51
|
Ahola R, Sand J, Laukkarinen J. Centralization of Pancreatic Surgery Improves Results: Review. Scand J Surg 2020; 109:4-10. [DOI: 10.1177/1457496919900411] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background and Aims: The effect of operation volume on the outcomes of pancreatic surgery has been a subject of research since the 1990s. In several countries around the world, this has led to the centralization of pancreatic surgery. However, controversy persists as to the benefits of centralization and what the optimal operation volume for pancreatic surgery actually is. This review summarizes the data on the effect of centralization on mortality, complications, hospital facilities used, and costs regarding pancreatic surgery. Materials and Methods: A systematic librarian-assisted search was performed in PubMed covering the years from August 1999 to August 2019. All studies comparing results of open pancreatic resections from high- and low-volume centers were included. In total 44, published articles were analyzed. Results: Studies used a variety of different criteria for high-volume and low-volume centers, which hampers the evaluating of the effect of operation volume. However, mortality in high-volume centers is consistently reported to be lower than in low-volume centers. In addition, failure to rescue critically ill patients is more common in low-volume centers. Cost-effectiveness has also been evaluated in the literature. Length of hospital stay in particular has been reported to be shorter in high-volume centers than in low-volume centers. Conclusion: The effect of centralization on the outcomes of pancreatic surgery has been under active research and the beneficial effect of it is associated especially with better short-term prognosis after surgery.
Collapse
Affiliation(s)
- R. Ahola
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - J. Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Tampere University Hospital, Tampere, Finland
| | - J. Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| |
Collapse
|
52
|
Hain E, Gharios J, Sindayigaya R, Gaujoux S. Quand et avec quelles conséquences opérer une tumeur neuroendocrine du pancréas ou du grêle ? ONCOLOGIE 2020. [DOI: 10.3166/onco-2019-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les tumeurs neuroendocrines (TNE) sont des tumeurs rares et peuvent survenir dans tout le tube digestif. On distingue les tumeurs fonctionnelles associées à des symptômes secondaires à l’activité sécrétoire de la tumeur et les tumeurs non fonctionnelles. Tout patient présentant une TNE doit être discuté en RCP RENATEN. Concernant les TNE duodénopancréatiques sporadiques, la chirurgie est nécessaire devant une TNE fonctionnelle ainsi que devant une TNE non fonctionnelle de plus de 2 cm, associées ou non à un retentissement canalaire. Pour les tumeurs supposées peu ou pas agressives, il sera toujours privilégié une stratégie d’épargne parenchymateuse afin d’éviter l’insuffisance pancréatique endocrine et exocrine. Concernant les TNE du grêle, la chirurgie doit être systématiquement envisagée, y compris en cas de métastases ou de carcinose associée afin d’éviter une complication mécanique telle qu’une occlusion. Un curage ganglionnaire comportant au minimum huit ganglions doit être effectué. Ce curage doit être large tout en préservant une vascularisation suffisante afin d’éviter la survenue d’un syndrome de grêle court.
Collapse
|
53
|
Hain E, Sindayigaya R, Fawaz J, Gharios J, Bouteloup G, Soyer P, Bertherat J, Prat F, Terris B, Coriat R, Gaujoux S. Surgical management of pancreatic neuroendocrine tumors: an introduction. Expert Rev Anticancer Ther 2019; 19:1089-1100. [PMID: 31825691 DOI: 10.1080/14737140.2019.1703677] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Neuroendocrine tumors of the pancreas (pNETs) represent only 1% to 2% of all pancreatic neoplasms. These tumors can be classified as functional or nonfunctional tumors; as sporadic or from a genetic origin; as neuroendocrine neoplasms or carcinoma. Over the last decade, diagnosis of pNETs has increased significantly mainly due to the widespread use of cross-sectional imaging. Those tumors are usually associated with a good prognosis. Surgery, the only curative option for those patients, should always be discussed, ideally in a multidisciplinary team setting.Areas covered: We discuss i), the preoperative management of pNETs and the importance of accurate diagnosis, localization, grading and staging with computed tomography, magnetic resonance imaging, endoscopic ultrasound, and nuclear medicine imaging; ii), surgical indications and iii), the surgical approach (standard pancreatectomy vs pancreatic-sparing surgery).Expert opinion: The treatment option of all patients presenting with pNETs should be discussed in a multidisciplinary team setting with surgeon's experienced in both pancreatic surgery and neuroendocrine tumor management. A complete preoperative imaging assessment - morphological and functional - must be performed. Surgery is usually recommended for functional pNETs, nonfunctional pNETs >2 cm (nf-pNETs) or for symptomatic nf-pNETs.
