Faculty Bibliography

BACKGROUND:To improve outcomes for patients with pancreatic ductal adenocarcinoma, a complete resection is crucial. However, evidence regarding the impact of microscopically positive surgical margins (R1) on recurrence is conflicting due to varying definitions and limited populations of patients with borderline-resectable and locally advanced pancreatic cancer. Therefore, we aimed to determine the impact of the resection margin status on recurrence and survival in patients with pancreatic ductal adenocarcinoma stratified by local tumor stage. METHODS:We performed a retrospective cohort study on patients with nonmetastatic pancreatic ductal adenocarcinoma undergoing pancreatectomy at a high-volume academic center (2012-2022). R1 was subclassified into microscopic invasion of the margin (R1 direct) or carcinoma present within 1 mm but not directly involving the margin (R1 <1 mm). Overall survival and time to recurrence were assessed by log-rank test and multivariable Cox regression. RESULTS:Of 472 included patients, 154 (33%) had an R1 resection. Of those 50 (32%) had R1 <1 mm and 104 (68%) R1 direct. The most commonly involved margin was the uncinate (41%) followed by the pancreatic neck (16%) and vascular margins (9%). Overall, a stepwise shortening of time to recurrence and overall survival was observed with an increasing degree of margin involvement (median time to recurrence: R0 39.3 months, R1 <1 mm 16.0 months, and R1 direct 13.4 months, all comparisons P < .05). Multivariable analyses confirmed the independent prognostic value of R1 direct across all surgical stages. CONCLUSION/CONCLUSIONS:The resection margin status portends an independent prognostic value. Moreover, this association persists in patients with borderline-resectable and locally advanced pancreatic cancer. Increasing the R0-resection rate is the most important potentially influenceable prognostic factor for improving surgery-related outcomes.

Gallstone ileus, a rare cause of mechanical bowel obstruction, occurs due to the formation of a cholecystenteric fistula allowing gallstones to migrate into the gastrointestinal tract. The condition occurs mostly in elderly patients, particularly women, and carries a significant mortality risk due to delayed diagnosis. This case report discusses a 77-year-old female patient with a history of chronic medical conditions, who self-presented with periumbilical pain, nausea, and reduced bowel movements. Initial imaging revealed pneumobilia and small bowel obstruction, leading to a diagnosis of partial obstruction attributed to adhesions. Despite surgical intervention and temporary symptom relief, the patient's condition deteriorated due to a subsequent colonic obstruction. The case was complicated by delayed recognition of gallstone ileus, as imaging initially misinterpreted the obstructive mass as a "stool ball" rather than a gallstone. Following diagnostic laparoscopy and subsequent exploratory surgeries, the patient was found to have a gallstone impacted in the rectum, leading to colonic ischemia and perforation. This resulted in progressive renal failure, respiratory failure, and ultimately, the patient's death in hospice care. This case underscores the diagnostic challenges of gallstone ileus and highlights two key delays: misattribution of obstructive symptoms to adhesions and failure to recognize colonic obstruction due to gallstone ileus. Early use of contrast-enhanced imaging and a high index of suspicion are crucial for timely diagnosis. This case emphasizes the importance of thorough inspection of the small bowel and ileocecal region during laparoscopy and the need for careful evaluation of imaging findings to improve patient outcomes in gallstone ileus cases.