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Zwart MJW, Nota CLM, de Rooij T, van Hilst J, Te Riele WW, van Santvoort HC, Hagendoorn J, Borei Rinkes IHM, van Dam JL, Latenstein AEJ, Takagi K, Tran KTC, Schreinemakers J, van der Schelling GP, Wijsman JH, Festen S, Daams F, Luyer MD, de Hingh IHJT, Mieog JSD, Bonsing BA, Lips DJ, Hilal MA, Busch OR, Saint-Marc O, Zehl HJ, Zureikat AH, Hogg ME, Molenaar IQ, Besselink MG, Koerkamp BG. Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3). Ann Surg 2022; 276:e886-e895. [PMID: 33534227 DOI: 10.1097/sla.0000000000004783] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess feasibility and safety of a multicenter training program in robotic pancreatoduodenectomy (RPD) adhering to the IDEAL framework for implementation of surgical innovation. BACKGROUND Good results for RPD have been reported from single center studies. However, data on feasibility and safety of implementation through a multicenter training program in RPD are lacking. METHODS A multicenter training program in RPD was designed together with the University of Pittsburgh Medical Center, including an online video bank, robot simulation exercises, biotissue drills, and on-site proctoring. Benchmark patients were based on the criteria of Clavien. Outcomes were collected prospectively (March 2016-October 2019). Cumulative sum analysis of operative time was performed to distinguish the first and second phase of the learning curve. Outcomes were compared between both phases of the learning curve. Trends in nationwide use of robotic and laparoscopic PD were assessed in the Dutch Pancreatic Cancer Audit. RESULTS Overall, 275 RPD procedures were performed in seven centers by 15 trained surgeons. The recent benchmark criteria for low-risk PD were met by 125 (45.5%) patients. The conversion rate was 6.5% (n = 18) and median blood loss 250ml [interquartile range (IQR) 150-500]. The rate of Clavien-Dindo grade ≥III complications was 44.4% (n = 122), postoperative pancreatic fistula (grade B/C) rate 23.6% (n = 65), 90-day complication-related mortality 2.5% (n = 7) and 90-day cancer-related mortality 2.2.% (n = 6). Median postoperative hospital stay was 12 days (IQR 8-20). In the subgroup of patients with pancreatic cancer (n = 80), the major complication rate was 31.3% and POPF rate was 10%. Cumulative sum analysis for operative time found a learning curve inflection point at 22 RPDs (IQR 10-35) with similar rates of Clavien-Dindo grade ≥III complications in the first and second phase (43.4% vs 43.8%, P = 0.956, respectively). During the study period the nationwide use of laparoscopic PD reduced from 15% to 1%, whereas the use of RPD increased from 0% to 25%. CONCLUSIONS This multicenter RPD training program in centers with sufficient surgical volume was found to be feasible without a negative impact of the learning curve on clinical outcomes.
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Affiliation(s)
- Maurice J W Zwart
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Carolijn L M Nota
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - Wouter W Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Inne H M Borei Rinkes
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jacob L van Dam
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Kosei Takagi
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Khé T C Tran
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Jan H Wijsman
- Department of Surgery, Amphia Ziekenhuis, Breda, the Netherlands
| | | | - Freek Daams
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Regional Orleans, Orleans, France
| | - Herbert J Zehl
- Department of Surgery, University of Texas, Southwestern, Dallas, Texas
| | - Amer H Zureikat
- Department of Surgery, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa E Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, Illinois
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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Digestive tract reconstruction in pancreaticoduodenectomy in University Hospitals of China: a national questionnaire survey. JOURNAL OF PANCREATOLOGY 2022. [DOI: 10.1097/jp9.0000000000000106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Raghavendra D, Balachandar TG, Prabhakaran R, Swain SK, Nirmal J, Sunil N, Shekhar H. Replaced right hepatic artery passing anterior to pancreas: a rare and challenging anatomical variant during pancreaticoduodenectomy. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-022-00721-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
During pancreaticoduodenectomy proper dissection of local vessels is required. Normal coeliac and hepatic arterial anatomy can be found in only 50–70% of individuals. Good knowledge about aberrant vascular anatomies is necessary to avoid unnecessary complications.
Case presentation
An elderly gentleman presented to us with history of jaundice. Periampullary carcinoma with abnormal right and left hepatic artery morphology was discovered after a contrast enhanced computerized tomography scan.
Conclusion
Despite the anomalous origin and anterior course of replaced right hepatic artery, Classical pancreatoduodenectomy with preservation of replaced right hepatic artery and regional lymphadenectomy with no major intra and post-operative problems was conducted by superior mesenteric artery first approach. Prior to major hepato-pancreatobiliary surgery, a thorough examination of a contrast enhanced computerized tomography scan is required to understand vascular anatomy, recognize anomalous vessels, and understand their significance. Nevertheless, if the abnormal vessel anatomy like replaced right hepatic artery are identified during surgery, a careful dissection of the anomalous vessel is essential to identify all vascular relationships and avoid irreversible injury.