Collapse
Affiliation(s)
- Elisabeth Hain
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France.,Facultéde Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Rémy Sindayigaya
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - Jade Fawaz
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - Joseph Gharios
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - Gaspard Bouteloup
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - Philippe Soyer
- Department of Radiology, Cochin Hospital, APHP, Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology, Cochin Hospital, APHP, Paris, France
| | - Frédéric Prat
- Facultéde Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Benoit Terris
- Facultéde Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department of Pathology, Cochin Hospital, APHP, Paris, France
| | - Romain Coriat
- Facultéde Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France.,Facultéde Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| |
Collapse
|
54
|
El Amrani M, Lenne X, Clement G, Delpero JR, Theis D, Pruvot FR, Bruandet A, Truant S. Specificity of Procedure volume and its Association With Postoperative Mortality in Digestive Cancer Surgery. Ann Surg 2019; 270:775-782. [DOI: 10.1097/sla.0000000000003532] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
55
|
Polonski A, Izbicki JR, Uzunoglu FG. Centralization of Pancreatic Surgery in Europe. J Gastrointest Surg 2019; 23:2081-2092. [PMID: 31037503 DOI: 10.1007/s11605-019-04215-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of this article is a review and an analysis of the current state of centralization of pancreatic surgery in Europe. Numerous recent publications demonstrate higher postoperative in-hospital mortality rates in low-volume clinics after pancreatic resection than previously assumed due to their not publishing significantly worse outcomes when compared to high-volume centres. Although the benefits of centralization of pancreatic surgery in high-volume centres have been demonstrated in many studies, numerous countries have so far failed to establish centralization in their respective health care systems. METHODS A systematic literature search of the Medline database for studies concerning centralization of pancreatic surgery in Europe was conducted. The studies were reviewed independently for previously defined inclusion and exclusion criteria. We included 14 studies with a total of 117,634 patients. All data were extracted from or provided by health insurance company or governmental registry databases. RESULTS Thirteen out of the 14 studies demonstrate an improvement in their respective outcome related to volume. Twelve studies showed a significantly lower postoperative mortality rate in the highest annual volume group in comparison to overall postoperative mortality rate in the whole patient cohort. CONCLUSION As the available data indicate, most European countries have so far failed to establish centralization of pancreatic surgery to high-volume centres due to numerous reasons. Considering a plateau in survival rates of patients undergoing treatment for pancreatic cancer in Europe during the last 15 years, this review enforces the worldwide plea for centralization to lower post-operative mortality after pancreatic surgery.
Collapse
Affiliation(s)
- Adam Polonski
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany. .,Department of General Visceral and Thoracic Surgery, University of Hamburg Medical Institutions, Martinistr 52, 20252, Hamburg, Germany.
| | - Faik G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
56
|
Gharios J, Hain E, Dohan A, Prat F, Terris B, Bertherat J, Coriat R, Dousset B, Gaujoux S. Pre- and intraoperative diagnostic requirements, benefits and risks of minimally invasive and robotic surgery for neuroendocrine tumors of the pancreas. Best Pract Res Clin Endocrinol Metab 2019; 33:101294. [PMID: 31351817 DOI: 10.1016/j.beem.2019.101294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatic neuroendocrine tumours (PanNET) are rare tumours, accounting for 1%-2% of all pancreatic neoplasms. These tumors are classified as functioning neuroendocrine tumours (F-PanNETs) or non-functioning (NF-PanNETs) depends on whether the tumour is associated with clinical hormonal hypersecretion syndrome or not. In the last decades, diagnosis of PanNETs has increased significantly due to the widespread of cross-sectional imaging. Whenever possible, surgery is the cornerstone of PanNETs management and the only curative option for these patients. Indeed, after R0 resection, the 5-year overall survival rate is around 90-100% for low grade lesions but significantly drops after incomplete resections. Compared to standard resections, pancreatic sparing surgery, i.e. enucleation and central pancreatectomy, significantly decreased the risk of pancreatic insufficiency. It should be performed in patients with good general condition and normal pancreatic function to limit the operative risk and enhance the benefit of surgery. Nowadays, due to many known advantages of minimally invasive surgery, there is an ongoing trend towards laparoscopic and robotic pancreatic surgery. The aim of this study is to describe the pre- and intraoperative diagnostic requirements for the management of PanNETs and the benefits and risks of minimally invasive surgery including laparoscopic and robotic approach in view of the recent literature.
Collapse
Affiliation(s)
- Joseph Gharios
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Elisabeth Hain
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Anthony Dohan
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Radiology, Cochin Hospital, APHP, Paris, France
| | - Fréderic Prat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Benoit Terris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Pathology, Cochin Hospital, APHP, Paris, France
| | - Jérôme Bertherat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Endocrinology, Cochin Hospital, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Romain Coriat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Bertrand Dousset
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France.
| |
Collapse
|
57
|
Burdío F, Grande L, Poves I. What's the next step in evaluating laparoscopic pancreaticoduodenectomy? Hepatobiliary Surg Nutr 2019; 8:555-556. [PMID: 31673557 DOI: 10.21037/hbsn.2019.07.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Fernando Burdío
- Department of Surgery, Hospital Universitari del Mar, Autonomous University of Barcelona. Barcelona, Spain
| | - Luís Grande
- Department of Surgery, Hospital Universitari del Mar, Autonomous University of Barcelona. Barcelona, Spain
| | - Ignasi Poves
- Department of Surgery, Hospital Universitari del Mar, Autonomous University of Barcelona. Barcelona, Spain
| |
Collapse
|
58
|
Is Centralization Needed for Patients Undergoing Distal Pancreatectomy?: A Nationwide Study of 3314 Patients. Pancreas 2019; 48:1188-1194. [PMID: 31593018 DOI: 10.1097/mpa.0000000000001410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The centralization of complex surgical procedures is associated with better postoperative outcomes. However, little is known about the impact of hospital volume on the outcome after distal pancreatectomy. METHODS Using the French national hospital discharge database, we identified all patients having undergone distal pancreatectomy in France between 2012 and 2015. A spline model was applied to determine the caseload cut-off in annual distal pancreatectomy that influenced 90-day postoperative mortality. RESULTS A total of 3314 patients were identified. Use of a spline model did not reveal a cut-off in the annual distal pancreatectomy caseload. By taking the median number of distal pancreatectomy (n = 5) and the third quartile (n = 15), we stratified centers into low, intermediate, and high hospital volume groups. The overall postoperative mortality rate was 3.0% and did not differ significantly between these groups. In a multivariable analysis, age, Charlson comorbidity score, septic complications, hemorrhage, shock, and reoperation were independently associated with a greater overall risk of death. However, hospital volume had no impact on mortality after distal pancreatectomy (odds ratio, 0.954; 95% confidence interval, 0.552-1.651, P = 0.867). CONCLUSIONS Hospital volume does not seem to influence mortality after distal pancreatectomy in France, and centralization may not necessarily improve outcomes.
