Giovanni Marchegiani
@Gio_Marchegiani
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Pancreas Surgeon @UniPadova 😷 @BJSOpen Editor 🗞️ @ISGPS_news Secretary 🎓 @YouppiePancreas Coordinator @EAHPBA board 🪡 @MGHSurgery @PancreasVerona trained
Padova, Italy
Joined January 2018
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Pinned Tweet
Peritoneal patch 🩹 after venous resection for PDAC on the uncinate process 😮
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Pancreas geeks 🤓 this is for you 🎁
It literally made my day!!!
Credits to
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Pancreas surgery progressively becoming 🔜 surgery of the mesentery! 😅
🌊 Tumor in the uncinate process getting down along the SMV
🙈 I can't even see the pancreas itself...
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🔪 A whipple is not a whipple without Henle’s trunk 🪵 identification…
👉Do you know all its variants ?! 👈
🎯 Check them all out here !!! … and have a great (and safe) next whipple you all!!!
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Interrupted 🤜🤛 continuous suture technique for biliary-enteric anastomosis 🪡 a RCT
⌛️ Interrupted longer time (22 vs. 12 min)
🌱 Anastomosis equally safe
👩🎓 What is your practice!? Choosing depending on size !? How do you train residents?!
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Setting the standards 📐 of common bile duct and pancreatic duct
🌱 CBD up to 8 mm < 65 y/o and up to 11 mm in ≥65 y/o
🍡 PD diameters up to 3 mm in <65 y/o and up to 4 mm in ≥65 y/o
Landmark open access
@Gut_BMJ
paper 👏 kudos to authors ! 👉
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It has been said that all roads lead to Rome 🛣️ ... but what about the SMA !?
🎋 SMA can be approached in multiple ways, check them all out here 👇 on
@BjsOpen
!!!
In the picture, an example of the Mesenteric approach (inferior infracolic) 🔪
💥Contemporary artery first approaches in PD summarized for
@young_bjs
⁉️What is your favorite approach to the mesenteric vessels?
🙏🏼grateful for the opportunity
@BJSurgery
and
@young_bjs
🔑open access
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😱 This right hepatic artery arising alone from the celiac trunk 🎋 gave us a hard time during a Whipple
Once again, the preop study of vascular anatomy is critical and key 🔑
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Neoadjuvant FOLFIRINOX 🤜🤛upfront surgery for resectable pancreatic cancer
NORPACT-1 out 🔥 now
@LancetGastroHep
📈 Median OS 25 vs. 38 months and resection rate did not differ
💉 60% neoadjuvant group had severe adverse event 🚨
🫵Comments?🧐
👉
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The first milestone 💫 of 2024 is out!
Updated IAP Guidelines 🍇 for IPMN
🔑 New key role of EUS
🔴 HRS remain same
🟡 WF slightly revised / dynamically evaluated
🟢 Possible STOP surveillance for Trivial BD-IPMN!
🫵 Are you going to apply them?! 🧐
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"Trivial" IPMNs as potential target of surveillance discontinuation are out now on
@AGA_Gastro
🔥
🧐 After 5 years of surveillance their risk comparable to that of the general population depending on
📏 Cyst size
👴 Patient Age
But how did we get here?
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👼 The reborn of surgery for uncomplicated acute appendicitis ?!
🧐 RCT comparing antibiotic 🤜🤛 appendicectomy: meta analysis of > 3000 patients
💊 No benefit on complications and LOS
🏥 Antibiotics 6X increase in hospital readmission!
🆓 full text
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Pancreas surgery meets 🤝 Transplant surgery when it comes to vascular resections in PDAC
🚨 LAPC involving CHA and PV
💉 Folfirinox x12 radiological / biological response + fit for surgery
🌽 CHA divestment
🧞♂️ PV resected + 10 cm graft allogenic cadaveric vein
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Liver transplant for colorectal cancer mets 😱 long term results from 🇳🇴
🧍♂️61 pts with non resectable CRLM in 14 years
👍 Predictor of outcomes were tumor size, CEA, number of lesions
🔟 year survival of 90% for Oslo score 0
🏔️ A new milestone ?!
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Left side pancreatectomy 🙊 do we speak the same language?!
