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Casadei R, Ricci C, Ingaldi C, Alberici L, Minni F. Contemporary indications for upfront total pancreatectomy. Updates Surg 2021; 73:1205-1217. [PMID: 34390466 DOI: 10.1007/s13304-021-01145-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022]
Abstract
Currently, advances in surgical techniques, improvements in perioperative care, new formulations of intermediate and long-acting insulin and of modern pancreatic enzyme preparations have allowed obtaining good short and long-term results and quality of life, especially in high-volume centres in performing total pancreatectomy (TP).Thus, the surgeon's fear in performing TP is not justified and total pancreatectomy can be considered a viable option in selected patients in high-volume centres. The aim of this review was to define the current indications for this procedure, in particular for upfront TP, considering not only the pancreatic disease, but also the surgical approach (open, mini-invasive) and the relationship with vascular resection.
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Affiliation(s)
- Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy. .,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
| | - Claudio Ricci
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Laura Alberici
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Francesco Minni
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Salvia R, Lionetto G, Perri G, Malleo G, Marchegiani G. Total pancreatectomy and pancreatic fistula: friend or foe? Updates Surg 2021; 73:1231-1236. [PMID: 34363601 PMCID: PMC8397676 DOI: 10.1007/s13304-021-01130-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022]
Abstract
Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was to critically analyze current evidence supporting the use of total pancreatectomy (TP) to prevent the development of POPF in patients with high-risk pancreas, and to explore the role of completion total pancreatectomy (CP) in the management of severe POPF. Considering the encouraging perioperative outcomes, TP may represent a promising tool to avoid the morbidity related to an extremely high-risk pancreatic anastomosis in selected patients. Surgical management of severe POPF is only required in few critical scenarios. In this context, even if anecdotal, CP might play a role as last resort in expert hands.
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Affiliation(s)
- Roberto Salvia
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy.
| | - Gabriella Lionetto
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
| | - Giampaolo Perri
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
| | - Giuseppe Malleo
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
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Total pancreatectomy sequelae and quality of life: results of islet autotransplantation as a possible mitigation strategy. Updates Surg 2021; 73:1237-1246. [PMID: 34319573 DOI: 10.1007/s13304-021-01129-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022]
Abstract
Total pancreatectomy (TP) is a procedure weighed down not only by postoperative morbidity and mortality but also by long-term effects as a consequence of endocrine and exocrine pancreatic insufficiency. While the latter is now managed quite effectively with pancreatic enzyme replacement therapy, the former remains a challenge. The diabetes resulting after TP, with the complete loss of endogenous insulin and contraregulatory hormones, is characterized by important glycemic variations and is, therefore, frequently referred to as "brittle diabetes". One method to reduce the impact of brittle diabetes in patients undergoing TP is the re-infusion of autologous pancreatic islets isolated from the resected pancreas. Indications to islet autotransplantation (IAT), originally described for patients undergoing TP for chronic pancreatitis, have since been extended to selected patients with other benign and malignant diseases of pancreas. This review recaps on the literature regarding long-term postoperative complications, their impact on quality of life after TP and the role of IAT.
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Principe DR, Underwood PW, Korc M, Trevino JG, Munshi HG, Rana A. The Current Treatment Paradigm for Pancreatic Ductal Adenocarcinoma and Barriers to Therapeutic Efficacy. Front Oncol 2021; 11:688377. [PMID: 34336673 PMCID: PMC8319847 DOI: 10.3389/fonc.2021.688377] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/29/2021] [Indexed: 12/15/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, with a median survival time of 10-12 months. Clinically, these poor outcomes are attributed to several factors, including late stage at the time of diagnosis impeding resectability, as well as multi-drug resistance. Despite the high prevalence of drug-resistant phenotypes, nearly all patients are offered chemotherapy leading to modest improvements in postoperative survival. However, chemotherapy is all too often associated with toxicity, and many patients elect for palliative care. In cases of inoperable disease, cytotoxic therapies are less efficacious but still carry the same risk of serious adverse effects, and clinical outcomes remain particularly poor. Here we discuss the current state of pancreatic cancer therapy, both surgical and medical, and emerging factors limiting the efficacy of both. Combined, this review highlights an unmet clinical need to improve our understanding of the mechanisms underlying the poor therapeutic responses seen in patients with PDAC, in hopes of increasing drug efficacy, extending patient survival, and improving quality of life.
