Drains can be safely omitted 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 significantly decreases the occurrence of clinically relevant pancreatic fistula.

The present study has confirmed the pertinence of the changes introduced in the 2016 ISGPS POPF definition and grading. This updated classification is effective in identifying three conditions that differ in terms of clinical and economic outcomes. These results suggested the reliability of the new definition and scheme in classifying POPF-related outcomes.

The aim of this study was to investigate the key molecular alterations in small primary pancreatic neuroendocrine tumors (PanNETs) associated with the development of liver metastases. Background: Well-differentiated PanNETs with small size are typically indolent; however, a limited subset metastasize to the liver. Methods: A total of 87 small primary PanNETs (<3cm), including 32 metastatic cases and 55 nonmetastatic cases after a 5-year follow-up, were immunolabeled for DAXX/ATRX and analyzed for alternative lengthening of telomeres (ALT) by Fluorescence In Situ Hybridization.

Objective: To develop a nomogram estimating the probability of recurrence free at 5 years after resection for localized G1/G2 pancreatic neuroendocrine tumors (PanNETs). Background: Among patients undergoing resection of PanNETs, approximately 17% experience recurrence. It is not established which patients are at risk, with no consensus on optimal followup. Method: A multi-institutional database of patients with G1/G2 PanNETs treated at two institutions was used to develop a nomogram estimating the rate of freedom from recurrence at 5-years after curative resection. A second cohort of patients from three additional institutions was used to validate the nomogram. Prognostic factors were assessed by univariate analysis using Cox regression model. The nomogram was internally validated using bootstrap resampling method and on the external cohort. Performance was assessed by concordance-index (c-index) and a calibration curve. Results: The nomogram was constructed using a cohort of 632 patients. Overall, 68% of PanNETs were G1, the median follow-up was 51 months and we observed 74 recurrences. Variables included in the nomogram were the number of positive nodes, tumor diameter, Ki-67 and vascular/perineural invasion. The model bias-corrected c-index from the internal validation was 0.85 which was higher than ENETS/AJCC 8th staging scheme (c-index 0.76, p=<0.001). On the external cohort of 328 patients, the nomogram c-index was 0.84 (95% CI: 0.79-0.88). Conclusion: Our externally validated nomogram predicts the probability of recurrence free survival at 5 years after PanNETs curative resection, with improved accuracy over current staging systems. Estimating individual recurrence risk will guide the development of personalized surveillance programs following surgery.

Background Total pancreatectomy is required to treat diseases involving the entire pancreas, and is characterized by high morbidity rates and impaired long‐term quality of life (QoL). To date, risk factors associated with perioperative and long‐term outcomes have not been determined fully. Methods Data from patients undergoing total pancreatectomy between 2000 and 2014 at two high‐volume centres were analysed retrospectively to assess risk factors for major surgical complications. Short Form (SF) 36, European Organisation for Research and Treatment of Cancer QLQ‐PAN26 and Audit of Diabetes Dependent questionnaires, as well as an original survey were used to investigate factors influencing QoL. Results A total of 329 consecutive patients underwent total pancreatectomy in the two centres. Overall, total pancreatectomy was associated with a morbidity rate of 59·3 per cent and a 30‐day mortality rate of 2·1 per cent. Age over 65 years and long duration of surgery (more than 420 min) were independently associated with major complications (at least Clavien–Dindo grade III). QoL analysis was available for 94 patients (28·6 per cent) with a median follow‐up of 63 (i.q.r. 20–109) months; the most common indication for total pancreatectomy in these patients was intraductal papillary mucinous neoplasms (46 per cent). Both physical (PCS) and mental (MCS) component summary scores of SF‐36® were lower after total pancreatectomy compared with scores for a normative population (P = 0·020 and P < 0·001 respectively). Linear regression analysis showed that young age, abdominal pain and worse perception of body image were negatively associated with the PCS, whereas diabetes, sexual satisfaction and perception of body image affected MCS. Conclusion Total pancreatectomy can be performed with acceptable morbidity and mortality rates. Older patients had a higher risk of postoperative complications but reported better QoL than younger patients.

Postoperative pancreatic fistula (POPF) remains the major postoperative cause of morbidity and mortality following pancreatic surgery. Since 2005, the International Study Group of Pancreatic Fistula (ISGPF) definition and classification has been adopted worldwide allowing the comparison among different surgical approaches and mitigation strategies. Over the last 11 years, several limitations have emerged from clinical practice and in 2016 the International Study Group for Pancreatic Surgery (ISGPS) updated the POPF definition and grading system. Objectives of this review article were to summarize modifications in the updated ISGPS definition and to illustrate their clinical impact.

The high incidence of POPF was accompanied by a shift from operative to non-operative management. However, the current management strategy is driven by the patient's condition and local expertise and is generally based on poor evidence. A randomized trial showed that enteral nutrition is superior to total parenteral nutrition, and pooled data of randomized trials failed to show any advantage of somatostatin analogs for accelerating fistula closure. The choice of percutaneous versus endoscopic drainage of peripancreatic collections remains arbitrary, and-when re-operation is needed-there are very few comparative data regarding local drainage with or without main pancreatic stenting as opposed to anastomotic revision or salvage re-anastomosis. The continuous development of specialist, high-volume units with appropriate resources and multidisciplinary experience in complication management might further improve the evidence and the outcomes.

This study shows that DBDC is a rare entity even if large surgical series are reviewed. Tumor differentiation and nodal status have been confirmed as important prognostic factors. Pancreaticoduodenectomy remains the procedure of choice in order to obtain free surgical margins and in order to harvest the correct number of lymph nodes for a correct staging.