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Staiger RD, Rössler F, Kim MJ, Brown C, Trenti L, Sasaki T, Uluk D, Campana JP, Giacca M, Schiltz B, Bahadoer RR, Lee KY, Kupper BEC, Hu KY, Corcione F, Paredes SR, Spampati S, Ukegjini K, Jedrzejczak B, Langer D, Stakelum A, Park JW, Phang PT, Biondo S, Ito M, Aigner F, Vaccaro CA, Panis Y, Kartheuser A, Peeters KCMJ, Tan KK, Aguiar S, Ludwig K, Bracale U, Young CJ, Dziki A, Ryska M, Winter DC, Jenkins JT, Kennedy RH, Clavien PA, Puhan MA, Turina M. Benchmarks in colorectal surgery: multinational study to define quality thresholds in high and low anterior resection. Br J Surg 2022; 109:1274-1281. [PMID: 36074702 DOI: 10.1093/bjs/znac300] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/15/2022] [Accepted: 07/31/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Benchmark comparisons in surgery allow identification of gaps in the quality of care provided. The aim of this study was to determine quality thresholds for high (HAR) and low (LAR) anterior resections in colorectal cancer surgery by applying the concept of benchmarking. METHODS This 5-year multinational retrospective study included patients who underwent anterior resection for cancer in 19 high-volume centres on five continents. Benchmarks were defined for 11 relevant postoperative variables at discharge, 3 months, and 6 months (for LAR). Benchmarks were calculated for two separate cohorts: patients without (ideal) and those with (non-ideal) outcome-relevant co-morbidities. Benchmark cut-offs were defined as the 75th percentile of each centre's median value. RESULTS A total of 3903 patients who underwent HAR and 3726 who had LAR for cancer were analysed. After 3 months' follow-up, the mortality benchmark in HAR for ideal and non-ideal patients was 0.0 versus 3.0 per cent, and in LAR it was 0.0 versus 2.2 per cent. Benchmark results for anastomotic leakage were 5.0 versus 6.9 per cent for HAR, and 13.6 versus 11.8 per cent for LAR. The overall morbidity benchmark in HAR was a Comprehensive Complication Index (CCI®) score of 8.6 versus 14.7, and that for LAR was CCI® score 11.9 versus 18.3. CONCLUSION Regular comparison of individual-surgeon or -unit outcome data against benchmark thresholds may identify gaps in care quality that can improve patient outcome.
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Affiliation(s)
- Roxane D Staiger
- Department of Colorectal Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Fabian Rössler
- Department of Colorectal Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Min Jung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Carl Brown
- Department of Surgery, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Loris Trenti
- Bellvitge University Hospital, Department of General and Digestive Surgery, and IDIBELL, University of Barcelona, Barcelona, Spain
| | - Takeshi Sasaki
- Department of Colorectal Surgery and Surgical Technology, National Cancer Centre Hospital East, Kashiwa, Chiba, Japan
| | - Deniz Uluk
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Juan P Campana
- Section of Colorectal Surgery, Hospital Italiano de Buenos Aires and Instituto de Medicina Traslacional e Ingeniería Biomédica (IMTIB), Buenos Aires, Argentina
| | - Massimo Giacca
- Department of Colorectal Surgery, Beaujon Hospital and University of Paris, Clichy, France
| | - Boris Schiltz
- Department of Colorectal Surgery, Cliniques Universitaires St-Luc - UCL, Brussels, Belgium
| | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Kai-Yin Lee
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, University Surgical Cluster, National University Health System, Singapore
| | | | - Katherine Y Hu
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Francesco Corcione
- Department of General Surgery and Specialty, University Federico II of Naples, Naples, Italy
| | - Steven R Paredes
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sebastiano Spampati
- Department of Colorectal Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Kristjan Ukegjini
- Department of Colorectal Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Daniel Langer
- Surgery Department, Charles University and Central Military Hospital, Prague, Czech Republic
| | - Aine Stakelum
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - P Terry Phang
- Department of Surgery, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Sebastiano Biondo
- Bellvitge University Hospital, Department of General and Digestive Surgery, and IDIBELL, University of Barcelona, Barcelona, Spain
| | - Masaaki Ito
- Department of Colorectal Surgery and Surgical Technology, National Cancer Centre Hospital East, Kashiwa, Chiba, Japan
| | - Felix Aigner
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Carlos A Vaccaro
- Section of Colorectal Surgery, Hospital Italiano de Buenos Aires and Instituto de Medicina Traslacional e Ingeniería Biomédica (IMTIB), Buenos Aires, Argentina
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital and University of Paris, Clichy, France
| | - Alex Kartheuser
- Department of Colorectal Surgery, Cliniques Universitaires St-Luc - UCL, Brussels, Belgium
| | - K C M J Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Ker-Kan Tan
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, University Surgical Cluster, National University Health System, Singapore
| | | | - Kirk Ludwig
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Umberto Bracale
- Department of General Surgery and Specialty, University Federico II of Naples, Naples, Italy
| | - Christopher J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Adam Dziki
- Centre for Bowel Diseases, Brzeziny, Poland.,Department of General and Colorectal Surgery, Medical University, Lodz, Poland
| | - Miroslav Ryska
- Surgery Department, Charles University and Central Military Hospital, Prague, Czech Republic
| | - Des C Winter
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - John T Jenkins
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Robin H Kennedy
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Pierre-Alain Clavien
- Department of Colorectal Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Matthias Turina
- Department of Colorectal Surgery, University Hospital Zurich, Zurich, Switzerland
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Stoop TF, Fröberg K, Sparrelid E, Del Chiaro M, Ghorbani P. Surgical management of severe pancreatic fistula after pancreatoduodenectomy: a comparison of early versus late rescue pancreatectomy. Langenbecks Arch Surg 2022; 407:3467-3478. [DOI: 10.1007/s00423-022-02708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/09/2022] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Rescue pancreatectomy for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) is associated with high mortality. However, in-depth literature is scarce and hard to interpret. This study aimed to evaluate the indications, timing and perioperative outcomes of rescue pancreatectomy for severe POPF after PD.
