Comparison of Efficacy and Safety of 4 Combinations of Laparoscopic and Intraoperative Techniques for Management of Gallstone Disease With Biliary Duct Calculi: A Systematic Review and Network Meta-analysis

Importance

Several techniques are used for surgical treatment of gallstone disease with biliary duct calculi, but the safety and efficacy of these approaches have not been compared.

Objectives

To compare the efficacy and safety of 4 surgical approaches to gallstone disease with biliary duct calculi.

Data Sources

MEDLINE, Scopus, and ISI-Web of Science databases, articles published between 1950 and 2017 and searched from August 12, 2017, to September 14, 2017. Search terms used were LCBDE, LC, preoperative, ERCP, postoperative, period, cholangiopancreatography, endoscopic, retrograde, rendezvous, intraoperative, one-stage, two-stage, single-stage, gallstone, gallstones, calculi, stone, therapy, treatment, therapeutics, surgery, surgical, procedures, clinical trials as topic, random, and allocation in several logical combinations.

Study Selection

Randomized clinical trials comparing at least 2 of the following strategies: preoperative endoscopic retrograde cholangiopancreatography (PreERCP) plus laparoscopic cholecystectomy (LC); LC with laparoscopic common bile duct exploration (LCDBE); LC plus intraoperative endoscopic retrograde cholangiopancreatography (IntraERCP); and LC plus postoperative ERCP (PostERCP).

Data Extraction and Synthesis

A frequentist random-effects network meta-analysis was performed. The surface under the cumulative ranking curve (SUCRA) was used to show the probability that each approach would be the best for each outcome.

Main Outcomes and Measures

Primary outcomes were the safety to efficacy ratio using overall mortality and morbidity rates as the main indicators of safety and the success rate as an indicator of efficacy. Secondary outcomes were acute pancreatitis, biliary leak, overall bleeding, operative time, length of hospital stay, total cost, and readmission rate.

Results

The 20 trials comprised 2489 patients (and 2489 procedures). Laparoscopic cholecystectomy plus IntraERCP had the highest probability of being the most successful (SUCRA, 87.2%) and safest (SUCRA, 69.7%) with respect to morbidity. All approaches had similar results regarding overall mortality. Laparoscopic cholecystectomy plus LCBDE was the most successful for avoiding overall bleeding (SUCRA, 83.3%) and for the shortest operative time (SUCRA, 90.2%) and least total cost (SUCRA, 98.9%). Laparoscopic cholecystectomy plus IntraERCP was the best approach for length of hospital stay (SUCRA, 92.7%). Inconsistency was found in operative time (indirect estimate, 19.05; 95% CI, 2.44-35.66; P = .02) and total cost (indirect estimate, 17.06; 95% CI, 3.56-107.21; P = .04). Heterogeneity was observed for success rate (τ, 0.8), operative time (τ, >1), length of stay (τ, >1), and total cost (τ, >1).

Conclusions and Relevance

The combined LC and IntraERCP approach had the greatest odds to be the safest and appears to be the most successful. Laparoscopic cholecystectomy plus LBCDE appears to reduce the risk of acute pancreatitis but may be associated with a higher risk of biliary leak.

Mutational burden of resectable pancreatic cancer, as determined by whole transcriptome and whole exome sequencing, predicts a poor prognosis

Despite the genomic characterization of pancreatic cancer (PC), marked advances in the development of prognosis classification and novel therapeutic strategies have yet to come. The present study aimed to better understand the genomic alterations associated with the invasive phenotype of PC, in order to improve patient selection for treatment options. A total of 30 PC samples were analysed by either whole transcriptome (9 samples) or exome sequencing (21 samples) on an Illumina platform (75X2 or 100X2 bp), and the results were matched with normal DNA to identify somatic events. Single nucleotide variants and insertions and deletions were annotated using public databases, and the pathogenicity of the identified variants was defined according to prior knowledge and mutation-prediction tools. A total of 43 recurrently altered genes were identified, which were involved in numerous pathways, including chromatin remodelling and DNA damage repair. In addition, an analysis limited to a subgroup of early stage patients (50% of samples) demonstrated that poor prognosis was significantly associated with a higher number of known PC mutations (P=0.047). Samples from patients with a better overall survival (>25 months) harboured an average of 24 events, whereas samples from patients with an overall survival of <25 months presented an average of 40 mutations. These findings indicated that a complex genetic profile in the early stage of disease may be associated with increased aggressiveness, thus suggesting an urgent requirement for an innovative approach to classify this disease.