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Affiliation(s)
- Daniel R. Principe
- Medical Scientist Training Program, University of Illinois College of Medicine, Chicago, IL, United States
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | | | - Murray Korc
- Department of Developmental and Cell Biology, University of California, Irvine, CA, United States
| | - Jose G. Trevino
- Department of Surgery, Division of Surgical Oncology, Virginia Commonwealth University, Richmond, VA, United States
| | - Hidayatullah G. Munshi
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Jesse Brown VA Medical Center, Chicago, IL, United States
| | - Ajay Rana
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
- Jesse Brown VA Medical Center, Chicago, IL, United States
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Diagnosis and management of secondary causes of steatohepatitis. J Hepatol 2021; 74:1455-1471. [PMID: 33577920 DOI: 10.1016/j.jhep.2021.01.045] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/09/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023]
Abstract
The term non-alcoholic fatty liver disease (NAFLD) was originally coined to describe hepatic fat deposition as part of the metabolic syndrome. However, a variety of rare hereditary liver and metabolic diseases, intestinal diseases, endocrine disorders and drugs may underlie, mimic, or aggravate NAFLD. In contrast to primary NAFLD, therapeutic interventions are available for many secondary causes of NAFLD. Accordingly, secondary causes of fatty liver disease should be considered during the diagnostic workup of patients with fatty liver disease, and treatment of the underlying disease should be started to halt disease progression. Common genetic variants in several genes involved in lipid handling and metabolism modulate the risk of progression from steatosis to fibrosis, cirrhosis and hepatocellular carcinoma development in NAFLD, alcohol-related liver disease and viral hepatitis. Hence, we speculate that genotyping of common risk variants for liver disease progression may be equally useful to gauge the likelihood of developing advanced liver disease in patients with secondary fatty liver disease.
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Traub B, Link KH, Kornmann M. Curing pancreatic cancer. Semin Cancer Biol 2021; 76:232-246. [PMID: 34062264 DOI: 10.1016/j.semcancer.2021.05.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/14/2022]
Abstract
The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.
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Affiliation(s)
- Benno Traub
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
| | - Karl-Heinz Link
- Clinic for General and Visceral Surgery, University of Ulm, Ulm, Germany; Surgical and Asklepios Tumor Center (ATC), Asklepios Paulinen Klinik Wiesbaden, Richard Strauss-Str. 4, Wiesbaden, Germany.
| | - Marko Kornmann
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
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Furbetta N, Comandatore A, Gianardi D, Palmeri M, Di Franco G, Guadagni S, Caprili G, Bianchini M, Fatucchi LM, Picchi M, Bastiani L, Biancofiore G, Di Candio G, Morelli L. Perioperative Nutritional Aspects in Total Pancreatectomy: A Comprehensive Review of the Literature. Nutrients 2021; 13:1765. [PMID: 34067286 PMCID: PMC8224756 DOI: 10.3390/nu13061765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 02/05/2023] Open
Abstract
Total pancreatectomy (TP) is a highly invasive procedure often performed in patients affected by anorexia, malabsorption, cachexia, and malnutrition, which are risk factors for bad surgical outcome and even may cause enhanced toxicity to chemo-radiotherapy. The role of nutritional therapies and the association between nutritional aspects and the outcome of patients who have undergone TP is described in some studies. The aim of this comprehensive review is to summarize the available recent evidence about the influence of nutritional factors in TP. Preoperative nutritional and metabolic assessment, but also intra-operative and post-operative nutritional therapies and their consequences, are analyzed in order to identify the aspects that can influence the outcome of patients undergoing TP. The results of this review show that preoperative nutritional status, sarcopenia, BMI and serum albumin are prognostic factors both in TP for pancreatic cancer to support chemotherapy, prevent recurrence and prolong survival, and in TP with islet auto-transplantation for chronic pancreatitis to improve postoperative glycemic control and obtain better outcomes. When it is possible, enteral nutrition is always preferable to parenteral nutrition, with the aim to prevent or reduce cachexia. Nowadays, the nutritional consequences of TP, including diabetes control, are improved and become more manageable.