🌍 International Delphi consensus
4️⃣ resection categories based on anatomy + additional procedures / technique 🔪🤖
👉 Distal is not just “distal”…
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Current evidence on borderline / locally advanced pancreatic cancer 💡
🥇Preoperative multi-agent chemo to obtain disease control and select for surgery
😢 Evidence-based international guideline lacking
🧬 Response evaluation still challenging
👉
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Neoadjuvant chemo has indeed expanded the indications for venous resections in
#PancreaticCancer
surgery
🚧 Resection and reconstruction of the portomesenteric confluence
🏗 Splenic vein ligation and end-to-end anastomosis
⁉️ What is your anticoagulation policy ⁉️
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Diagnostic mistake 🙈 in pancreatic cyst ‼️
Despite guidelines and wide use of EUS (50%)
30% misdiagnosis pre 🤜🤛 post op
😱 Relevant mistakes include
60% of all cystic NET 🦓
13% presumed serous cysts > malignant 👹
25% HRS IPMN > bening 👼
👉
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At the Mecca 🕋 🇩🇪 of pancreas to talk about stereotypes about Italians
🍝 Eat spaghetti
☕️ Drink espresso
🍇 Keep watching IPMNs … not in all cases and sometimes not anymore!
And finally being a witness of the 7 concomitant pancreas ORs 😳🦾
What an amazing team effort
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IPMN under surveillance 🍇 new follow up intervals and duration ?!
🦘 First short term FU at 6 months for everyone
🦘 Again 6 months if > 3 cm
🦘🦘 12 if 2-3 cm
🦘🦘🦘 18 if < 2 cm
🫸 Stop after 5 years of stability if life expectancy 10 years
👉
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Mucinous cystic neoplasms of the pancreas 🐡 are they all surgical candidates ?!
🥑 Size < 4cm, normal CA19.9 and no mural nodules exclude invasive cancer
🪡 Pro surgery advocates cancer prevention and usually MIS
Your practice ?!
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True story / Sad story
✍️ Are we all aware of the criteria for authorship?! 🤓
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Postpancreatectomy Acute Pancreatitis (PPAP) definition and grading by ISGPS
⚡️ Acute inflammation of pancreatic remnant beginning within POD 3
For diagnosis:
🧪 Hyperamylasemia for at least 48h
🏥 Clinically relevant features
☢️ Radiologic alterations
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Should ALL mucinous cystic neoplasms 🥑 of the pancreas be resected?! 🤔
Guidelines 🤜🤛 Meta Analysis 4k pts
😱 Malignancy 16%
🦀 Size 65 mm and mural nodules are predictors
👀 Surveillance has definelty a role in MCN, at least at 1st observation
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Oligometastatic pancreatic cancer 🎯 definition and management syst review
🤐 Lack of standardized definition (60% do not report)
🪡 Promising results of aggressive approach BUT no high quality data / selection bias
🏔️ Still long way to build evidence
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FOLFIRINOX 🤜🤛 Gemcitabine as Adjuvant therapy for Pancreatic Cancer 💉 5 year outcomes
🇫🇷🇨🇦 Final results RCT of 500 PDAC
⬆️ Median overall survival Folfirinox 53 vs. 35 months then it's recommended
⚠️ Careful: Veeery selected patients!
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3000 Whipples at
@PancreasVerona
A 20 year long history of love.
Un articolo pubblicato su
@AnnalsofSurgery
, rivista di chirurgia a livello internazionale, analizza i traguardi raggiunti dall’unità di
#chirurgia
dell’Istituto del
#pancreas
di
#Verona
diretto dal docente di Chirurgia generale
#Univr
Claudio Bassi >
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Distal pancreatectomy for IPMN 🍇 with or without splenectomy ?!
🦀 Malignancy 30% out of 700
🫘 Spleen preserving ⬇️ blood loss, OR time, hospital stay but 🟰 overall survival
🍒 Node mets 7%
Once malignancy not suspected spleen can be preserved 👌
👉
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A Simple Classification Of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula on
@AnnalsofSurgery
🧈 Soft texture
📏 Duct size < 3 mm
🚨 Maximum risk of POPF
Another pearl from the ISGPS
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God save the ... spleen! 🫘
Distal Pancreatectomy for body PDAC: is Splenectomy necessary? 🧐
🇫🇷 PSM analysis spleen preserving had ⬇️ harvested LN but ...