Copy number gain of chromosome 3q is a recurrent event in patients with intraductal papillary mucinous neoplasm (IPMN) associated with disease progression

Background

Intraductal papillary mucinous neoplasm (IPMN) is the most common cystic preneoplastic lesion of pancreatic cancer. We used an approach coupling high resolution cytogenetic analysis (Affymetrix Oncoscan FFPE Array) with clinically-oriented bioinformatic interpretation of data to understand the most relevant alterations of precursor lesions at different stages to identify new diagnostic markers.

Results

We identified multiple copy number alterations, particularly in lesions with severe dysplasia, with 7 IPMN with low-intermediate dysplasia carrying a nearly normal karyotype and 13 IPMN with complex Karyotype (> 4 alterations), showing high grade dysplasia. A specific gain of chromosome arm 3q was found in IPMN with complex Karyotype (92%). This gain of 3q is particularly interesting for the presence of oncogenes such as PIK3CA, GATA2 and TERC that are part of pathways that deregulate cell growth and promote disease progression. Quantitative PCR and FISH analysis confirmed the data. Further demonstration of the overexpression of the PIK3CA gene supports the identification of this alteration as a possible biomarker in the early identification of patients with IPMN at higher risk for disease progression.

Materials and methods

High resolution cytogenetic analysis was performed in 20 formalin fixed paraffin embedded samples of IPMN by Oncoscan FFPE assay. Results were validated by qPCR and FISH analysis.

Conclusions

The identification of these markers at an early stage of disease onset could help to identify patients at risk for cancer progression and new candidates for a more specific targeted therapy.

Multicolour versus monocolour inking specimens after pancreaticoduodenectomy for periampullary cancer: A single centre prospective randomised clinical trial

BACKGROUND

R status represents an important prognostic factors in periampullary cancers. Thus, it is useful to verify if it can be influenced by different techniques of margination.

METHODS

Single-centre, randomised clinical trial of patients affected by periampullary cancer who underwent pancreaticoduodenectomies which included two different types of margination: arm A (multicolour inking) and arm B (monocolour inking). The primary endpoint was the overall R1 resection rate and its difference between the two arms. The secondary endpoints were the R1 resection rate in each margin and its difference between the two arms, and the impact of margin status on survival.

RESULTS

Fifty patients were randomised, 41 analysed: 22 in arm A, 19 arm B. The overall R1 status was 61%, without significant differences between the two arms. The margin most commonly involved was the superior mesenteric artery (SMA) (36.6%). A trend in favour of arm B was shown for the superior mesenteric artery margin (arm A = 22.7% versus arm B = 52.6%; P = 0.060). The anterior surface (P = 0.015), SMA (P = 0.047) and pancreatic remnant (P = 0.018) margins significantly influenced disease-free survival.

CONCLUSIONS

The R status was not influenced by different techniques of margination using a standardised pathological protocol. The SMA margin seemed to be the most important margin for evaluating both R status and disease-free survival.

Prognostic role of nodal ratio, LODDS, pN in patients with pancreatic cancer with venous involvement

Background

The UICC/AJCC TNM staging system classifies lymph nodes as N0 and N1 in pancreatic cancer. Aim of the study is to determine whether the number of examine nodes, the nodal ratio (NR) and the logarithm odds of positive lymph nodes (LODDS) may better stratify the prognosis of patients undergoing pancreatectomy combined with venous resection for pancreatic cancer with venous involvement.