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Affiliation(s)
- Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Annalisa Comandatore
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Giovanni Caprili
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Lorenzo Maria Fatucchi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Martina Picchi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Luca Bastiani
- Institute of Clinical Physiology, National Council of Research, 56124 Pisa, Italy;
| | | | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
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Radical Resection for Locally Advanced Pancreatic Cancers in the Era of New Neoadjuvant Therapy-Arterial Resection, Arterial Divestment and Total Pancreatectomy. Cancers (Basel) 2021; 13:cancers13081818. [PMID: 33920314 PMCID: PMC8068970 DOI: 10.3390/cancers13081818] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Aggressive arterial resection or total pancreatectomy in surgical treatment for locally advanced pancreatic cancer (LAPC) has gradually been encouraged thanks to new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel, which have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. The development of surgical techniques provides the safety of arterial resection (AR) for even major visceral arteries, such as the celiac axis or superior mesenteric artery. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for locally advanced pancreatic cancer (LAPC) and discuss the rationale of such an aggressive approach in the treatment of PC. Abstract Aggressive arterial resection (AR) or total pancreatectomy (TP) in surgical treatment for locally advanced pancreatic cancer (LAPC) had long been discouraged because of their high mortality rate and unsatisfactory long-term outcomes. Recently, new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for LAPC and discuss the rationale of such an aggressive approach in the treatment of PC. AR for LAPCs is divided into three, according to the target vessel. The hepatic artery resection is the simplest one, and the reconstruction methods comprise end-to-end, graft or transposition, and no reconstruction. Celiac axis resection is mainly done with distal pancreatectomy, which allows collateral arterial supply to the liver via the pancreas head. Resection of the superior mesenteric artery is increasingly reported, though its rationale is still controversial. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In conclusion, more and more aggressive pancreatectomy has become justified by the principle of total neoadjuvant therapy. Further technical standardization and optimal neoadjuvant strategy are mandatory for the global dissemination of aggressive pancreatectomies.
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Shaw K, Thomas AS, Rosario V, Kwon W, Schrope BA, Sugahara K, Chabot JA, Genkinger JM, Kluger MD. Long term quality of life amongst pancreatectomy patients with diabetes mellitus. Pancreatology 2021; 21:501-508. [PMID: 33509685 DOI: 10.1016/j.pan.2021.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/01/2020] [Accepted: 01/18/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pancreatogenic diabetes is common after pancreatectomy, and the impact on quality of life (QOL) is poorly understood. The objective of this study was to investigate QOL between diabetic and non-diabetic patients at least five years after pancreatectomy. METHODS Patients were recruited from a prospectively maintained institutional database. Participants were administered the Audit of Diabetes-Dependent Quality of Life (ADDQOL). Quality of life was compared between diabetics and non-diabetics using validated European Organization for Research and Treatment of Cancer questionnaires. RESULTS 80 individuals completed surveys. 55% were female, 80% non-Hispanic white, 44% underwent Whipple, 48% were cystic neoplasms and 39% were adenocarcinoma. Diabetic patients (42.5%) reported comparable EORTC QLQ-C30 and Pan26 scores to non-diabetic patients. Pre-operative diabetic patients reported more dyspnea (p = 0.02) and greater pain (p = 0.02) than new-onset diabetics. Diabetic patients reported an overall ADDQOL quality of life score 'very good' (IQR: excellent, good) though felt life would be much better without diabetes (IQR: very much better, little better). While operation type was not influential, patients diagnosed with cystic neoplasms were almost twice as likely as those with other pathologies to report that life would be much better without diabetes (p < 0.01). CONCLUSION At a median of 9.3 years from pancreatic surgery, ADDQoL scores of patients were similar to cohorts of non-pancreatogenic diabetics in the general population. Patients without cancer were more likely to report that diabetes affected their overall QOL, regardless of operation. This study provides nuanced understanding of long-term QOL to improve the informed consent process and post-operative long-term care.