Collapse
|
59
|
Lambert A, Schwarz L, Borbath I, Henry A, Van Laethem JL, Malka D, Ducreux M, Conroy T. An update on treatment options for pancreatic adenocarcinoma. Ther Adv Med Oncol 2019; 11:1758835919875568. [PMID: 31598142 PMCID: PMC6763942 DOI: 10.1177/1758835919875568] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
Pancreatic cancer is one of the most lethal solid organ tumors. Due to the rising incidence, late diagnosis, and limited treatment options, it is expected to be the second leading cause of cancer deaths in high income countries in the next decade. The multidisciplinary treatment of this disease depends on the stage of cancer at diagnosis (resectable, borderline, locally advanced, and metastatic disease), and combines surgery, chemotherapy, chemoradiotherapy, and supportive care. The landscape of multidisciplinary pancreatic cancer treatment is changing rapidly, especially in locally advanced disease, and the number of treatment options in metastatic disease, including personalized medicine, innovative targets, immunotherapy, therapeutic vaccines, adoptive T-cell transfer, or stemness inhibitors, will probably expand in the near future. This review summarizes the current literature and provides an overview of how new therapies or new therapeutic strategies (neoadjuvant therapies, conversion surgery) will guide multidisciplinary disease management, future clinical trials, and, hopefully, will increase overall survival.
Collapse
Affiliation(s)
- Aurélien Lambert
- Department of Medical Oncology, Institut de Cancérologie de Lorraine and Université de Lorraine, Nancy, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Rouen University Hospital and Université de Rouen Normandie, France
| | - Ivan Borbath
- Department of Gastroenterology and Digestive Oncology, Cliniques Universitaires Saint-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - Aline Henry
- Department of Supportive Care in Oncology, Institut de Cancérologie de Lorraine, Nancy, France
| | - Jean-Luc Van Laethem
- Department of Gastroenterology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Belgium
| | - David Malka
- Department of Medical Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Michel Ducreux
- Department of Medical Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Thierry Conroy
- Institut de Cancérologie de Lorraine, 6 avenue de Bourgogne, 50519 Vandoeuvre-lès-Nancy CEDEX, France
| |
Collapse
|
60
|
Comparison of Perioperative Outcomes Between Laparoscopic and Open Approach for Pancreatoduodenectomy: The PADULAP Randomized Controlled Trial. Ann Surg 2019; 268:731-739. [PMID: 30138162 DOI: 10.1097/sla.0000000000002893] [Citation(s) in RCA: 223] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare perioperative outcomes of pancreatoduodenectomy (PD) performed through the laparoscopic route or by open surgery. SUMMARY BACKGROUND DATA Laparoscopic PD is being progressively performed in selected patients. METHODS An open-label single-center RCT was conducted between February 2013 and September 2017. The primary endpoint was the length of hospital stay (LOS). Secondary endpoints were operative time, transfusion requirements, specific pancreatic complications (pancreatic or biliary fistula, pancreatic hemorrhage, and delayed gastric emptying), Clavien-Dindo grade ≥ 3 complications, comprehensive complication index (CCI) score, poor quality outcome (PQO), and the quality of pathologic resection. Analyses were performed on an intention to treat basis. RESULTS Of 86 patients assessed for PD, 66 were randomized (34 laparoscopic approach, 32 open surgery). Conversion to an open procedure was needed in 8 (23.5%) patients. Laparoscopic versus open PD was associated with a significantly shorter LOS (median 13.5 vs. 17 d; P = 0.024) and longer median operative time (486 vs. 365 min; P = 0.0001). The laparoscopic approach was associated with significantly better outcomes regarding Clavien-Dindo grade ≥ 3 complications (5 vs. 11 patients; P = 0.04), CCI score (20.6 vs. 29.6; P = 0.038), and PQO (10 vs. 14 patients; P = 0.041). No significant differences in transfusion requirements, pancreas-specific complications, the number of lymph nodes retrieved, and resection margins between the two approaches were found. CONCLUSIONS Laparoscopic PD versus open surgery is associated with a shorter LOS and a more favorable postoperative course while maintaining oncological standards of a curative-intent surgical resection. TRIAL REGISTRY ISRCTN93168938.
Collapse
|
61
|
Failure-to-rescue in Patients Undergoing Pancreatectomy: Is Hospital Volume a Standard for Quality Improvement Programs? Nationwide Analysis of 12,333 Patients. Ann Surg 2019; 268:799-807. [PMID: 30048329 DOI: 10.1097/sla.0000000000002945] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the influence of hospital volume on failure-to-rescue (FTR) after pancreatectomy in France. BACKGROUND There are growing evidences that FTR is an important source of postoperative mortality (POM) after pancreatectomy. However, few studies have analyzed the volume-FTR relationship following pancreatic surgery. METHODS All patients undergoing pancreatectomy between 2012 and 2015 were included. FTR is defined as the 90-day POM rate among patients with major complications. According to the spline model, the critical cutoff was 20 resections per year and hospitals were divided into low (<10 resections/an), intermediate (11-19 resections/yr), and high volume centers (≥20 resections/yr). RESULTS Overall, 12,333 patients who underwent pancreatectomy were identified. The POM was 6.9% and decreased significantly with increased hospital volume. The rate of FTR was 14.5% and varied significantly with hospital volume (18.3% in low hospital volume vs 11.9% in high hospital volume, P < 0.001), age (P < 0.001) and ChCl (CCl0-2: 11.5%, ChCl3: 13%, CCl ≥4:18.6%; P < 0.001). FTR for renal failure was the highest of all complications (40.2%), followed by postoperative shock (36.4%) and cardiac complications (35.1%). The FTR was significantly higher in low and intermediate compared with high volume hospitals for shock, digestive, and thromboembolic complications and reoperation. In multivariable analysis, intermediate (OR = 1.265, CI95%[1.103-1.701], P = 0.045) and low volume centers (OR = 1.536, CI95%[1.165-2.025], P = 0.002) were independently associated with increased FTR rates. CONCLUSION FTR after pancreatectomy is high and directly correlated to hospital volume, highlighting variability in the management of postoperative complications. Measurement of the FTR rate should become a standard for quality improvement programs.