Methods

A multicenter database of 303 patients undergoing pancreatectomy in 9 Italian referral centers was analyzed. The prognostic impact of number of retrieved and examined nodes, NR, LODDS was analyzed and compared with ROC curves analysis, Pearson test, univariate and multivariate analysis.

Results

The number of metastatic nodes, pN, the NR and LODDS was significantly correlated with survival at multivariate analyses. The corresponding AUC for the number of metastatic nodes, pN, the NR and LODDS were 0.66, 0.69, 0.63 and 0.65, respectively. The Pearson test showed a significant correlation between the number of retrieved lymph nodes and number of metastatic nodes, pN and the NR. LODDS had the lower coefficient correlation. Concerning N1 patients, the NR, the LODDS and the number of metastatic nodes were able to significantly further stratify survival (p = 0.040; p = 0.046; p = 0.038, respectively).

Conclusions

The number of examined lymph nodes, the NR and LODDS are useful for further prognostic stratification of N1 patients in the setting of pancreatectomy combined with PV/SMV resection. No superiority of one over the others methods was detected.

Prospective validation of a preoperative risk score model based on pancreatic texture to predict postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

In 2015, basing on objective preoperative factors related to pancreas remnant texture (body mass index, Wirsung duct size and preoperative diagnosis), we proposed a score model to predict the risk of postoperative pancreatic fistula after partial pancreatectomies. The aim of the present study was to prospectively validate this preoperative predictive risk score for postoperative pancreatic fistula after pancreaticoduodenectomy.

METHODS

Prospective study of consecutive patients who underwent pancreaticoduodenectomy in which a preoperative risk score, based on factors related to the pancreatic texture, was calculated. The risk score model was tested by comparison with subjective intraoperative assessment of the pancreas remnant texture and drain amylase value on postoperative day 1. Sensitivity, specificity, positive and negative likelihood ratio and area under the curve were calculated.

RESULTS

Eighty-four patients who underwent pancreaticoduodnectomy were analyzed. Clinically relevant pancreatic fistulas rate was 40.6%. The risk score model with a cut-off of 6 increased the odds of pancreatic fistula approximately 3 fold but it was not independently related to it. On the contrary, considering a cut-off of 5, the risk score model increased the odds of pancreatic fistula 11-16 fold and it was independently related to it. The new risk score model and pancreatic texture had high sensitivity (97% and 88%, respectively) and low specificity (34% and 60%, respectively) while the amylase drain value had low sensitivity (44%) and high specificity (92%).

CONCLUSIONS

The preoperative risk score model with a cut-off of 5 was a useful predictor of clinically relevant pancreatic fistula after pancreaticoduodenectomy. The drain amylase value represents a complementary factor to the risk score in predicting a pancreatic fistula.

Is pancreaticogastrostomy safer than pancreaticojejunostomy after pancreaticoduodenectomy? A meta-regression analysis of randomized clinical trials

OBJECTIVE

To evaluate the clinically relevant POPF rate between Pancreatogastrostomy (PG) and pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD). To evaluate the confounding factors affecting meta-analytic results.

METHODS

A systematic literature search of randomized clinical trials (RCTs) comparing PG to PJ with an International Study Group of Pancreatic Fistula (ISGPF) definition of postoperative pancreatic fistula (POPF). Risk difference (RD) and number needed to treat or harm (NNT and NNH) were used. Fixed and random-effect models were applied. Impact of confounding covariates on the meta-analytic results was evaluated using meta-regression analysis, reporting β coefficient ± standard error (SE).

RESULTS

Seven RCTs were identified involving 1184 patients: 603 PG and 581 PJ. RD in the fixed model of clinically relevant POPFs suggested that PG was superior to PJ (RD-0.07; 95% CI: -0.11 to -0.03) with an NNT of 14 (95% CI: 9 to 33). In random model, PG was not superior to PJ (RD-0.06; 95% CI: -0.13 to 0.01) with an NNT of 17 and a possibility of harm in some cases (NNH = 100). Meta-regression suggested that the increase in the proportion of "soft pancreas" in the PG arm corresponded to a more positive value of RD (β = 0.47 ± 0.19; P value: 0.045 ± 0.003).