Methods
Retrospective single-centre study from all consecutive patients (2008–2020) with POPF-C after PD (ISGPS 2016 definition). Major morbidity and mortality during hospitalization or within 90 days after index surgery were evaluated. Time from index surgery to rescue pancreatectomy was dichotomized in early and late (≤ 11 versus > 11 days).
Results
From 1076 PDs performed, POPF-B/C occurred in 190 patients (17.7%) of whom 53 patients (4.9%) with POPF-C were included. Mortality after early rescue pancreatectomy did not differ significantly compared to late rescue pancreatectomy (13.6% versus 35.3%; p = 0.142). Timing of a rescue pancreatectomy did not change significantly during the study period: 11 (IQR, 8–14) (2008–2012) versus 14 (IQR, 7–33) (2013–2016) versus 8 days (IQR, 6–11) (2017–2020) (p = 0.140). Over time, the mortality in patients with POPF grade C decreased from 43.5% in 2008–2012 to 31.6% in 2013–2016 up to 0% in 2017–2020 (p = 0.014). However, mortality rates after rescue pancreatectomy did not differ significantly: 31.3% (2008–2012) versus 28.6% (2013–2016) versus 0% (2017–2020) (p = 0.104).
Conclusions
Rescue pancreatectomy for severe POPF is associated with high mortality, but an earlier timing might favourably influence the mortality. Hypothetically, this could be of value for pre-existent vulnerable patients. These findings must be carefully interpreted considering the sample sizes and differences among subgroups by patient selection.
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Sánchez-Velázquez P, Pueyo-Périz E, Álamo JM, Suarez Artacho G, Gómez Bravo MÁ, Marcello M, Vicente E, Quijano Y, Ferri V, Caruso R, Dorcaratto D, Sabater L, González Chávez P, Noguera J, Navarro Gonzalo A, Bellido-Luque J, Téllez-Marques C, Ielpo B, Burdio F. Radiofrequency-assisted transection of the pancreas versus stapler in distal pancreatectomy: study protocol for a multicentric randomised clinical trial (TRANSPAIRE). BMJ Open 2022; 12:e062873. [PMID: 36332946 PMCID: PMC9639090 DOI: 10.1136/bmjopen-2022-062873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION To date, no pancreatic stump closure technique has been shown to be superior to any other in distal pancreatectomy. Although several studies have shown a trend towards better results in transection using a radiofrequency device (radiofrequency-assisted transection (RFT)), no randomised trial for this purpose has been performed to date. Therefore, we designed a randomised clinical trial, with the hypothesis that this technique used in distal pancreatectomies is superior in reducing clinically relevant postoperative pancreatic fistula (CR-POPF) than mechanical closures. METHODS AND ANALYSIS TRANSPAIRE is a multicentre randomised controlled trial conducted in seven Spanish pancreatic centres that includes 112 patients undergoing elective distal pancreatectomy for any indication who will be randomly assigned to RFT or classic stapler transections (control group) in a ratio of 1:1. The primary outcome is the CR-POPF percentage. Sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-β), expected POPF in control group of 32%, expected POPF in RFT group of 10% and a clinically relevant difference of 22%. Secondary outcomes include postoperative results, complications, radiological evaluation of the pancreatic stump, metabolomic profile of postoperative peritoneal fluid, survival and quality of life. Follow-ups will be carried out in the external consultation at 1, 6 and 12 months postoperatively. ETHICS AND DISSEMINATION TRANSPAIRE has been approved by the CEIM-PSMAR Ethics Committee. This project is being carried out in accordance with national and international guidelines, the basic principles of protection of human rights and dignity established in the Declaration of Helsinki (64th General Assembly, Fortaleza, Brazil, October 2013), and in accordance with regulations in studies with biological samples, Law 14/2007 on Biomedical Research will be followed. We have defined a dissemination strategy, whose main objective is the participation of stakeholders and the transfer of knowledge to support the exploitation of activities. REGISTRATION DETAILS ClinicalTrials.gov Registry (NCT04402346).