Collapse
|
62
|
Buscail E, Cauvin T, Fernandez B, Buscail C, Marty M, Lapuyade B, Subtil C, Adam JP, Vendrely V, Dabernat S, Laurent C, Chiche L. Intraductal papillary mucinous neoplasms of the pancreas and European guidelines: importance of the surgery type in the decision-making process. BMC Surg 2019; 19:115. [PMID: 31438917 PMCID: PMC6704670 DOI: 10.1186/s12893-019-0580-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/11/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The European Consensus 2018 established a new algorithm with absolute and relative criteria for intraductal papillary mucinous neoplasms of the pancreas (IPMN) management. The aim of this study was to validate these criteria and analyse the outcomes in function of the surgical procedure and IPMN subtype. METHODS Clinical, radiological and surgical data (procedure, morbidity/mortality rates) of patients who underwent surgery for IPMN between 2007 and 2017. The predictive value of the different criteria was analysed. RESULTS 124 patients (men 67%; mean age 65 years) underwent surgery for IPMN (n = 62 malignant tumours; 50%). Jaundice, cyst ≥4 cm and Wirsung duct size 5-9.9 mm or ≥ 10 mm were significantly associated with malignancy (4.77 < OR < 11.85 p < 0.0001). The positive predictive value of any isolated criterion ranged from 71 to 87%, whereas that of three relative criteria together reached 100%. The mortality and morbidity (grade III-IV complications according to the Dindo-Clavien classification) rates were 3 and 8%, respectively. Morbidity/mortality after duodenopancreatectomy and total pancreatectomy were significantly higher for benign IPMN (p = 0.01). CONCLUSION Considering the morbidity associated with extended surgery, particularly for benign IPMN, the results of the present study suggest that high-risk surgery should be considered only in the presence of three relative criteria and including the surgery type in the decision-making algorithm.
Collapse
Affiliation(s)
- Etienne Buscail
- Department of Digestive Surgery, Haut Leveque Hospital, University of Bordeaux, Bordeaux, France. .,INSERM 1035, University of Bordeaux, Bordeaux, France. .,Department of Surgery, Haut Leveque Hospital, Bordeaux, France.
| | - Thomas Cauvin
- Department of Digestive Surgery, Haut Leveque Hospital, University of Bordeaux, Bordeaux, France.,INSERM 1035, University of Bordeaux, Bordeaux, France.,Department of Surgery, Haut Leveque Hospital, Bordeaux, France
| | - Benjamin Fernandez
- Department of Digestive Surgery, Haut Leveque Hospital, University of Bordeaux, Bordeaux, France.,Department of Surgery, Haut Leveque Hospital, Bordeaux, France
| | - Camille Buscail
- Department of Epidemiology, EREN UMR INSERM INRA, University of Sorbonne Paris 13, Bobigny, France
| | - Marion Marty
- Department of Pathology, Haut Leveque Hospital, University of Bordeaux, Bordeaux, France
| | - Bruno Lapuyade
- Department of Radiology, Haut Leveque Hospital, University of Bordeaux, Bordeaux, France
| | - Clément Subtil
- Department of Gastroenterology and Endoscopy, Haut Leveque Hospital, University of Bordeaux, Bordeaux, France
| | - Jean-Philippe Adam
- Department of Digestive Surgery, Haut Leveque Hospital, University of Bordeaux, Bordeaux, France
| | | | | | - Christophe Laurent
- Department of Digestive Surgery, Haut Leveque Hospital, University of Bordeaux, Bordeaux, France.,INSERM 1035, University of Bordeaux, Bordeaux, France.,Department of Surgery, Haut Leveque Hospital, Bordeaux, France
| | - Laurence Chiche
- Department of Digestive Surgery, Haut Leveque Hospital, University of Bordeaux, Bordeaux, France.,INSERM 1035, University of Bordeaux, Bordeaux, France.,Department of Surgery, Haut Leveque Hospital, Bordeaux, France
| |
Collapse
|
63
|
Ahola R, Sand J, Laukkarinen J. Pancreatic resections are not only safest but also most cost-effective when performed in a high-volume centre: A Finnish register study. Pancreatology 2019; 19:769-774. [PMID: 31239104 DOI: 10.1016/j.pan.2019.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/26/2019] [Accepted: 06/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND It is not known whether the treatment costs of pancreatic surgery can be reduced by centralisation. The aim of this study was to analyse the impact of hospital volume on the short-term prognosis and costs in a nationwide study. METHODS The National registry was searched for patients undergoing pancreatoduodenectomy (PD) in Finland between 2012 and 2014. Patient data was recorded up to ninety days postoperatively and Charlson comorbidity index (CCI) calculated. Complications were classified according to Clavien-Dindo. A CCI was calculated for each patient. The hospitals were categorized by yearly resection rate: high (≥20, HVC), medium (6-19, MVC) and low (≤5, LVC). Costs were calculated according to the 2012 billing list. RESULTS The study population comprised 466 patients. Demographics were similar in the HVC, MVC and LVC groups. Mortality was lower in the HVCs than in MVCs and LVCs at 30 days (0.8% vs. 8.8-12.9%; p < 0.01) and at 90 days (1.9% vs. 10.5-16.1%; p < 0.01). Hospital volume and CCI were significant factors for mortality in multivariate analysis. Median costs among all patients were lower in the HVC group than in the MVC/LVC groups (p = 0.019), among Clavien-Dindo class III (0.020), among patients over 75 years (p < 0.001) and among patients who survived over five days (p = 0.015). CONCLUSIONS Thirty- and 90-day mortality is 10 times lower when the patient is operated on in an HVC. The study shows that the median overall costs of surgical treatment are 82-88% of the median costs in lower volume centres.