CONCLUSION

A PG could be slightly superior to PJ in the prevention of clinically relevant POPF. The presence of high risk pancreatic remnant remains the main limitation of PG.

Impact of surgery and surveillance in the management of branch duct intraductal papillary mucinous neoplasms of the pancreas according to Fukuoka guidelines: the Bologna experience

The objective of the study was to evaluate the Fukuoka guidelines in indicating the proper management for recognising the risk factors of malignancy. Data of patients with branch duct intraductal papillary mucinous neoplasms who underwent pancreatic resection or surveillance according to the Fukuoka risk parameters were collected in a prospective database. The clinical outcome (development of pancreatic cancer, overall and disease-specific survival) and pathological results were evaluated in all patients and in resected cases, respectively. The data of 197 patients were collected: 23 primarily resected and 174 primarily followed. Of the latter, 16 were secondarily resected. Among the patients resected, 21 (53.9%) showed diagnosis of in situ or invasive carcinoma and only contrast-enhancing mural nodules were significantly related to malignancy (P = 0.002), with a DOR of 3.3 and an LH+ of 2.2. Development of pancreatic cancer was shown in ten (5.7%) of the patients primarily followed. The overall survival and disease-specific survival were similar between patients primarily followed and primarily resected. It seems reasonable to suggest that a branch duct intraductal papillary mucinous neoplasm should be treated as a benign and indolent disease that is rarely malignant. Enhancing mural nodules represent the best indicator for surgery.

Is surgery the best treatment for sporadic small (≤2 cm) non-functioning pancreatic neuroendocrine tumours? A single centre experience

BACKGOUND

There is currently there is substantial controversy regarding the best management of non-functioning pancreatic neuroendocrine tumours ≤2 cm.

METHODS

Retrospective study involving 102 surgically treated patients affected by non-functioning pancreatic neuroendocrine tumours. Patients having small tumours (≤2 cm) (Group A) and those having large tumours (>2 cm) (Group B) were compared regarding demographics, clinical and pathological factors with the aim of evaluating the risk of malignancy and survival times.

RESULTS

The small tumours were T3-4 in 11% and G2-3 in 36.6% of cases; lymph node and distant metastases were present in 31% and 8% of the cases, respectively. When small and large tumours were compared, significant differences were found in relation to the presence of symptoms (P = 0.012), tumour status (P > 0.001), grading (P > 0.001) and years lost due to disability (P = 0.002). Multivariate analysis of the factors predicting malignancy and survival times showed that tumour size was related only to grading (P < 0.001). The years of life lost and disability adjusted life years were influenced by age at of diagnosis, the presence of symptoms and years lost due to disability only by grading.

CONCLUSIONS

Tumour size alone did not seem to be reliable in predicting malignancy because, first, small tumours (≤2 cm) could present lymph node or distant metastases, and could be G2-3 in a non-negligible percentage of cases and second, their risk of malignancy and survival time are similar to large tumours. Additional parameters have to be considered in order to establish the proper management of small tumours, such as age at diagnosis, presence of symptoms and grading.

Is total pancreatectomy as feasible, safe, efficacious, and cost-effective as pancreaticoduodenectomy? A single center, prospective, observational study

BACKGROUND

Total pancreatectomy is actually considered a viable option in selected patients even if large comparative studies between partial versus total pancreatectomy are not currently available. Our aim was to evaluate whether total pancreatectomy can be considered as feasible, safe, efficacious, and cost-effective as pancreaticoduodenectomy.

METHODS

A single center, prospective, observational trial, regarding postoperative outcomes, long-term results, and cost-effectiveness, in a tertiary referral center was conducted, comparing consecutive patients who underwent elective total pancreatectomy and/or pancreaticoduodenectomy.