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Affiliation(s)
- Patricia Sánchez-Velázquez
- Department of Surgery, Hospital del Mar, Barcelona, Spain
- Department of Surgery, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Eva Pueyo-Périz
- Department of Surgery, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - J M Álamo
- Department of Surgery, University Hospital Virgen del Rocío, Sevilla, Spain
| | | | | | - Manuel Marcello
- Department of Surgery, Alcorcon Hospital Foundation, Alcorcon, Spain
| | - Emilio Vicente
- Department of Surgery, Hospital Universitario Sanchinarro, Madrid, Spain
| | - Yolanda Quijano
- Department of Surgery, Hospital Universitario Sanchinarro, Madrid, Spain
| | - Valentina Ferri
- Department of Surgery, Hospital Universitario Sanchinarro, Madrid, Spain
| | - Riccardo Caruso
- Department of Surgery, Hospital Universitario Sanchinarro, Madrid, Spain
| | - Dimitri Dorcaratto
- Liver, Biliary and Pancreatic Unit, Department of General Surgery. Biomedical Research Institute INCLIVA, Hospital Clínico Valencia, Valencia, Spain
| | - Luis Sabater
- Liver, Biliary and Pancreatic Unit, Department of General Surgery. Biomedical Research Institute INCLIVA, Hospital Clínico Valencia, Valencia, Spain
| | | | - Jose Noguera
- Hospital Juan Canalejo de La Coruña, A Coruña, Spain
| | | | | | | | - Benedetto Ielpo
- Department of Surgery, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Parc Salut Mar Hospital, Barcelona, Spain
| | - Fernando Burdio
- Department of Surgery, Hospital del Mar Medical Research Institute, Barcelona, Spain
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Abstract
OBJECTIVE To define benchmark cutoffs for redo liver transplantation (redo-LT). BACKGROUND In the era of organ shortage, redo-LT is frequently discussed in terms of expected poor outcome and wasteful resources. However, there is a lack of benchmark data to reliably evaluate outcomes after redo-LT. METHODS We collected data on redo-LT between January 2010 and December 2018 from 22 high-volume transplant centers. Benchmark cases were defined as recipients with model of end stage liver disease (MELD) score ≤25, absence of portal vein thrombosis, no mechanical ventilation at the time of surgery, receiving a graft from a donor after brain death. Also, high-urgent priority and early redo-LT including those for primary nonfunction (PNF) or hepatic artery thrombosis were excluded. Benchmark cutoffs were derived from the 75th percentile of the medians of all benchmark centers. RESULTS Of 1110 redo-LT, 373 (34%) cases qualified as benchmark cases. Among these cases, the rate of postoperative complications until discharge was 76%, and increased up to 87% at 1-year, respectively. One-year overall survival rate was excellent with 90%. Benchmark cutoffs included Comprehensive Complication Index CCI ® at 1-year of ≤72, and in-hospital and 1-year mortality rates of ≤13% and ≤15%, respectively. In contrast, patients who received a redo-LT for PNF showed worse outcomes with some values dramatically outside the redo-LT benchmarks. CONCLUSION This study shows that redo-LT achieves good outcome when looking at benchmark scenarios. However, this figure changes in high-risk redo-LT, as for example in PNF. This analysis objectifies for the first-time results and efforts for redo-LT and can serve as a basis for discussion about the use of scarce resources.
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Paik KY, Oh JS, Lee SM. Integration of Effort for Secure Pancreaticoduodenectomy Improved Surgical Outcomes: Historical Observational Study. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Liver Transplantation as a New Standard of Care in Patients With Perihilar Cholangiocarcinoma? Results From an International Benchmark Study. Ann Surg 2022; 276:846-853. [PMID: 35894433 PMCID: PMC9983747 DOI: 10.1097/sla.0000000000005641] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To define benchmark values for liver transplantation (LT) in patients with perihilar cholangiocarcinoma (PHC) enabling unbiased comparisons. BACKGROUND Transplantation for PHC is used with reluctance in many centers and even contraindicated in several countries. Although benchmark values for LT are available, there is a lack of specific data on LT performed for PHC. METHODS PHC patients considered for LT after Mayo-like protocol were analyzed in 17 reference centers in 2 continents over the recent 5-year period (2014-2018). The minimum follow-up was 1 year. Benchmark patients were defined as operated at high-volume centers (≥50 overall LT/year) after neoadjuvant chemoradiotherapy, with a tumor diameter <3 cm, negative lymph nodes, and with the absence of relevant comorbidities. Benchmark cutoff values were derived from the 75th to 25th percentiles of the median values of all benchmark centers. RESULTS One hundred thirty-four consecutive patients underwent LT after completion of the neoadjuvant treatment. Of those, 89.6% qualified as benchmark cases. Benchmark cutoffs were 90-day mortality ≤5.2%; comprehensive complication index at 1 year of ≤33.7; grade ≥3 complication rates ≤66.7%. These values were better than benchmark values for other indications of LT. Five-year disease-free survival was largely superior compared with a matched group of nodal negative patients undergoing curative liver resection (n=106) (62% vs 32%, P <0.001). CONCLUSION This multicenter benchmark study demonstrates that LT offers excellent outcomes with superior oncological results in early stage PHC patients, even in candidates for surgery. This provocative observation should lead to a change in available therapeutic algorithms for PHC.