Collapse
Affiliation(s)
- R Ahola
- Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland
| | - J Sand
- Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland; Päijät-Häme Central Hospital, Medical School, University of Tampere, Finland
| | - J Laukkarinen
- Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland; Medical School, University of Tampere, Finland.
| |
Collapse
|
64
|
Pouypoudat C, Buscail E, Cossin S, Cassinotto C, Terrebonne E, Blanc JF, Smith D, Marty M, Dupin C, Laurent C, Dabernat S, Chiche L, Vendrely V. FOLFIRINOX-based neoadjuvant chemoradiotherapy for borderline and locally advanced pancreatic cancer: A pilot study from a tertiary centre. Dig Liver Dis 2019; 51:1043-1049. [PMID: 31000479 DOI: 10.1016/j.dld.2019.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 02/25/2019] [Accepted: 03/11/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy, potentially relevant to increase resection rate in pancreatic cancer, is still debated. AIMS To assess tolerance, resection rate and outcomes of patients with non-metastatic pancreatic ductal adenocarcinoma treated by concomitant chemoradiotherapy. METHODS This monocentric study included all consecutive patients treated from 2010 to 2014 for non-metastatic pancreatic adenocarcinoma. Chemotherapy was followed by chemoradiotherapy in operable patients, surgical resectability being assessed by CT-scan. RESULTS Seventy-nine patients were included: 41 patients had borderline and 38 locally advanced tumours. All patients were treated by chemotherapy (FOLFIRINOX), followed by chemoradiotherapy (median dose: 59 Gy, range 45-66 Gy) for 94% of patients. Thirty-seven patients (47%) could subsequently benefit from surgery with a complete R0 resection in 94% of cases, with a postoperative mortality of 5%. Median overall survival was 21.5 months (median follow-up: 48.8 months). Local control, overall and disease-free survival were significantly higher for patients who underwent resection compared to others, with 89.2% vs 59.5% (p = 0.01), 49.7 vs 17.4 months (p < 0.01) and 25.5 vs 9.2 months (p < 0.01), respectively. CONCLUSION Neoadjuvant treatment consisting of FOLFIRINOX chemotherapy followed by chemoradiotherapy is an efficient strategy for patients with borderline and locally advanced pancreatic cancer, resulting in a 43% rate of secondary complete surgical resection associated with high local control, overall and disease-free survival.
Collapse
Affiliation(s)
| | - Etienne Buscail
- Bordeaux University, INSERM U1035, Bordeaux, France; CHU Bordeaux, Department of Surgery, Bordeaux, France
| | | | | | | | | | - Denis Smith
- CHU Bordeaux, Department of Oncology, Bordeaux, France
| | - Marion Marty
- CHU Bordeaux, Department of Pathology, Bordeaux, France
| | - Charles Dupin
- CHU Bordeaux, Department of Radiotherapy, Bordeaux, France
| | - Christophe Laurent
- Bordeaux University, INSERM U1035, Bordeaux, France; CHU Bordeaux, Department of Surgery, Bordeaux, France
| | | | - Laurence Chiche
- Bordeaux University, INSERM U1035, Bordeaux, France; CHU Bordeaux, Department of Surgery, Bordeaux, France
| | - Véronique Vendrely
- CHU Bordeaux, Department of Radiotherapy, Bordeaux, France; Bordeaux University, INSERM U1035, Bordeaux, France.
| |
Collapse
|
65
|
Sauvanet A. Gastroenteropancreatic neuroendocrine tumors: Role of surgery. ANNALES D'ENDOCRINOLOGIE 2019; 80:175-181. [PMID: 31079831 DOI: 10.1016/j.ando.2019.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Natural history of gastroenteropancreatic (GEP) Neuroendocrine tumors (NETs) is better and better known so indications of surgery are presently selective. Surgical resection, but also endoscopic resection and observation, can be proposed for gastric NETs according to presentation, size and grade. For small bowel NETs, resection is frequently needed but should obtain the best compromise between radicality and postoperative functional disorders. Appendiceal NETs are frequently diagnosed by appendectomy for appendicitis, but some patients at high risk for lymph node metastasis and recurrence should be reoperated for radical resection. Rectal NETs are often diagnosed incidentally; the smallest (<1cm) can be resected endoscopically but the most aggressive need a oncological proctectomy. Pancreatic NETs represent a wide spectrum, ranging from fully benign tumors to very aggressive ones. Insulinomas are mostly benign, responsible for incapacitating symptoms despite medical treatment, and should ideally be treated by parenchyma sparing resection, mainly enucleation. Conversely, symptoms of gastrinomas are efficiently treated medically but their resection needs an oncological approach. Nonfunctioning PNETs are more and more frequently and incidentally discovered. According to their size, presentation and patient's characteristics, they need a resection (oncological or parenchyma-sparing) or a close observation.