RESULTS

Seventy-three consecutive elective total pancreatectomies and 184 pancreaticoduodenectomies were compared. There were no significant differences regarding postoperative outcomes and overall survival. The quality of life, evaluated in 119 patients according to the EQ-5D-5L questionnaire, showed that there were no significant differences regarding the five items considered. The mean EQ-5D-5L score was similar in the two procedures (total pancreatectomy = 0.872, range 0.345-1.000; pancreaticoduodenectomy = 0.832, range 0.393-1.000; P = 0.320). The impact of diabetes according to the Problem Areas in Diabetes (PAID) questionnaire did not show any significant differences except for question 13 (total pancreatectomy = 0.60; pancreaticoduodenectomy = 0.19; P = 0.022). The cost-effectiveness analysis suggested that the quality-adjusted life year was not significantly different between the two procedures (total pancreatectomy = 0.910, range 0.345-1.000; pancreaticoduodenectomy = 0.910, range -0.393-1.000; P = 0.320).

CONCLUSIONS

From this study, it seems reasonable to suggest that total pancreatectomy can be considered as safe, feasible, and efficacious as PD and acceptable in terms of cost-effectiveness.

Laparoscopic versus open distal pancreatectomy in pancreatic tumours: a case-control study

Laparoscopic distal pancreatectomy has become an increasingly used procedure in the surgical treatment of benign or borderline cystic and endocrine tumours. The feasibility and safety of this technique is well known but its results when compared with open distal pancreatectomy were rarely reported in literature. Data from 22 consecutive patients who underwent laparoscopic distal pancreatectomy were recorded in a prospective database from January 2006 to January 2010. These patients were matched with 22 patients who underwent open distal pancreatectomy from January 2000 to December 2005, regarding age, gender, American Society of Anesthesiologists score, pancreatic pathology. Intraoperative parameters and postoperative outcome were compared between the two groups. Blood loss, amount of analgesic drugs administered, postoperative mortality and morbidity and pancreatic fistula rate were similar in laparoscopic and open groups. Tumour size was significantly smaller in laparoscopic group (2.0 ± 3.3 vs. 5.0 ± 4.2 cm; P = 0.038). Operative time was significantly shorter in open group (145 ± 49 vs. 225 ± 83 min, P = 0.045). Time to adequate oral intake and length of postoperative hospital stay were significantly better in laparoscopic group than in open group (3.0 ± 0.8 vs. 4.0 ± 0.7 days; P = 0.030 and 8.0 ± 1.3 vs. 11.0 ± 3.0 days; P = 0.011, respectively). Laparoscopic distal pancreatectomy is a feasible and safe surgical approach as well as open distal pancreatectomy.

Validation of the 2010 WHO classification and a new prognostic proposal: A single centre retrospective study of well-differentiated pancreatic neuroendocrine tumours

BACKGOUND

In 2010, the World Health Organization (WHO) modified the classification for pancreatic neuroendocrine tumours (NETs). Recently, some modifications were proposed to improve its prognostic value. The aim of this study was to test the prognostic value of both the original and the modified 2010 WHO grading systems.

METHODS

One hundred and twenty consecutive patients surgically resected for well-differentiated NETs were evaluated in multivariate Cox regression models. Age, sex, hormonal status, size, lymph node ratio, stage, margin status and grading were evaluated in order to predict disease-free survival (DFS). Four models were evaluated: model 1: grading according to the 2010 WHO; model 2: modified grading with cut-off at 5% of the Ki-67 index; model 3: modified grading in which the G2 category was divided into two subgroups (2-5% and 5-20%) and model 4: the Ki-67 index as a continuous variable. Decision curve analysis (DCA) was carried out to evaluate the clinical utility of the various cut-offs.

RESULTS

All the grading systems remained independent factors in predicting DFS. Model 2 (c index = 0.814 and P = 0.012) and model 3 (c index = 0.865 and P = 0.015) showed higher predictive powers with respect to model 1 (c index = 0.799). Model 4 had a high predictive value (c index 0.848, P = 0.013). Decision curve analysis confirmed that biological behaviour represented the best prognostic parameter.

