictive value of preoperative albumin-bilirubin score and other risk factors for short-term outcomes after open pancreatoduodenectomy

BACKGROUND Pancreatoduodenectomy represents a complex procedure involving extensive organ resection and multiple alimentary reconstructions.It is still associated with high morbidity,even in high-volume centres.Prediction tools including preoperative patient-related factors to preoperatively identify patients at high risk for postoperative complications could enable tailored perioperative management and improve patient outcomes.AIM To evaluate the clinical significance of preoperative albumin-bilirubin score and other risk factors in relation to short-term postoperative outcomes in patients after open pancreatoduodenectomy.METHODS This retrospective study included all patients who underwent open pancreatic head resection(pylorus-preserving pancreatoduodenectomy or Whipple resection)for various pathologies during a five-year period(2017-2021)in a tertiary care setting at University Medical Centre Ljubljana,Slovenia and Cattinara Hospital,Trieste,Italy.Short-term postoperative outcomes,namely,postoperative complications,postoperative pancreatic fistula,reoperation,and mortality,were evaluated in association with albumin-bilirubin score and other risk factors.Multiple logistic regression models were built to identify risk factors associated with these short-term postoperative outcomes.RESULTS Data from 347 patients were collected.Postoperative complications,major postoperative complications,postoperative pancreatic fistula,reoperation,and mortality were observed in 52.7%,22.2%,23.9%,21.3%,and 5.2%of patients,respectively.There was no statistically significant association between the albumin-bilirubin score and any of these short-term postoperative complications based on univariate analysis.When controlling for other predictor variables in a logistic regression model,soft pancreatic texture was statistically significantly associated with postoperative complications[odds ratio(OR):2.09;95%confidence interval(95%CI):1.19-3.67];male gender(OR:2.12;95%CI:1.15-3.93),soft pancreatic texture(OR:3.06;95%CI:1.56-5.97),and blood loss(OR:1.07;95%CI:1.00-1.14)were statistically significantly associated with major postoperative complications;soft pancreatic texture was statistically significantly associated with the development of postoperative pancreatic fistula(OR:5.11;95%CI:2.38-10.95);male gender(OR:1.97;95%CI:1.01-3.83),soft pancreatic texture(OR:2.95;95%CI:1.42-6.11),blood loss(OR:1.08;95%CI:1.01-1.16),and resection due to duodenal carcinoma(OR:6.58;95%CI:1.20-36.15)were statistically significantly associated with reoperation.CONCLUSION The albumin-bilirubin score failed to predict short-term postoperative outcomes in patients undergoing pancreatoduodenectomy.However,other risk factors seem to influence postoperative outcomes,including male sex,soft pancreatic texture,blood loss,and resection due to duodenal carcinoma.

Health-related quality of life after curative resection for gastric adenocarcinoma

BACKGROUND With improved survival in gastric cancer patients,health-related quality of life has become an important clinical endpoint alongside primary oncological outcomes.AIM To investigate health-related quality of life after various surgical procedures for gastric cancer treatment.METHODS The validated Slovenian version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire(QLQ-C30)and its gastric cancer-specific module(QLQ STO-22)was sent for self-completion to patients that underwent curative resection for gastric adenocarcinoma between January 2014 and December 2018 at our centre.In total,116 patients responded.Scores were compared between patients after subtotal distal vs total gastrectomy and patients after subtotal distal gastrectomy with Billroth II vs Roux-en-Y reconstruction.RESULTS Interestingly,the extent of resection did not influence daily functioning;however,more dysphagia and eating restrictions were reported in patients after total gastrectomy when compared to patients after subtotal distal gastrectomy.Moreover,patients with Billroth II reconstruction after subtotal distal resection experienced worse physical and role functioning and reported more pain,fatigue and reflux compared to Roux-en-Y reconstruction.CONCLUSION Based on our results,Roux-en-Y reconstruction after subtotal distal gastrectomy should be preferred over Billroth II reconstruction.The data obtained from this study will help surgeons when preoperatively informing their patients about expected functional outcomes after gastrectomy and enable them to ensure proper supportive care of their patients in the postoperative period.

Intra-ampullary papillary-tubular neoplasm combined with ampullary neuroendocrine carcinoma:A case report

BACKGROUND The ampulla of Vater is an anatomically and histologically complex region giving rise to a heterogenous group of tumors.This is,to the best of our knowledge,the first case of intra-ampullary papillary-tubular neoplasm combined with ampullary neuroendocrine carcinoma reported in the literature.CASE SUMMARY A 61-year-old woman presented to the emergency department for evaluation of painless jaundice.Contrast-enhanced computed tomography(CT)of the abdomen and chest showed a periampullary tumor mass measuring 15 mm×12 mm×14 mm,with no evidence of locoregional and distant metastases,for which she underwent pancreatoduodenectomy.Histopathologic examination of a resected specimen revealed an intra-ampullary papillary tubular neoplasm with highgrade dysplasia in combination with poorly differentiated grade 3 neuroendocrine carcinoma with a mitotic count of more than 20 mitoses per 10 high power fields and Ki-67 index of 100%.No positive lymph nodes were identified.Her postoperative course was uneventful.Postoperatively,she remained under close surveillance.Multiple liver metastases were observed on follow-up CT 8 mo after the surgery,so systemic therapy with cisplatin and etoposide was initiated.CONCLUSION The simultaneous occurrence of neuroendocrine and non-neuroendocrine tumors in the ampulla of Vater is rare and the pathogenesis of such tumors is largely unknown.Due to unpredictable clinical behavior and lack of solid evidence on optimal treatment strategy,close patient surveillance is advised after radical resection of the primary tumor.

Acquired haemophilia in patients with malignant disease:A case report

BACKGROUND Acquired haemophilia is a rare coagulation disorder characterized by autoantibodies against coagulation factor VIII leading to severe and potentially life-threatening haemorrhages.The underlying disorder causing the development of an autoimmune phenomenon is not always known,but 10%-15%could be linked to malignancies.Patients with cancer who require surgical resection represent a treatment challenge not solely due to increased risk of bleeding but also due to adverse events of immunosuppressive therapy.CASE SUMMARY We present the case of a 67-year-old man with non-metastatic adenocarcinoma of the distal bile duct who developed concomitant acquired haemophilia a month after having been diagnosed with malignant disease.Haemostasis was established with recombinant activated factor VII,and immunosuppressive therapy was started immediately.An extensive surgical procedure was performed in order to remove the cancer and,therefore,eliminate the inhibitory autoantibodies.Due to a complicated postoperative course,relatively short period of treatment and likelihood of micrometastases,no improvement in the patient’s status was observed.Diagnosis and treatment of acquired haemophilia as well as other coagulation disorders in patients with cancer are discussed.CONCLUSION Prompt diagnosis of acquired haemophilia is required in order to start appropriate treatment and reduce mortality.Among patients with cancer,other causes of abnormal bleeding related to malignancy should be considered.