Collapse
Affiliation(s)
- Alain Sauvanet
- Department of HPB surgery, pôle des maladies de l'appareil digestif (PMAD), université Paris Diderot, hôpital Beaujon, AP-HP, 100, boulevard du Général-Leclerc, 92110 Clichy, France.
| |
Collapse
|
66
|
Response to Comment on "Comparison of Perioperative Outcomes Between the Laparoscopic and Open Approach for Pancreaticoduodenectomy. Can We Compare the Results of the Laparoscopic Approach With Bad Results of the Open Approach?". Ann Surg 2019; 270:e92. [PMID: 31045872 DOI: 10.1097/sla.0000000000003343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
67
|
Sham JG, Gage MM, He J. Contemporary issues in the surgical management of pancreatic neuroendocrine tumours. SURGICAL PRACTICE 2019. [DOI: 10.1111/1744-1633.12349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jonathan G. Sham
- Department of SurgeryJohns Hopkins Hospital Baltimore Maryland USA
| | - Michele M. Gage
- Department of SurgeryJohns Hopkins Hospital Baltimore Maryland USA
| | - Jin He
- Department of SurgeryJohns Hopkins Hospital Baltimore Maryland USA
| |
Collapse
|
68
|
Nymo LS, Søreide K, Kleive D, Olsen F, Lassen K. The effect of centralization on short term outcomes of pancreatoduodenectomy in a universal health care system. HPB (Oxford) 2019; 21:319-327. [PMID: 30297306 DOI: 10.1016/j.hpb.2018.08.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/21/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Centralization of pancreatic resections is advocated due to a volume-outcome association. Pancreatic surgery is in Norway currently performed only in five teaching hospitals. The aim was to describe the short-term outcomes after pancreatoduodenectomy (PD) within the current organizational model and to assess for regional disparities. METHODS All patients who underwent PD in Norway between 2012 and 2016 were identified. Mortality (90 days) and relaparotomy (30 days) were assessed for predictors including demographic data and multi-visceral or vascular resection. Aggregated length-of-stay and national and regional incidences of the procedure were also analysed. RESULTS A total of 930 patients underwent PD during the study period. In-hospital mortality occurred in 20 patients (2%) and 34 patients (4%) died within 90 days. Male gender, age, multi-visceral resection and relaparotomy were independent predictors of 90-day mortality. Some 131 patients (14%) had a relaparotomy, with male gender and multi-visceral resection as independent predictors. There was no difference between regions in procedure incidence or 90-day mortality. There was a disparity within the regions in the use of vascular resection (p = 0.021). CONCLUSION The short-term outcomes after PD in Norway are acceptable and the 90-day mortality rate is low. The outcomes may reflect centralization of pancreatic surgery.
Collapse
Affiliation(s)
- Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Sykehusveien 38, 9019, Tromsø, Norway; Institute of Clinical Medicine, The Arctic University of Norway, Hansine Hansens Veg 18, 9019, Tromsø, Norway.
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Postboks 8100, 4068, Stavanger, Norway; Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, UK; Department of Clinical Medicine, University of Bergen, Jonas Lies Vei 65, 5021, Bergen
| | - Dyre Kleive
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Problemveien 7, 0315, Oslo, Norway
| | - Frank Olsen
- Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Sykehusveien 38, 9019, Tromsø, Norway
| | - Kristoffer Lassen
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Sykehusveien 38, 9019, Tromsø, Norway; Institute of Clinical Medicine, The Arctic University of Norway, Hansine Hansens Veg 18, 9019, Tromsø, Norway; Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
| |
Collapse
|
69
|
Abstract
For the management of diminutive duodenal neuroendocrine tumors (d-NETs), Harshit et al. have proposed - in the work accompanying this editorial - an interesting approach, the endoscopic banding without resection (BWR) technique. Given the risks associated with classic endoscopic resections and surgical procedures, and the likely favorable natural history of diminutive d-NETs, BWR may be an option for these selected patients with a very low risk of LN + and recurrence. However, a close follow-up (endoscopic, EUS and thoraco-abdominal CT scan) is then required to guarantee the safety of this policy.
Collapse
Affiliation(s)
- Thomas Walter
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Department d’Oncologie Médicale, Lyon, France
| |
Collapse
|
70
|
Rezende AQDM, Dutra JPS, Gestic MA, Utrini MP, Callejas-Neto F, Chaim EA, Cazzo E. PANCREATICODUODENECTOMY: IMPACT OF THE TECHNIQUE ON OPERATIVE OUTCOMES AND SURGICAL MORTALITY. ACTA ACUST UNITED AC 2019; 32:e1412. [PMID: 30624521 PMCID: PMC6323629 DOI: 10.1590/0102-672020180001e1412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/09/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a procedure associated with significant morbidity and mortality. Initially described as gastropancreaticoduodenectomy (GPD), the possibility of preservation of the gastric antrum and pylorus was described in the 1970s. AIM To evaluate the mortality and operative variables of PD with or without pyloric preservation and to correlate them with the adopted technique and surgical indication. METHOD Retrospective cohort on data analysis of medical records of individuals who underwent PD from 2012 through 2017. Demographic, anthropometric and operative variables were analyzed and correlated with the adopted technique (GPD vs. PD) and the surgical indication. RESULTS Of the 87 individuals evaluated, 38 (43.7%) underwent GPD and 49 (53.3%) were submitted to PD. The frequency of GPD (62.5%) was significantly higher among patients with pancreatic neoplasia (p=0.04). The hospital stay was significantly shorter among the individuals submitted to resection due to neoplasias of less aggressive behavior (p=0.04). Surgical mortality was 10.3%, with no difference between GPD and PD. Mortality was significantly higher among individuals undergoing resection for chronic pancreatitis (p=0.001). CONCLUSION There were no differences in mortality, surgical time, bleeding or hospitalization time between GPD and PD. Pancreas head neoplasm was associated with a higher indication of GPD. Resection of less aggressive neoplasms was associated with lower morbidity and mortality.