CONCLUSION

This study presented some limitations: single centre, retrospective design and a long period of enrolment. The result showed that, by increasing the cut-off of the G2 category to 5% or by creating two subgroups in the G2 category, it was possible to obtain a better stratification of patients.

Is age a barrier to pancreaticoduodenectomy? An Italian dual-institution study

The aim of this study is to evaluate the role of age after pancreaticoduodenectomy. This is a retrospective study of 223 patients who underwent pancreaticoduodenectomy for periampullary diseases. Three age groups of patients were compared: ≤70 years of age (group A); between 71 and 79 years of age (group B) and 80 years of age or older (group C). The primary endpoint was the postoperative mortality rate. Secondary endpoints were the overall postoperative morbidity, postoperative pancreatic fistula, postoperative pancreatic haemorrhage, bile leakage, delayed gastric emptying rates, the length of hospital stay, intensive care unit stay, the type of discharge from hospital, reoperation rate and overall survival. Uni-multivariate analyses and Kaplan-Meier curve were carried out. At univariate analysis, only the type of discharge from hospital showed that group B and C patients required a period of rehabilitation more frequently than group A (P = 0.047 and P < 0.001, respectively). Multivariate analysis confirmed that age was not related to postoperative mortality (P = 0.258), morbidity (P = 0.912) and overall survival (P = 0.658), but it was related to type of discharge (P < 0.001). The present study seems to suggest that a pancreaticoduodenectomy is a feasible and safe procedure, even in elderly and very elderly patients even if the latter require a longer period of rehabilitation.

Neoadjuvant Chemoradiotherapy and Surgery Versus Surgery Alone in Resectable Pancreatic Cancer: A Single-Center Prospective, Randomized, Controlled Trial Which Failed to Achieve Accrual Targets

OBJECTIVE

The objective of the study is to evaluate the usefulness of neoadjuvant chemoradiotherapy in resectable pancreatic cancer.

METHODS

A single-center RCT of patients affected by resectable pancreatic adenocarcinoma which included arm A (surgery alone) and arm B (neoadjuvant chemoradiation and surgery). The primary endpoint was R0 resection; the secondary endpoints were toxicity; number of patients who completed the neoadjuvant therapy; radiological and pathological response after chemoradiation; and pTNM stage, postoperative morbidity, mortality, and overall and disease-free survival. A sample size of 32 patients was required for each group.

RESULTS

The study was terminated early, and 38 patients were randomized: 20 in arm A and 18 in arm B. There was no significant difference regarding R0 resection rate in the two groups (intention-to-treat, OR = 1.91, P = 0.489). Neoadjuvant chemoradiotherapy was completed in 14 out of 18 cases (77.8 %) and the radiological and pathological response was efficacious in 72.3 and 90.9 % of cases, respectively.

CONCLUSIONS

Neoadjuvant chemoradiation was feasible, safe, and efficacious, although non-significant results were obtained as a result of the underpowered data due to the difficulty in recruiting patients. Additional multicenter RCTs are needed in the future.

Characterization of pancreatic ductal adenocarcinoma using whole transcriptome sequencing and copy number analysis by single-nucleotide polymorphism array