🐳 Less POPF and CCI
🪽 Same risk recurrence / survival
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💫 Pancreas highlights from
@IHPBA
2022
Isolated Pancreatectomy Using Mesenteric Approach by living legend Akimasa Nakao 🇯🇵
👉 The surgeon who have mastered mesenteric approach can control pancreatic cancer surgery 👈
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Tug of war 🪢 of a leaking P-J with trans-anastomotic stent 😱
🧯 Stents are solid mitigation strategies for high risk anastomoses
👹 Stent malfunction increases morbidity 👇
🥇 Stented PJ superior to PG 👇
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The horrible pancreas 😱 Would you dare to proceed to total pancreatectomy vs. anastomosis ⁉️
🔥 Debate is ongoing in recent literature 🤜🤛
1⃣
@AnnalsofSurgery
2⃣
@AnnSurgOncol
3⃣
@LAOS1860
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🏁 Board certified for Full Professor in Surgery - Thanks to all those who made this possible 🥰
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Postoperative serum hyperamylasemia (POH) 🧪
predicts additional morbidity after Whipple
🟢 No POH best outcome
🟡 POH > infections, PPH, PPAP
🔴 POH+POPF early onset bad complications
👉 POH predicts morbidity - not only POPF! 👈
🆓 on
@SurgJournal
!
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Do you drain 💦 a distal pancreatectomy?! 🧐
🚨 Practice changing RCT
@LancetGastroHep
🇳🇱 🇮🇹 282 pts
✋ NO drain better outcomes!
⬇️ Major Morbidity 15% vs. 20%
⬇️ POPF 12% vs. 27%
👉Drainless DP new standard! 👈
🆓 download 👉
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Laparoscopic cholecystectomy: 3 port 🤜🤛 4 port
📚 Syst review meta-analysis of 18 trials
🟰 length procedure and adverse events
⌛️ 3 ports LOS 0.3 days less 🫤
📐 Use of 3 ports should not be at the expense of safe dissection of Calot’s triangle
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Nasogastric decompression after pancreaticoduodenectomy 🐘 what is your practice?!
👎 Routine NG tube associated with ⬆️ rates of DGE, major complications and longer length of stay
✅
@ErasSociety
policies should be standard
New meta analys on
@BjsOpen
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Thank you 2⃣0⃣2⃣1⃣ for giving us ...
The definition and grading of POST PANCREATECTOMY ACUTE PANCREATITIS (PPAP)
✅ Acute inflammation of pancreatic remnant < POD 3
Diagnosis:
🧪 Hyperamylasemia < 48h
🩺 Clinical features
☢️ Radiology alterations
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Happy Easter 🐣 read on POPF risk assessment for distal pancreatectomy! Full text now on available
@AnnalsofSurgery
🧮 Do you calculate D-FRS ?!
🧯 Would you perform drainless DP for negligible / low risk !?
🎯 RCT ongoing ...
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Robotic 🤜🤛 open pancreatoduodenectomy : the EUROPA RCT 🇩🇪
🥇 Primary endpoint CCI no difference 🟰 90 days mortality 4.8 % 🟰 blood loss
🤖 Higher pancreas specific complications (60% vs. 30%) and DGE
🙅♂️ Intraop conversion rate 23%
🫵 Comments?!
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Three 🇮🇹 in 🇩🇪 and one is chief of surgery in 🇺🇸!!!
#internationalpancreas
happening in
@surgery_hps
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🫵 Seeking for a fellowship in HPB surgery ?!
🤷♀️ No established training in Europe but 3⃣2⃣ programs exist 🥳
😷 Fellow median age 34 💰 70% funded
🪡 HPB major surgeries performed between 0-10 / minimally invasive 10% 😭
👉 Standard CV needed! 👈
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Three champions 🏆 of pancreas surgery
and a very lucky guy 🍀
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Strategies to prevent / mitigate 🚒 post-pancreatectomy hemorrhage (PPH) 🔥
🧑🚒 Review of 99 RCT revealed to 👇 PPH
Intraop: PJ, 🫔 GDA wrap, small jej incision of PJ
Postop: Pasireotide 💉 and algorithm-based 🧮
management
😱 NO RCT on PPH treatment!
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The first ever Radiomics 👾 preoperative fistula risk score !!!
Development 🇳🇱 and external validation 🇮🇹
🐳 The radiomics-based preop FRS performed similarly to the existing scores ( ROC 0.8)
💪 Great added value considering only CT derived data!
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Postoperative complications 🐳 after a Whipple for malignancy: analysis of 1.3k cases
🔴 Major morbidity 17% - Mortality 4% 🔴
🔮 ASA and BMI predict complications
📐 Targeted prehabilitation / individualized treatment regimens are key
👉
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Surveillance for pancreatic cancer in high-risk individuals 🔍 leads to improved outcomes
🧬 Patients with a CDKN2A/p16 pathogenic variant under surveillance
🎯 Earlier detection / increased resectability
↗️ Median survival (26 vs. 5 mos)
@AGA_Gastro
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Finally part of my favorite podcast 🔪
@BehindTheKnife
!!!