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Affiliation(s)
- Kaitlin Shaw
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Alexander S Thomas
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Vilma Rosario
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Wooil Kwon
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Beth A Schrope
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Kazuki Sugahara
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - John A Chabot
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Jeanine M Genkinger
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Michael D Kluger
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
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Oh MY, Kim EJ, Kim H, Byun Y, Han Y, Choi YJ, Kang JS, Kwon W, Jang JY. Changes in postoperative long-term nutritional status and quality of life after total pancreatectomy. Ann Surg Treat Res 2021; 100:200-208. [PMID: 33854989 PMCID: PMC8019983 DOI: 10.4174/astr.2021.100.4.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/14/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Quality of life (QoL) is widely known to be poor after total pancreatectomy (TP) due to the loss of pancreatic function and poor nutritional status, but prospective studies on changes in QoL over time are lacking. The aim of this study was to prospectively evaluate the short- and long-term consequences of pancreatic exocrine insufficiency, changes in nutritional status, and their associated effects on QoL after TP. Methods Prospective data were collected from patients who underwent TP between 2008 and 2018. Validated questionnaires (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ] Core 30, EORTC QLQ-pancreatic cancer module, and the Mini Nutritional Assessment), measured frequency of bowel movement, relative body weight (RBW), triceps skinfold thickness (TSFT), and serum levels of protein, albumin, transferrin, and hemoglobin A1c were collected serially for 1 year. Results Thirty patients who underwent TP were eligible for the study. Bowel movement frequency increased over time, and the RBW and TSFT were lowest by 1 year. The global health status score showed no significant difference over time. At 3 months, physical and role function scores as well as symptoms of fatigue, constipation, and digestive difficulties worsened significantly. Most indices recovered after 1 year, but poorer physical function scores, digestive difficulties, and altered bowel habits persisted. Conclusion Because some symptoms do not recover over time, careful follow-up and supportive postoperative management are needed for TP patients, including nutritional support with pancreatic enzyme replacement and education about medication adherence and diet.
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Affiliation(s)
- Moon Young Oh
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Joo Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoonhyeong Byun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo Jin Choi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Bicu F, Rink JS, Froelich MF, Cyran CC, Rübenthaler J, Birgin E, Röhrich M, Tollens F. Supplemental 18F-FDG-PET/CT for Detection of Malignant Transformation of IPMN-A Model-Based Cost-Effectiveness Analysis. Cancers (Basel) 2021; 13:1365. [PMID: 33803522 PMCID: PMC8002963 DOI: 10.3390/cancers13061365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 12/26/2022] Open
Abstract
Accurate detection of malignant transformation and risk-stratification of intraductal papillary mucinous neoplasms (IPMN) has remained a diagnostic challenge. Preliminary findings have indicated a promising role of positron emission tomography combined with computed tomography and 18F-fluorodeoxyglucose (18F-FDG-PET/CT) in detecting malignant IPMN. Therefore, the aim of this model-based economic evaluation was to analyze whether supplemental FDG-PET/CT could be cost-effective in patients with IPMN. Decision analysis and Markov modeling were applied to simulate patients' health states across a time frame of 15 years. CT/MRI based imaging was compared to a strategy with supplemental 18F-FDG-PET/CT. Cumulative costs in US-$ and outcomes in quality-adjusted life years (QALY) were computed based on input parameters extracted from recent literature. The stability of the model was evaluated by deterministic sensitivity analyses. In the base-case scenario, the CT/MRI-strategy resulted in cumulative discounted costs of USD $106,424 and 8.37 QALYs, while the strategy with supplemental FDG-PET/CT resulted in costs of USD $104,842 and a cumulative effectiveness of 8.48 QALYs and hence was cost-saving. A minimum specificity of FDG-PET/CT of 71.5% was required for the model to yield superior net monetary benefits compared to CT/MRI. This model-based economic evaluation indicates that supplemental 18F-FDG-PET/CT could have a favorable economic value in the management of IPMN and could be cost-saving in the chosen setting. Prospective studies with standardized protocols for FDG-PET/CT could help to better determine the value of FDG-PET/CT.
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Affiliation(s)
- Felix Bicu
- Department of Nuclear Medicine, University Hospital Heidelberg, D-68120 Heidelberg, Germany; (F.B.); (M.R.)
| | - Johann S. Rink
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany; (M.F.F.); (F.T.)
| | - Matthias F. Froelich
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany; (M.F.F.); (F.T.)
| | - Clemens C. Cyran
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, D-81377 Munich, Germany; (C.C.C.); (J.R.)
| | - Johannes Rübenthaler
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, D-81377 Munich, Germany; (C.C.C.); (J.R.)
| | - Emrullah Birgin
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, D-68167 Mannheim, Germany;
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, D-68120 Heidelberg, Germany; (F.B.); (M.R.)
| | - Fabian Tollens
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany; (M.F.F.); (F.T.)