The aim of the current study was to implement whole transcriptome massively parallel sequencing (RNASeq) and copy number analysis to investigate the molecular biology of pancreatic ductal adenocarcinoma (PDAC). Samples from 16 patients with PDAC were collected by ultrasound‑guided biopsy or from surgical specimens for DNA and RNA extraction. All samples were analyzed by RNASeq performed at 75x2 base pairs on a HiScanSQ Illumina platform. Single‑nucleotide variants (SNVs) were detected with SNVMix and filtered on dbSNP, 1000 Genomes and Cosmic. Non‑synonymous SNVs were analyzed with SNPs&GO and PROVEAN. A total of 13 samples were analyzed by high resolution copy number analysis on an Affymetrix SNP array 6.0. RNAseq resulted in an average of 264 coding non‑synonymous novel SNVs (ranging from 146‑374) and 16 novel insertions or deletions (In/Dels) (ranging from 6‑24) for each sample, of which a mean of 11.2% were disease‑associated and somatic events, while 34.7% were frameshift somatic In/Dels. From this analysis, alterations in the known oncogenes associated with PDAC were observed, including Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations (93.7%) and inactivation of cyclin‑dependent kinase inhibitor 2A (CDKN2A) (50%), mothers against decapentaplegic homolog 4 (SMAD4) (50%), and tumor protein 53 (TP53) (56%). One case that was negative for KRAS exhibited a G13D neuroblastoma RAS viral oncogene homolog mutation. In addition, gene fusions were detected in 10 samples for a total of 23 different intra‑ or inter‑chromosomal rearrangements, however, a recurrent fusion transcript remains to be identified. SNP arrays identified macroscopic and cryptic cytogenetic alterations in 85% of patients. Gains were observed in the chromosome arms 6p, 12p, 18q and 19q which contain KRAS, GATA binding protein 6, protein kinase B and cyclin D3. Deletions were identified on chromosome arms 1p, 9p, 6p, 18q, 10q, 15q, 17p, 21q and 19q which involve TP53, CDKN2A/B, SMAD4, runt‑related transcription factor 2, AT‑rich interactive domain‑containing protein 1A, phosphatase and tensin homolog and serine/threonine kinase 11. In conclusion, genetic alterations in PDCA were observed to involve numerous pathways including cell migration, transforming growth factor‑β signaling, apoptosis, cell proliferation and DNA damage repair. However, signaling alterations were not observed in all tumors and key mutations appeared to differ between PDAC cases.

Laparoscopic Distal Pancreatectomy in Benign or Premalignant Pancreatic Lesions: Is It Really More Cost-Effective than Open Approach?

BACKGROUND

Data regarding the quality of life in patients undergoing laparoscopic distal pancreatectomy are lacking and no studies have reported a real cost-effectiveness analysis of this surgical procedure. The aim of this study was to evaluate and compare the quality of life and the cost-effectiveness of a laparoscopic distal pancreatectomy with respect to an open distal pancreatectomy.

METHODS

Forty-one patients who underwent a laparoscopic distal pancreatectomy and 40 patients who underwent an open distal pancreatectomy were retrospectively studied as regards postoperative results, quality of life and cost-effectiveness analysis. The Italian neutral version of the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire C-30, version 3.0, was used to rate the quality of life.

RESULTS

Postoperative results were similar in the two groups; the only difference was that the first oral intake took place significantly earlier in the laparoscopic group than in the open group (P < 0.001). Regarding quality of life, the laparoscopic approach was able to ameliorate physical functioning (P = 0.049), role functioning (P = 0.044) and cognitive functioning (P = 0.030) and reduce the sleep disturbance scale (P = 0.050). The cost-effectiveness analysis showed that the acceptability curve for a laparoscopic distal pancreatectomy had a higher probability of being more cost-effective than an open distal pancreatectomy when a willingness to pay above 5400 Euros/quality-adjusted life years (QALY) was accepted.

CONCLUSION

Despite the limitations of the study, laparoscopic distal pancreatectomy can be considered not only safe and feasible but also permits a better quality of life and is acceptable in terms of cost-effectiveness to Italian and European health care services.

Portal/Superior Mesenteric Vein Reconstruction during Pancreatic Resection Using a Cryopreserved Arterial Homograft

BACKGROUND

Portal-superior mesenteric vein (PV/SMV) resection during pancreatic resection has been widely applied in clinical practice.

METHODS

From a prospective data base of pancreatic resections, patients undergoing PV/SMV resection and reconstruction with a cryopreserved arterial homograft were extracted with the aim of evaluating the safety, feasibility and reproducibility of the procedure. Data regarding patient demographics, preoperative staging, surgery, histopathology and postoperative outcomes were analyzed.