Collapse
Affiliation(s)
| | - João Paulo Simões Dutra
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Martinho Antonio Gestic
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Murillo Pimentel Utrini
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Francisco Callejas-Neto
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Elinton Adami Chaim
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Everton Cazzo
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| |
Collapse
|
71
|
Rodriguez-Lopez M, Tejero-Pintor FJ, Perez-Saborido B, Barrera-Rebollo A, Bailon-Cuadrado M, Pacheco-Sanchez D. Severe morbidity after pancreatectomy is accurately predicted by preoperative pancreatic resection score (PREPARE): A prospective validation analysis from a medium-volume center. Hepatobiliary Pancreat Dis Int 2018; 17:559-565. [PMID: 30316626 DOI: 10.1016/j.hbpd.2018.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 09/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Major morbidity in pancreatic surgery remains high. Different scores for predicting complications have been described. Preoperative pancreatic resection (PREPARE) score is based on objective preoperative variables and offers good predictive accuracy for Clavien ≥ III complications. This study aimed to validate this score and analyze other preoperative variables in a prospective study performed in a medium-volume center. METHODS A total of 50 pancreatic resections were included. Preoperative variables were registered and PREPARE was calculated. The main outcome was severe morbidity (Clavien ≥ III) up to 30 days after discharge. The secondary outcomes were length of stay (LOS) and readmission. Statistical validation was performed to compare severe morbidity rate among the scores categories. Association with other preoperative variables (not included in PREPARE) was also tested. RESULTS Of the 50 pancreatic resections, the severe morbidity was 34.0%, with median LOS of 11 days. Readmission rate was 25.5%. Severe morbidity rates according to PREPARE categories were 18.5% in low-risk group, 41.7% in intermediate-risk group, and 63.6% in high-risk group, respectively (P = 0.023). The accuracy was 72% (Hosmer-Lemeshow, P = 0.86). ROC curve was obtained both for PREPARE score expressed as incremental values and categorized as the three risk groups, showing an area under curve (AUC) of 0.736 (95% CI: 0.586-0.887; P = 0.007) and 0.712 (95% CI: 0.555-0.869; P = 0.015), respectively. PREPARE was significant in multivariate analysis. Median LOS was statistically higher as PREPARE category increases (9, 11 and 15 days in low-, intermediate- and high-risk groups, respectively; P = 0.009). Readmission was not associated with any variables. CONCLUSIONS PREPARE behaves as an independent risk factor for severe morbidity after pancreatic surgery. Score validation shows good accuracy prediction. Increasing PREPARE category is also associated with longer LOS.
Collapse
Affiliation(s)
- Mario Rodriguez-Lopez
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain.
| | | | - Baltasar Perez-Saborido
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - Asterio Barrera-Rebollo
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - Martin Bailon-Cuadrado
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - David Pacheco-Sanchez
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| |
Collapse
|
72
|
Neuzillet C, Gaujoux S, Williet N, Bachet JB, Bauguion L, Colson Durand L, Conroy T, Dahan L, Gilabert M, Huguet F, Marthey L, Meilleroux J, de Mestier L, Napoléon B, Portales F, Sa Cunha A, Schwarz L, Taieb J, Chibaudel B, Bouché O, Hammel P. Pancreatic cancer: French clinical practice guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, AFC). Dig Liver Dis 2018; 50:1257-1271. [PMID: 30219670 DOI: 10.1016/j.dld.2018.08.008] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND This document is a summary of the French intergroup guidelines regarding the management of pancreatic adenocarcinoma (PA), updated in July 2018. DESIGN This collaborative work was produced under the auspices of all French medical and surgical societies involved in the management of PA. It is based on the previous guidelines, recent literature review and expert opinions. Recommendations were graded in three categories, according to the level of evidence. RESULTS Over the last seven years, significant changes in PA management have been implemented in clinical practice. Imaging/staging: diffusion magnetic resonance imaging is useful before surgery to rule out small liver metastases. SURGERY centralization of pancreatic surgery in expert centers is associated with a decreased postoperative mortality. Adjuvant chemotherapy: modified FOLFIRINOX in fit patients, or gemcitabine, or 5-FU, or gemcitabine plus capecitabine, to be discussed on a case-by-case basis. Locally advanced PA: no survival benefit of chemoradiotherapy. Metastatic PA: FOLFIRINOX and gemcitabine plus nab-paclitaxel combination are first-line standards in fit patients; second-line with 5FU/nal-IRI or 5FU/oxaliplatin combination after first-line gemcitabine. CONCLUSION Guidelines for management of PA are continuously evolving and need to be regularly updated. This constant progress is made possible through clinical and translational research. However, as each individual case is particular, they cannot substitute to multidisciplinary tumor board discussion.
Collapse
Affiliation(s)
- Cindy Neuzillet
- Department of Medical Oncology, Curie Institute, Versailles Saint-Quentin University (UVSQ), Saint-Cloud, France.
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-Biliary and Pancreatic Surgery, Cochin Hospital, AP-HP, Paris Descartes Faculty of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Nicolas Williet
- Hepato-Gastroenterology Department, University Hospital of Saint-Etienne, Saint Priest en Jarez, France
| | - Jean-Baptiste Bachet
- Hepato-Gastroenterology Department, Pitié Salpétrière University Hospital, AP-HP, Paris Cedex 13, France
| | - Lucile Bauguion
- Hepato-Gastroenterology Department, Departmental Hospital Center, La Roche sur Yon, France
| | - Laurianne Colson Durand
- Department of Radiotherapy, Henri Mondor Hospital, AP-HP, Université Paris Est Creteil, Créteil, France
| | - Thierry Conroy
- Department of Medical Oncology, Lorraine Institute of Oncology and Lorraine University, Vandoeuvre-lès-Nancy Cedex, France
| | - Laetitia Dahan
- Digestive Oncology Department, "DACCORD" (Digestif, Anatomie pathologique, Chirurgie, CISIH, Oncologie, Radiothérapie, Dermatologie) pole, CHU Timone, Marseille Cedex 05, France
| | - Marine Gilabert
- Paoli Calmettes Institute, Department of Medical Oncology and Cancer Research Center of Marseille (CRCM), INSERM U1068 Stress Cell, Aix-Marseille University, Marseille, France
| | - Florence Huguet
- Department of Oncology and Radiotherapy, Tenon Hospital, East Paris University Hospitals, AP-HP, Paris Sorbonne University, Paris, France
| | - Lysiane Marthey
- Gastroenterology Department, Béclère Hospital, AP-HP, Clamart, France
| | - Julie Meilleroux
- Pathology Department, Toulouse University Hospital, Toulouse, France
| | - Louis de Mestier
- Department of Gastroenterology-Pancreatology, Beaujon Hospital, APHP, Paris 7 University, Clichy, France
| | - Bertrand Napoléon
- Jean Mermoz Private Hospital, Ramsay Générale de Santé, Lyon, France
| | - Fabienne Portales
- Digestive Oncology Department, Regional Institute of Cancer, Montpellier, France
| | - Antonio Sa Cunha
- INSERM UMR 935, Paul Brousse Hospital, Hepatobiliary Center, AP-HP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France and Genomic and Personalized Medicine in Cancer and Neurological Disorders, UMR 1245 INSERM, Rouen University, France
| | - Julien Taieb
- Hepato-Gastroenterology and Digestive Oncology Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Benoist Chibaudel
- Department of Medical Oncology, Franco-British Institute, Levallois-Perret, France
| | - Olivier Bouché
- Hepato-Gastroenterology and Digestive Oncology Department, Robert Debré University Hospital, Avenue Général Koenig, 51092 Reims Cedex, France
| | - Pascal Hammel
- Department of Digestive Oncology, Beaujon University Hospital (AP-HP), Paris VII Diderot University, Clichy-la-Garenne, France.