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62
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Surgical management of chronic calcified pancreatitis. SURGERY IN PRACTICE AND SCIENCE 2021. [DOI: 10.1016/j.sipas.2021.100027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Luu AM, Olchanetski B, Herzog T, Tannapfel A, Uhl W, Belyaev O. Is primary total pancreatectomy in patients with high-risk pancreatic remnant justified and preferable to pancreaticoduodenectomy? -a matched-pairs analysis of 200 patients. Gland Surg 2021; 10:618-628. [PMID: 33708545 PMCID: PMC7944076 DOI: 10.21037/gs-20-670] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 11/11/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Total pancreatectomy (TP) eliminates the risk of postoperative pancreatic fistula (POPF) and its associated secondary complications. Hence, it may theoretically offer advantages over pancreaticoduodenectomy (PD) regarding early postoperative outcome of patients with high-risk pancreatic remnant. METHODS Ninety-day mortality and morbidity of 100 TP vs. 100 PD for pancreatic head lesions were retrospectively compared. Groups were matched for pancreatic texture, pancreatic duct size, final histology, age, gender and surgeon. Only patients at high risk for POPF due to soft pancreatic texture and small pancreatic duct <3 mm were included. RESULTS Preoperatively, the TP-group was characterized by poorer general condition, more comorbidities and more pronounced obesity than the PD-group. Postoperatively, overall morbidity was lower after TP (63% vs. 88%, P<0.001) due to less mild complications. Postpancreatectomy hemorrhage rate was lower after TP than after PD (2% vs. 12%, P=0.014). Duration of surgery, hospital stay, major morbidity (30%) and mortality (7% vs. 5%) were the same. POPF was the most common complication after PD with 32%. Emergency completion pancreatectomy was necessary in 10% of PD with a significantly higher mortality compared to elective TP (50% vs. 7%, P=0.001). CONCLUSIONS TP may reduce severe POPF-associated complications and prevent mortality related to emergency completion pancreatectomy in some elderly, obese and polymorbid patients with high-risk pancreatic remnant. Careful individual selection by an experienced pancreatic surgeon is mandatory.
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Affiliation(s)
- Andreas Minh Luu
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Bella Olchanetski
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | | | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Orlin Belyaev
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Han Y, Jang JY, Oh MY, Kim HS, Byun Y, Kang JS, Kim SH, Lee KB, Kim H, Kwon W. Natural history and optimal treatment strategy of intraductal papillary mucinous neoplasm of the pancreas: Analysis using a nomogram and Markov decision model. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:131-142. [PMID: 33283481 DOI: 10.1002/jhbp.878] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND/PURPOSE With the increase in detection of intraductal papillary mucinous neoplasms (IPMN), a tailored approach is needed. This study was aimed at exploring the natural history of IPMN and suggest optimal treatment based on malignancy risk using a nomogram and Markov decision model. METHODS Patients with IPMN who underwent surveillance or surgery were included. Changes in worrisome features/high-risk stigmata and malignancy conversion rate were assessed. Life expectancy and quality-adjusted life year (QALY) were compared using a nomogram predicting malignancy. RESULTS Overall, 2006 patients with histologically confirmed or radiologically typical IPMN were enrolled. Of these, 1773 (88.4%), 81 (4.0%), and 152 (7.6%), respectively, had branch duct (BD)-, main duct-, and mixed-type IPMN at initial diagnosis. The cumulative risk of developing worrisome feature or high-risk stigmata was 19.0% and 35.0% at 5- and 10-year follow-up, respectively. The progression of malignancy rate at 10-year follow-up was 79.9% for main and mixed IPMNs and 5.9% for BD-IPMN. Nomogram-based malignancy risk prediction is well correlated with natural history based on pathologic biopsy and shows good stratification of survival. The decision model recommends surgery to maximize survival and QALY especially in those with >35% malignancy risk. CONCLUSIONS Compared with main duct- and mixed-type IPMN, which have a high risk of malignancy (79.9%), BD-IPMN is very indolent (5.9%). The nomogram-based decision model suggests surgery rather than surveillance for patients with a high malignancy risk. The optimal treatment strategy between surgery and surveillance should consider patients' health status, malignancy risk, and centers' experience.