RESULTS

Five patients were extracted in the last year. Indications for this technique were type IV-V degree of vein involvement and a 3.5 cm median length of vein infiltration. Median operative and clamping times were satisfactory (385 and 27 min, respectively), postoperative outcomes were good and there was no graft infection, thrombosis or stenosis occurred postoperatively and during the follow-up period.

CONCLUSION

The use of a cryopreserved arterial homograft for PV/SMV reconstruction after pancreatic resection seems to be a feasible, safe and easily reproducible surgical technique in high-volume specialized centers and can be added to the pool of surgical solutions in selected patients.

Laparoscopic versus open distal pancreatectomy for ductal adenocarcinoma: a systematic review and meta-analysis

BACKGROUND

Laparoscopic distal pancreatectomy was proposed as an oncologically safe approach for pancreatic ductal adenocarcinoma.

METHODS

A systematic review of the studies comparing laparoscopic and open distal pancreatectomy was conducted. The primary endpoint was an R0 resection rate. The secondary endpoints were intra- and postoperative results, tumour size, mean harvested lymph node, number of patients eligible for adjuvant therapy and overall survival.

RESULTS

Five comparative case control studies involving 261 patients (30.7% laparoscopic and 69.3% open) who underwent a distal pancreatectomy were included. The R0 resection rate was similar between the two groups (P = 0.53). The laparoscopic group had longer operative times (P = 0.04), lesser blood loss (P = 0.01), a shorter hospital stay (P < 0.001) and smaller tumour size (P = 0.04) as compared with the laparotomic group. Overall morbidity, postoperative pancreatic fistula, reoperation, mortality and number of patients eligible for adjuvant therapy were similar. The mean harvested lymph nodes were comparable in the two groups (P = 0.33). The laparoscopic approach did not affect the overall survival rate (P = 0.32).

CONCLUSION

Even if the number of patients compared is underpowered, the laparoscopic approach in the treatment of PDAC seems to be safe and efficacious. However, additional prospective, randomised, multicentric trials are needed to correctly evaluate the laparoscopic approach in PDAC.

Efficacy and cost-effectiveness of immediate surgery versus a wait-and-see strategy for sporadic nonfunctioning T1 pancreatic endocrine neoplasms

BACKGROUND

Whether patients with small (<2 cm), sporadic nonfunctioning pancreatic endocrine tumors (NF-PETs) should directly undergo pancreatic surgery or should be followed longitudinally to detect growth and malignancy still has to be defined.

STUDY DESIGN

Based on the pertinent literature of the past decade, a Markov model was developed to investigate this issue. In the wait-and-see strategy arm, surgery was performed if the tumor attained a size ≥2 cm or surpassed 20% of the initial size. In a Monte Carlo probabilistic analysis, 100 hypothetical patients undergoing a wait-and-see strategy were compared to 100 patients directly undergoing surgery, with the aim of investigating the efficacy and cost-effectiveness of the two strategies.

RESULTS

During the postdiagnostic lifetime, 63 NF-PETs in the wait-and-see group showed significant growth and underwent surgery: 38 were stage I, 10 were stage II, 15 were stage III and none were stage IV. In the base-case scenario, the mean life expectancy and quality-adjusted life expectancy were found to be superior after immediate surgery [26.1 years and 11.8 quality-adjusted life years (QALYs)] than with the wait-and-see strategy (22.1 years and 8.3 QALYs) as the consequence of ageing during the wait-and-see follow-up which increased mortality due to surgery, when surgery was needed. The model was sensitive to starting age and length of follow-up; in particular, for patients >65 years of age, the two strategies provided similar results but the wait-and-see strategy was more cost-effective.

CONCLUSIONS

The wait-and-see strategy for NF-PETs <2 cm represents a reasonable approach in patients over 65 years of age; otherwise, immediate surgery is preferable.