| |
Collapse
|
73
|
Impact of Centralized Management of Bariatric Surgery Complications on 90-day Mortality. Ann Surg 2018; 268:831-837. [DOI: 10.1097/sla.0000000000002949] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
74
|
The Impact of Hospital Volume and Charlson Score on Postoperative Mortality of Proctectomy for Rectal Cancer. Ann Surg 2018; 268:854-860. [DOI: 10.1097/sla.0000000000002898] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
75
|
|
76
|
Duconseil P, Marchese U, Ewald J, Giovannini M, Mokart D, Delpero JR, Turrini O. A pancreatic zone at higher risk of fistula after enucleation. World J Surg Oncol 2018; 16:177. [PMID: 30157952 PMCID: PMC6116563 DOI: 10.1186/s12957-018-1476-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 08/20/2018] [Indexed: 02/06/2023] Open
Abstract
Background To determine predictive factors of postoperative pancreatic fistula (POPF) in patients undergoing enucleation (EN). Methods From 2005 to 2017, 47 patients underwent EN and had magnetic resonance imaging available for precise analysis of tumor location. Three pancreatic zones were delimited by the right side of the portal vein and the main pancreatic head duct (zone #3 comprising the lower head parenchyma and the uncinate process). Results The mortality and morbidity rates were 0% and 62%, respectively. POPF occurred in 23 patients (49%) and was graded as B or C (severe) in 15 patients (32%). Four patients (8.5%) developed a postoperative hemorrhage, and 5 patients (11%) needed a reintervention. In univariate and multivariate analyses, the pancreatic zone was the unique predictive factor of overall (P = .048) or severe POPF (P = .05). We did not observe any difference in postoperative courses when comparing the EN achieved in zones #1 and #2. We noted a longer operative duration (P = .016), higher overall (P = .017) and severe POPF (P = .01) rates, and longer hospital stays (P = .04) when comparing the EN achieved in zone #3 versus that in zones #1 and #2. Patients who underwent EN in zone #3 had a relative risk of developing a severe POPF of 3.22 compared with patients who underwent EN in the two other pancreatic zones. Conclusion Our study identifies the lower head parenchyma and the uncinate process as a high-risk zone of severe POPF after EN. Patients with planned EN in this zone could be selected and benefit from preoperative and/or intraoperative techniques to reduce the severe POPF rate. Electronic supplementary material The online version of this article (10.1186/s12957-018-1476-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Ugo Marchese
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Jacques Ewald
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Marc Giovannini
- Department of Endoscopy, Institut Paoli-Calmettes, Marseille, France
| | - Djamel Mokart
- Department of Intensive Care, Institut Paoli-Calmettes, Marseille, France
| | | | - Olivier Turrini
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, CNRS, Inserm, CRCM, Marseille, France.
| |
Collapse
|
77
|
Revishvili AS, Kriger AG, Vishnevsky VA, Smirnov AV, Berelavichus SV, Gorin DS, Akhtanin EA, Kaldarov AR, Raevskaya MB, Zakharova MA. [Current issues in pancreatic surgery]. Khirurgiia (Mosk) 2018:5-14. [PMID: 30307415 DOI: 10.17116/hirurgia20180915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
AIM To present own experience of pancreatic surgery and to analyze literature data for this issue. MATERIAL AND METHODS We have analyzed work of abdominal surgery department over the last 5 years. Moreover, MEDLINE and RSCI databases regarding surgical treatment of pancreatic diseases were assessed. RESULTS There were 456 pancreatectomies. Postoperative complications arose in 176 (38.6%) patients, 11 patients died (2.4%). According to world data, mortality after pancreatectomy reaches 10%. Only creation of specialized centers is proven way to improve the outcomes. CONCLUSION Current medical assistance for pancreatic disease may be only achieved in specialized centers with large number of various pancreatic procedures. The organization of such centers is required throughout the country and certain accreditation criteria should be developed for this purpose. Targeted routing of patients to specialized pancreatology centers will be able to reduce incidence of diagnostic, tactical and technical errors.
Collapse
Affiliation(s)
- A Sh Revishvili
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - A G Kriger
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - V A Vishnevsky
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - A V Smirnov
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - S V Berelavichus
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - D S Gorin
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - E A Akhtanin
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - A R Kaldarov
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - M B Raevskaya
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| | - M A Zakharova
- Vishnevsky National Medical Research Center of Surgery, Healthcare Ministry of the Russian Federation Moscow, Russia
| |
Collapse
|