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Affiliation(s)
- Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Moon Young Oh
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong Seok Kim
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yoonhyeong Byun
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Se Hyung Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung-Bun Lee
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Functional Impairments and Quality of Life in Older Adults With Upper Gastrointestinal Cancers. J Surg Res 2020; 260:267-277. [PMID: 33360693 DOI: 10.1016/j.jss.2020.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 09/14/2020] [Accepted: 11/01/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Functional impairments (measured by activities of daily living [ADLs]) and health-related quality of life (HRQOL) may complicate outcomes in older adults diagnosed with cancer. In this retrospective cohort analysis, we characterized ADLs and HRQOL in adults older than 65 y with upper gastrointestinal (UGI) cancers and evaluated for an association to cancer-specific survival. MATERIALS AND METHODS Patients with UGI cancers aged 65 y or older were selected from the Surveillance, Epidemiology and End Results and the Medicare Health Outcomes Survey-linked database. Demographics, comorbidities, stage, ADLs, and HRQOL were summarized by patients managed with and without surgery. Because of the wide variety of cancers, we subdivided patients into cohorts of esophagogastric [EG; n = 88] or hepatobiliary/pancreatic [n = 68]. Cancer-specific survival curves were modeled for changes in ADL and HRQOL scores after diagnosis. Risk factors for cancer-specific survival were assessed with hazard ratios (HRs) and adjusted for demographics, stage, comorbidities, and disease cohorts. RESULTS HRQOL scores declined after diagnosis, with a sharper decline in nonsurgery patients. On multivariate analysis, inability to perform specific ADLs was associated with worse survival in multiple cohorts: hepatobiliary/pancreatic nonsurgery patients unable to eat (HR 3.3 95% confidence interval (CI) 1.7-6.5); all patients with EG unable to use the toilet (HR 3.3 95% CI 1.5-7.9); EG nonsurgery cohort unable to dress or use the toilet (dress HR 14.1 95% CI 4.0-49.0; toilet HR 4.7 95% CI 1.8-12.3). CONCLUSIONS Older survivors with UGI cancers report declines in HRQOL, especially those not undergoing surgery. The ability to perform ADLs may be linked to survival in this population.
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Xie D, Qian B, Yang J, Peng X, Li Y, Hu T, Lu S, Chen X, Han Y. Can Elderly Patients With Pancreatic Cancer Gain Survival Advantages Through More Radical Surgeries? A SEER-Based Analysis. Front Oncol 2020; 10:598048. [PMID: 33194764 PMCID: PMC7660699 DOI: 10.3389/fonc.2020.598048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/06/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Aims In recent years, the best treatment method for pancreatic cancer in elderly patients has remained controversial. Surgery is the main treatment modality for pancreatic cancer. This study aimed to determine whether elderly patients with pancreatic cancer can gain survival advantages through more active and radical surgical treatment and evaluate the best treatment method and potential prognostic factors. Methods From the Surveillance, Epidemiology, and End Results program (SEER) database, 10,557 elderly patients (aged ≥65 years) with pancreatic cancer were included as Cohort 1, and Propensity Score Matching (PSM) evaluation was performed to generate Cohort 2 (424 pairs). Overall Survival (OS) and Cause-Specific Survival (CSS) were determined using Kaplan-Meier survival curves, and differences were assessed using the Log-rank test. Multivariate logistic regression analysis and the forest plot of hazard ratio (HR) was made to assess the association between potential prognostic factors, including surgery and different surgical methods, and survival in elderly patients. Results We identified 10,557 eligible patients with pancreatic cancer, who formed Cohort 1. The total OS and CSS in the surgery group were significantly higher than those in the non-surgery group (P < 0.001). Age, stage (AJCC 8th), grade, lymph node metastasis, radiation, chemotherapy, and surgical methods were independent factors affecting the prognosis of elderly patients. In Cohort 2, Total pancreatectomy (Total PT) had the lowest risk ratio (HR = 0.31, P < 0.001) and longest median CSS (18.000 months), while Extension Total pancreatectomy (Ex-Total PT, HR = 0.34, P < 0.001) showed the lower median CSS (17.000 months) and median OS (14.000 months). Partial pancreatectomy (Partial PT, HR = 0.46, P < 0.001) showed the lowest median CSS (13.000 months) and median OS (12.000 months), although they were still higher than the median CSS (6.000 months) and median OS (5.000 months) in the non-surgery group. Conclusions Based on the SEER database, surgical treatment is an independent prognostic factor in elderly patients with pancreatic cancer. Compared with other surgical methods, Total PT can offer elderly patients the best survival advantages. However, Ex-Total PT, a more radical method, does not seem to be the best treatment option for the survival and benefit of elderly patients.