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Takeda Y, Mise Y, Kishi Y, Sugo H, Kyoden Y, Hasegawa K, Takahashi Y, Saiura A. Enteral versus parental nutrition after pancreaticoduodenectomy under enhanced recovery after surgery protocol: study protocol for a multicenter, open-label randomized controlled trial (ENE-PAN trial). Trials 2022; 23:917. [PMID: 36309760 PMCID: PMC9618181 DOI: 10.1186/s13063-022-06856-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Infectious complications are the main causes of morbidity after pancreaticoduodenectomy (PD). Early enteral nutrition (EN) is a reasonable form of nutritional support that aims to mitigate the occurrence and severity of infectious complications by maintaining gut immunity. However, it remains unclear whether EN is beneficial for patients who underwent PD and are under enhanced recovery after surgery (ERAS) protocol. Methods A multicenter (six hospitals), open-label, randomized controlled trial will be started in July 2022. A total of 320 patients undergoing open PD will be randomly assigned to an EN group or a peripheral parental nutrition (PPN) group in a 1:1 ratio. The stratification factors will be the hospital, age (≥ 70 or not), and preoperative diagnosis (pancreatic cancer or not). In the EN group, enteral nutrition will start on postoperative day (POD) 1 at 200–300 ml/day via the percutaneous tube placed operatively. The volume of the diet will be increased to 400–600 ml/day on POD 2 and depend on the surgeon’s decision from POD 3. In the PPN group, PPN will be delivered after surgery. In both groups, oral feeding will start on POD 3. Each treatment will be finished when patients’ oral food intake reaches 60% of the nutritional requirement (25–30 kcal/day). The primary endpoint will be the occurrence of postoperative infectious complications within 90 days of surgery. The secondary endpoints will be all complications, including major ones such as Clavien–Dindo grade 3 or more and clinically relevant postoperative pancreatic fistula. Data will be analyzed per the intention to treat. Discussion This will be the first, large, and well-designed RCT that aims to determine whether EN is beneficial for patients who underwent PD under the ERAS protocol. According to the results of this study, either EN or PPN would be adopted as the standard nutritional support for patients undergoing PD. Trial registration jRCT1030210691. Registered on March 23, 2022.
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Giani A, van Ramshorst T, Mazzola M, Bassi C, Esposito A, de Pastena M, Edwin B, Sahakyan M, Kleive D, Jah A, van Laarhoven S, Boggi U, Kauffman EF, Casadei R, Ricci C, Dokmak S, Ftériche FS, White SA, Kamarajah SK, Butturini G, Frigerio I, Zerbi A, Capretti G, Pando E, Sutcliffe RP, Marudanayagam R, Fusai GK, Fabre JM, Björnsson B, Timmermann L, Soonawalla Z, Burdio F, Keck T, Hackert T, Groot Koerkamp B, d’Hondt M, Coratti A, Pessaux P, Pietrabissa A, Al-Sarireh B, Marino MV, Molenaar Q, Yip V, Besselink M, Ferrari G, Hilal MA. Benchmarking of minimally invasive distal pancreatectomy with splenectomy: European multicentre study. Br J Surg 2022; 109:1124-1130. [DOI: 10.1093/bjs/znac204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/14/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Benchmarking is the process to used assess the best achievable results and compare outcomes with that standard. This study aimed to assess best achievable outcomes in minimally invasive distal pancreatectomy with splenectomy (MIDPS).
Methods
This retrospective study included consecutive patients undergoing MIDPS for any indication, between 2003 and 2019, in 31 European centres. Benchmarks of the main clinical outcomes were calculated according to the Achievable Benchmark of Care (ABC™) method. After identifying independent risk factors for severe morbidity and conversion, risk-adjusted ABCs were calculated for each subgroup of patients at risk.
Results
A total of 1595 patients were included. The ABC was 2.5 per cent for conversion and 8.4 per cent for severe morbidity. ABC values were 160 min for duration of operation time, 8.3 per cent for POPF, 1.8 per cent for reoperation, and 0 per cent for mortality. Multivariable analysis showed that conversion was associated with male sex (OR 1.48), BMI exceeding 30 kg/m2 (OR 2.42), multivisceral resection (OR 3.04), and laparoscopy (OR 2.24). Increased risk of severe morbidity was associated with ASA fitness grade above II (OR 1.60), multivisceral resection (OR 1.88), and robotic approach (OR 1.87).
Conclusion
The benchmark values obtained using the ABC method represent optimal outcomes from best achievable care, including low complication rates and zero mortality. These benchmarks should be used to set standards to improve patient outcomes.