🎧 The episode on IPMN is out now
🍇 The implications of this
@JAMASurgery
paper will be reviewed 👉
Thank you 🙏 for having me!
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Today a great
@BJSurgery
meeting and tomorrow is the World Pancreatic Cancer day 💜
😢 Pancreas surgery still associated to poor outcomes worldwide
🌍 In low human development index countries 🔺failure to rescue
🛟 Urgent measures needed!
🆓 access!
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Natural disease course 🧬 of pancreatic cyst evolving into cancer
@AGA_Gastro
landmark paper 🕋 sets times of progression
🍇 HGD ➡️ cancer median 4 years
🍇 Mean LHD state 14 years
🧐 Is HGD our REAL target?! Is one life “enough” to develop cancer?
👉
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Pancreatic surgery in 2023, the close relationship between 3 🔑 factors:
🏥 Centralization 🤖 Innovation and 🕸️Dissemination
Example: “MI surgery implementation depends on dissemination and standardization of training”
🎓 competency <> mastery 👑
👉
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The textbook of
#pancreatic
#cancer
has made it to Verona 🇮🇹
Can’t wait to dive into it 📚
Congratulations to
@ksoreide
and
@SStattner
for putting all this together ... See you guys at chapter 49! 😉
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Surveillance for BD-IPMN 🍇 latest evidence from literature included in Guidelines!
🫧 BD-IPMN < 2 cm and no WF 👉 less frequent surveillance recommended
✋ STOP surveillance after 5 years of stability considering life expectancy 🙈
🆓 full text 👉
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Predict Pancreatic Fistula 🐳 using only preoperative data and Machine Learning 🤖
🇺🇸 ACS-NQIP
@AmCollSurgeons
9k whipples
4 models identified 🔝 predictors as BMI, 🤏 small duct, NO chemo / adenocarcinoma
👏 Great tool, when would you apply it ?! 🧐
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Sometimes IPMNs 🍇 of the MPD just erupt 🌋 into the duodenum
🐳 Mucus can cause duct obstruction
🐟 Fish mouth papilla visibile at endoscopy
🍄 Invasive component growing into the duodenum is visible
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Somatostatin 🤜🤛 Octreotide for prevention of pancreatic fistula 🇫🇷 RCT for PD and DP
💉 7 days continuous IV / 4 times a day
🐳 POPF rate similar at 23% even after correction for MPD size
So… would you use ☝️,✌️, or… neither of the two?! 🤦♂️
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Pancreatoduodenectomy in
#obese
patients 🍕🍟🍔 out now on
@hpbjournal
🔪 Surgery for nonmalignant tumors might be deferred
↔️ Complication rate not different
😱 Failure to rescue 26% vs. 14%
☠️ Mortality 6% vs. 3%
Online first ⬇️
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First ✨ highlights from
@APHPBA2023
🇨🇳 Prof Miao and the 40/40 rules for PDAC according to
@ProfessorMWB
before showing arterial divestment 👗
🇯🇵 The Nakao / mesenteric approach for PDAC involving SMA / SMV
🇮🇳 Palanivelu 👑 on tips tricks of laparoscopic whipple
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Acute pancreatitis 💥 A procalcitonin-based algorithm to guide antibiotic use
🇬🇧 RCT usual care 🤜🤛 PCT based
💊 PCT Antibiotic prescription 45 % vs 63 %
🪲 No difference in infections and mortality
🧪 PCT should guide antibiotic management !!!
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And so it ends!
#EAHPBA2023
🇫🇷 in Lyon 🦁 was a blast!!!
👑 A new president to guide us through a younger and more inclusive society
Excited to serve as the chair 🪑 of the membership committee, we need more trainee and more HPB surgeons from Africa !!!
Make HPB great again!
Thank you
@EHPBA
for your trust in me as
#President
‘23-‘25
#EAHPBA2023
The future is 🌟 with this
#DreamTeam
of new commitee (vice) chairs incl new secretary-general
@iisifrigerio
and
@AAFretland
@Gio_Marchegiani
@berrevoet
@JorgKleeff
@Abuhilal9Abu
@TomGallagherHPB
@ksoreide
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