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Affiliation(s)
- Danna Xie
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Baolin Qian
- Department of Hepatobiliary Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jing Yang
- Department of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Xinya Peng
- Department of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Yinghua Li
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Teng Hu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Simin Lu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaojing Chen
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yunwei Han
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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Stoop TF, Del Chiaro M. ASO Author Reflections: The Beneficial Effect of High-Volume Center Experience on Surgical Outcomes After Total Pancreatectomy. Ann Surg Oncol 2020; 27:878-879. [PMID: 32783120 PMCID: PMC7677144 DOI: 10.1245/s10434-020-08986-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/25/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Thomas F Stoop
- Pancreatic Surgery Unit, Division of Surgery, Department of Science Intervention and Technology (CLINTEC), Karolinska Institutet at Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden. .,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. .,Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.
| | - Marco Del Chiaro
- Pancreatic Surgery Unit, Division of Surgery, Department of Science Intervention and Technology (CLINTEC), Karolinska Institutet at Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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68
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Stoop TF, Ateeb Z, Ghorbani P, Scholten L, Arnelo U, Besselink MG, Del Chiaro M. Surgical Outcomes After Total Pancreatectomy: A High-Volume Center Experience. Ann Surg Oncol 2020; 28:1543-1551. [PMID: 32761326 DOI: 10.1245/s10434-020-08957-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/14/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The impact of high-volume care in total pancreatectomy (TP) is barely explored since annual numbers are mostly low. This study evaluated surgical outcomes after TP over time in a high-volume center. METHODS All adult patients (age ≥ 18 years) who underwent an elective single-stage TP at Karolinska University Hospital were retrospectively analysed (2008-2017). High volume was defined as > 20 TPs/year. RESULTS Overall, 145 patients after TP were included, including 86 (59.3%) extended resections. Major morbidity was 34.5% (50/145) and 90-day mortality 5.5% (8/145). The relative use of TP within all pancreatectomies increased from 5.4% (63/1175) in 2008-2015 to 17.3% (82/473) in 2016-2017 (p < 0.001). Over time, TP was more often performed to achieve radicality (n = 11, 17.5% to n = 31, 37.8%; p = 0.007). In multivariable logistic regression analysis, an annual TP-volume of > 20 was associated with reduced major morbidity (odds ratio [OR] = 0.225, 95% confidence interval [CI], 0.097-0.521; p < 0.001). In the high-volume years (2016-2017), major morbidity (n = 31, 49.2% to n = 19, 23.2%; p = 0.001) and relaparotomy rate (n = 13, 20.6% to n = 5, 6.1%; p = 0.009) improved. Improvements occurred mainly after extended TP, including lower major morbidity (n = 22, 57.9% to n = 12, 25.0%; p = 0.002) and in-hospital mortality (n = 3, 7.9% to n = 0, 0%; p = 0.082). CONCLUSIONS In a single, high-volume center study, an increase in surgical volume of TP was associated with improved perioperative outcomes, especially for extended resections.
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Affiliation(s)
- Thomas F Stoop
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet at Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden. .,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. .,Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.
| | - Zeeshan Ateeb
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet at Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Poya Ghorbani
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet at Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Lianne Scholten
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Urban Arnelo
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet at Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marco Del Chiaro
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet at Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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69
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Scholten L, Latenstein AE, Aalfs CM, Bruno MJ, Busch OR, Bonsing BA, Koerkamp BG, Molenaar IQ, Ubbink DT, van Hooft JE, Fockens P, Glas J, DeVries JH, Besselink MG. Prophylactic total pancreatectomy in individuals at high risk of pancreatic ductal adenocarcinoma (PROPAN): systematic review and shared decision-making programme using decision tables. United European Gastroenterol J 2020; 8:865-877. [PMID: 32703081 PMCID: PMC7707864 DOI: 10.1177/2050640620945534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Individuals with a very high lifetime risk of developing pancreatic ductal adenocarcinoma; for example, hereditary pancreatitis and main-duct or mixed-type intraductal papillary mucinous neoplasm, may wish to discuss prophylactic total pancreatectomy but strategies to do so are lacking. Objective To develop a shared decision-making programme for prophylactic total pancreatectomy using decision tables. Methods Focus group meetings with patients were used to identify relevant questions. Systematic reviews were performed to answer these questions. Results The first tables included hereditary pancreatitis and main-duct or mixed-type intraductal papillary mucinous neoplasm. No studies focused on prophylactic total pancreatectomy in these groups. In 52 studies (3570 patients), major morbidity after total pancreatectomy was 25% and 30-day mortality was 6%. After minimally invasive total pancreatectomy (seven studies, 35 patients) this was, respectively, 13% and 0%. Exocrine insufficiency-related symptoms occurred in 33%. Quality of life after total pancreatectomy was slightly lower compared with the general population. Conclusion The decision tables can be helpful for discussing prophylactic total pancreatectomy with individuals at high risk of pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Lianne Scholten