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Affiliation(s)
- Alessandro Giani
- Division of Minimally Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda , Milan , Italy
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza , Brescia , Italy
| | - Tess van Ramshorst
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza , Brescia , Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam , Amsterdam , the Netherlands
| | - Michele Mazzola
- Division of Minimally Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda , Milan , Italy
| | - Claudio Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital , Verona , Italy
| | - Alessandro Esposito
- Department of Surgery, Pancreas Institute, Verona University Hospital , Verona , Italy
| | - Matteo de Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital , Verona , Italy
| | - Bjørn Edwin
- Intervention Centre and Department of Hepatopancreatobiliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo , Oslo Norway
| | - Mushegh Sahakyan
- Intervention Centre and Department of Hepatopancreatobiliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo , Oslo Norway
| | - Dyre Kleive
- Intervention Centre and Department of Hepatopancreatobiliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo , Oslo Norway
| | - Asif Jah
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - Stijn van Laarhoven
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - Ugo Boggi
- Department of Surgery, University Hospital of Pisa , Pisa , Italy
| | | | - Riccardo Casadei
- Department of Surgery, Sant’Orsola Malpighi Hospital , Bologna , Italy
| | - Claudio Ricci
- Department of Surgery, Sant’Orsola Malpighi Hospital , Bologna , Italy
| | - Safi Dokmak
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Beaujon Hospital , Clichy , France
| | - Fadhel Samir Ftériche
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Beaujon Hospital , Clichy , France
| | - Steven A White
- Department of Surgery, Freeman Hospital Newcastle upon Tyne , Newcastle upon Tyne , UK
| | - Sivesh K Kamarajah
- Department of Surgery, Freeman Hospital Newcastle upon Tyne , Newcastle upon Tyne , UK
| | | | | | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University , Pieve Emanuele , Italy
- IRCCS Humanitas Research Hospital , Rozzano , Italy
| | - Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University , Pieve Emanuele , Italy
- IRCCS Humanitas Research Hospital , Rozzano , Italy
| | - Elizabeth Pando
- Department of Surgery, Vall d’Hebron University Hospital , Barcelona , Spain
| | - Robert P Sutcliffe
- Department of Hepatopancreatobiliary Surgery, University Hospitals Birmingham NHS Foundation Trust , Birmingham , UK
| | - Ravi Marudanayagam
- Department of Hepatopancreatobiliary Surgery, University Hospitals Birmingham NHS Foundation Trust , Birmingham , UK
| | - Giuseppe Kito Fusai
- Hepatopancreatobiliary and Liver Transplant Unit, Royal Free London , London , UK
| | | | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University , Linköping , Sweden
| | | | | | - Fernando Burdio
- Department of Surgery, University Hospital del Mar , Barcelona , Spain
| | - Tobias Keck
- Department of Surgery, University Medical Centre Schleswig-Holstein , Campus Lübeck, Lübeck , Germany
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital , Heidelberg , Germany
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre , Rotterdam, the Netherlands
| | - Mathieu d’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital , Kortrijk , Belgium
| | - Andrea Coratti
- Division of Oncological and Robotic General Surgery, Careggi University Hospital , Florence , Italy
| | - Patrick Pessaux
- Division of Hepato-Biliary and Pancreatic Surgery, Nouvel Hôpital Civil, University Hospital, Institut Hospitalo-Universitaire de Strasbourg , Strasbourg , France
| | - Andrea Pietrabissa
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | | | - Marco V Marino
- General and Emergency Surgery Department, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello , Palermo , Italy
- General Surgery Department, Istituto Villa Salus , Siracusa , Italy
| | - Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Centre, University Medical Centre Utrecht , Utrecht , the Netherlands
| | - Vincent Yip
- Department of Hepatopancreatobiliary Surgery, Royal London Hospital, Barts Health NHS Trust , London , UK
| | - Marc Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam , Amsterdam , the Netherlands
| | - Giovanni Ferrari
- Division of Minimally Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda , Milan , Italy
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza , Brescia , Italy
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112
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Halle-Smith JM, Pande R, Powell-Brett S, Pathak S, Pandanaboyana S, Smith AM, Roberts KJ. Early oral feeding after pancreatoduodenectomy: a systematic review and meta-analysis. HPB (Oxford) 2022; 24:1615-1621. [PMID: 35606323 DOI: 10.1016/j.hpb.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 02/17/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The effect of early oral feeding (EOF) after pancreatoduodenectomy (PD) upon perioperative complications and outcomes is unknown, therefore the aim of this systematic review and meta-analysis was to investigate the effect of EOF on clinical outcomes after PD, such as postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and length of stay (LOS). METHODS A systematic review and meta-analysis was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and assimilated evidence from studies reporting outcomes for patients who received EOF after PD compared to enteral tube feeding (EN) or parenteral nutrition (PN). RESULTS Four studies reported outcomes after EOF compared to EN/PN after PD and included 553 patients. Meta-analyses showed no difference in rates of CR-POPF (OR 0.74; 95%CI 0.44-1.24; p = 0.25) or DGE (Grade B/C) (OR 0.83; 95%CI 0.31-2.21; p = 0.70). LOS was significantly shorter in the EOF group compared to the EN/PN group (Mean Difference -3.40 days; 95% -6.11-0.70 days; p = 0.01). CONCLUSION Current available evidence suggests that EOF after PD is not associated with increased risk of DGE, does not exacerbate POPF and appears to reduce length of stay.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.
| | - Rupaly Pande
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Sarah Powell-Brett
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Samir Pathak
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, United Kingdom
| | - Sanjay Pandanaboyana
- Hepatobiliary and Pancreatic Surgery Unit, Newcastle Upon Tyne Teaching Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Andrew M Smith
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, United Kingdom
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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113
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Elshami M, Hue JJ, Ahmed FA, Kakish H, Hoehn RS, Rothermel LD, Hardacre JM, Ammori JB, Winter JM, Ocuin LM. Defining Facility Volume Threshold for Optimization of Short- and Long-Term Outcomes in Patients Undergoing Resection of Perihilar Cholangiocarcinoma. J Gastrointest Surg 2022; 27:730-740. [PMID: 36138311 DOI: 10.1007/s11605-022-05465-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/10/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND We determined the minimum threshold (Tmin) of annual facility case volume to optimize outcomes for patients with resected perihilar cholangiocarcinoma. METHODS We identified patients with localized perihilar cholangiocarcinoma who underwent resection within the National Cancer Database (2010-2017). We used marginal structural logistic regression models to estimate the average treatment effect of receiving care in facilities meeting/exceeding Tmin on 90-day mortality and other postoperative outcomes. RESULTS A total of 2471 patients underwent resection for perihilar cholangiocarcinoma at 471 facilities. There was no effect of total hepatopancreatobiliary, surgical hepatopancreatobiliary, total hepatobiliary, surgical hepatobiliary, or total perihilar cholangiocarcinoma case volume on 90-day mortality. A Tmin of seven perihilar cholangiocarcinoma resections/year resulted in lower odds of 90-day mortality (IP-weighted OR = 0.49, 95% CI: 0.66-0.87). A total of two facilities met the Tmin. Patients receiving treatment at Tmin facilities had lower odds of length of stay ≥ 7 days (IP-weighted OR = 0.85, 95% CI: 0.75-0.97) and positive surgical resection margins (IP-weighted OR = 0.40, 95% CI: 0.47-0.55). Additionally, undergoing surgery at Tmin facilities resulted in higher (≥ 4 nodes) lymph node yields (IP-weighted OR = 1.94, 95% CI: 1.21-3.11) but no change in the odds of nodal positivity. There was no effect of undergoing surgery at Tmin facilities on 30-day mortality or re-admission. CONCLUSIONS Resection of perihilar cholangiocarcinoma is infrequently performed at a high number of facilities. A Tmin of ≥ 7 resections/year resulted in lower 90-day mortality and improved postoperative outcomes. Our data suggest that regionalization of care for patients with perihilar cholangiocarcinoma could potentially improve outcomes in the USA.
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Affiliation(s)
- Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Fasih Ali Ahmed
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Hanna Kakish
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Richard S Hoehn
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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Trends in pancreatic surgery in Switzerland: a survey and nationwide analysis over two decades. Langenbecks Arch Surg 2022; 407:3423-3435. [DOI: 10.1007/s00423-022-02679-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 09/08/2022] [Indexed: 12/24/2022]
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115
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Chen H, Wang W, Zou S, Wang X, Ying X, Cheng D, Weng Y, Deng X, Shen B. Serum lipase on postoperative day one is a strong predictor of clinically relevant pancreatic fistula after pancreaticoduodenectomy: A retrospective cohort. Pancreatology 2022; 22:810-816. [PMID: 35717304 DOI: 10.1016/j.pan.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/07/2022] [Accepted: 06/01/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Increased postoperative serum amylase has been recently reported to be associated with increased postoperative morbidity, but studies on postoperative serum lipase are limited. The aim of this study was to evaluate the value of postoperative serum lipase in predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). METHOD A retrospective analysis was performed on 212 patients who underwent PD from September 2018 and March 2021, focusing on the association between postoperative day (POD) 1 serum lipase and CR-POPF. RESULTS Overall, 108 (50.9%) patients had elevated serum lipase levels (>68 U/L) on POD 1. Patients with elevated serum lipase exhibited a significantly higher incidence of CR-POPF (37.0% vs. 6.7%, p < 0.001). Receiver operating characteristic (ROC) analyses showed improved diagnostic accuracy for POD 1 serum lipase compared with POD 1 serum amylase in predicting CR-POPF (AUC: 0.801 vs. 0.745, p = 0.029). Elevated serum lipase on POD 1 and elevated serum CRP on POD 3 were identified as independent predictors of CR-POPF. A simple early postoperative model, consisting of POD 1 serum lipase levels and POD 3 serum CRP levels, showed good discrimination (AUC 0.76, 95% CI 0.69-0.83) to identify the onset of CR-POPF. CONCLUSION Serum lipase on POD 1 outperformed serum amylase on POD 1 in predicting CR-POPF after PD. The combination of POD 1 serum lipase and POD 3 serum CRP provides a reliable predicting model for CR-POPF.
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Affiliation(s)
- Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Siyi Zou
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinjing Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiayang Ying
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dongfeng Cheng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Xu Q, Liu T, Zou X, Li P, Gao R, Dai M, Guo J, Zhang T, Liao Q, Liu Z, Wang W, Cong L, Wu W, Zhao Y. The learning curve for robot-assisted distal pancreatectomy: a single-center experience of 301 cases. JOURNAL OF PANCREATOLOGY 2022; 5:118-124. [PMID: 36419868 PMCID: PMC9665946 DOI: 10.1097/jp9.0000000000000096] [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: 05/28/2022] [Accepted: 08/18/2022] [Indexed: 11/26/2022] Open
Abstract
Robotic distal pancreatectomy (RDP) has become a routine procedure in many pancreatic centers. This study aimed to describe a single-center experience with RDP since the first case, identify the learning curves of operation time and complication rate, and discuss the safety and feasibility of RDP. Methods We collected and retrospectively analyzed the single-center surgical experience of 301 patients undergoing RDP at Peking Union Medical College Hospital (PUMCH) between 2012 and 2022 and described the change in operation proficiency and occurrence of perioperative complications in this observational study. The learning curve was assessed using the cumulative sum method. Results We observed a three-phase pattern of RDP learning with operation time, complications, and postoperative pancreatic fistula as indicators and a two-phase pattern for spleening-preserving success. The mean operation time was 3.9 hours. The incidence rate of clinically significant postoperative pancreatic fistula (CRPOPF) was 17.9% and overall Clavien-Dindo complication rate (≥3) was 16.6%. The change of postoperative complicate rate was correlated with percentage of malignant cases. Conclusion In the last decade, an evident decrease was seen in operation time, complication rate, and an increase in the spleen-preserving rate of distal pancreatectomy. With proper training, RDP is a safe and feasible procedure.