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands.,Department of Internal Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Cora M Aalfs
- Department of Clinical Genetics, University of Amsterdam, Amsterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, St Antonius Hospital Nieuwegein and University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Dirk T Ubbink
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, University of Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, University of Amsterdam, The Netherlands
| | - Jolanda Glas
- Dutch Pancreatic Cancer Patient Organisation, 'Living with Hope', Utrecht, The Netherlands
| | - J Hans DeVries
- Department of Internal Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
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70
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[Quality of indications in cystic lesions of the pancreas]. Chirurg 2020; 91:736-742. [PMID: 32642818 DOI: 10.1007/s00104-020-01217-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cystic tumors of the pancreas (PCN) have increasingly gained importance in the clinical routine as they are frequently diagnosed as an incidental finding due to the continuous improvement in cross-sectional imaging. A differentiation is made between non-neoplastic and neoplastic cysts, whereby the latter has a tendency to malignant transformation to a varying extent. Therefore, they can be considered as precursor lesions of pancreatic cancer (PDAC). In addition to a detailed patient history and examination, imaging modalities, such as computed tomography (CT), magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) with fine needle aspiration (FNA) are used for the differential diagnosis. The indications for surgical resection of these lesions are based on the current European guidelines from 2018; however, the content is not evidence-based but relies on knowledge and recommendations from experts. According to these consensus recommendations asymptomatic serous cystic neoplasms (SCN) are serous lesions with a low tendency for malignant transformation and can be monitored. In contrast resection is warranted for all mucinous cystic neoplasms (MCN) >4 cm and all solid pseudopapillary neoplasms (SPN). Intraductal papillary mucinous neoplasms (IPMN), which are differentiated into main duct (MD-IPMN) and branch duct type (BD-IPMN) IPMN based on the position in the pancreatic duct system, should be resected as MD-IPMN and mixed type (MT)-IPMN. The risk of malignant transformation in BD-IPMN is variable and depends on risk factors, which are defined clinically and by imaging morphology. The treatment management is therefore carried out on an individual basis following risk estimation. In order to quantify the quality of indications in PCN and thereby also contributing to optimized medical care, prospective long-term studies are urgently needed.
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71
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Stoop TF, Scholten L, Besselink MG. Author response to: Comment on: Systematic review of functional outcome and quality of life after total pancreatectomy. Br J Surg 2020; 107:618. [PMID: 32187669 DOI: 10.1002/bjs.11536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/16/2020] [Indexed: 11/10/2022]
Affiliation(s)
- T F Stoop
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - L Scholten
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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72
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Amir-Behghadami M, Janati A, Gholizadeh M. Comment on: Systematic review of functional outcome and quality of life after total pancreatectomy. Br J Surg 2020; 107:617-618. [DOI: 10.1002/bjs.11535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/16/2020] [Indexed: 12/13/2022]
Affiliation(s)
- M Amir-Behghadami
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz, Iran
- Iranian Center of Excellence in Health Management (IceHM), Department of Health Service Management, School of Management and Medical Informatics, Tabriz, Iran
- Student Research Committee (SRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - A Janati
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz, Iran
- Iranian Center of Excellence in Health Management (IceHM), Department of Health Service Management, School of Management and Medical Informatics, Tabriz, Iran
| | - M Gholizadeh
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz, Iran
- Iranian Center of Excellence in Health Management (IceHM), Department of Health Service Management, School of Management and Medical Informatics, Tabriz, Iran
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73
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Stoop TF, Del Chiaro M. ASO Author Reflections: Acceptable Impact of Endocrine and Exocrine Insufficiency on Quality of Life After Total Pancreatectomy. Ann Surg Oncol 2019; 27:597-598. [PMID: 31654166 DOI: 10.1245/s10434-019-08008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Thomas F Stoop
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Pancreatic Surgery Unit, Division of Surgery, CLINTEC, Karolinska Institute at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Del Chiaro
- Pancreatic Surgery Unit, Division of Surgery, CLINTEC, Karolinska Institute at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden. .,Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO, USA. .,University of Colorado Cancer Center, Denver, CO, USA.
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