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Affiliation(s)
- Qiang Xu
- Department of General Surgery, Peking Union Medical College Hospital
| | - Tiantong Liu
- Department of General Surgery, Peking Union Medical College Hospital
- School of Medicine, Tsinghua University
| | - Xi Zou
- Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Pengyu Li
- Department of General Surgery, Peking Union Medical College Hospital
| | - Ruichen Gao
- Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital
| | - Junchao Guo
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital
| | - Ziwen Liu
- Department of General Surgery, Peking Union Medical College Hospital
| | - Weibin Wang
- Department of General Surgery, Peking Union Medical College Hospital
| | - Lin Cong
- Department of General Surgery, Peking Union Medical College Hospital
| | - Wenming Wu
- Chinese Academy of Medical Sciences and Peking Union Medical College
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital
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Ignatavicius P, Oberkofler CE, Jonas JP, Mullhaupt B, Clavien PA. The essential requirements for an HPB centre to deliver high-quality outcomes. J Hepatol 2022; 77:837-848. [PMID: 35577030 DOI: 10.1016/j.jhep.2022.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/12/2022] [Accepted: 04/27/2022] [Indexed: 12/04/2022]
Abstract
The concept of a centre approach to the treatment of patients with complex disorders, such as those with hepato-pancreato-biliary (HPB) diseases, is widely applied, although what is needed for an HPB centre to achieve high-quality outcomes remains unclear. We therefore conducted a literature review, which highlighted the paucity of information linking centre structure or process to outcome data outside of caseloads, specialisation, and quality of training. We then conducted an international survey among the largest 107 HPB centres with experts in HPB surgery and found that most responders work in 'virtual' HPB centres without dedicated space, assigned beds, nor personal. We finally analysed our experience with the Swiss HPB centre, previously reported in this journal 15 years ago, disclosing that budget priorities set by the hospital administration may prevent the development of a fully integrated centre, for example through inconsistent assignment of the centre's beds to HBP patients or removal of dedicated intermediate care beds. We propose criteria for essential requirements for an HPB centre to deliver high-quality outcomes, with the concept of "centre of reference" limited to actual, as opposed to virtual, centres.
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Affiliation(s)
- Povilas Ignatavicius
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christian E Oberkofler
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jan Philipp Jonas
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Beat Mullhaupt
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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Padovano M, Scopetti M, Manetti F, Morena D, Radaelli D, D’Errico S, Di Fazio N, Frati P, Fineschi V. Pancreatic transplant surgery and stem cell therapy: Finding the balance between therapeutic advances and ethical principles. World J Stem Cells 2022; 14:577-586. [PMID: 36157914 PMCID: PMC9453273 DOI: 10.4252/wjsc.v14.i8.577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/24/2022] [Accepted: 07/31/2022] [Indexed: 02/07/2023] Open
Abstract
The latest achievements in the field of pancreas transplantation and stem cell therapy require an effort by the scientific community to clarify the ethical implications of pioneering treatments, often characterized by high complexity from a surgical point of view, due to transplantation of multiple organs at the same time or at different times, and from an immunological point of view for stem cell therapy. The fundamental value in the field of organ transplants is, of course, a solidarity principle, namely that of protecting the health and life of people for whom transplantation is a condition of functional recovery, or even of survival. The nature of this value is that of a concept to which the legal discipline of transplants entrusts its own ethical dignity and for which it has ensured a constitutional recognition in different systems. The general principle of respect for human life, both of the donor and of the recipient, evokes the need not to put oneself and one’s neighbor in dangerous conditions. The present ethical reflection aims to find a balance between the latest therapeutic advances and several concepts including the idea of the person, the respect due to the dead, the voluntary nature of the donation and the consent to the same, the gratuitousness of the donation, the scientific progress and the development of surgical techniques, and the policies of health promotion.
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Affiliation(s)
- Martina Padovano
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome 00185, Italy
| | - Matteo Scopetti
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome 00189, Italy
| | - Federico Manetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome 00185, Italy
| | - Donato Morena
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome 00185, Italy
| | - Davide Radaelli
- Department of Medicine, Surgery and Health, University of Trieste, Trieste 34149, Italy
| | - Stefano D’Errico
- Department of Medicine, Surgery and Health, University of Trieste, Trieste 34149, Italy
| | - Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome 00185, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome 00185, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome 00185, Italy
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Hardt JL, Merkow RP, Reissfelder C, Rahbari NN. Quality assurance and quality control in surgical oncology. J Surg Oncol 2022; 126:1560-1572. [PMID: 35994027 DOI: 10.1002/jso.27074] [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: 07/28/2022] [Accepted: 08/10/2022] [Indexed: 11/09/2022]
Abstract
Even though surgery has remained a key component within multi-disciplinary cancer care, the expectations have changed. Instead of serving as a modality to free a patient of a mass at all means and at the risk of high morbidity, modern cancer surgery is expected to provide adequate tumor clearance with lowest invasiveness. This review summarizes the evidence on quality assurance in surgical oncology and gives a comprehensive overview of quality improvement tools.
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Affiliation(s)
- Julia L Hardt
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nuh N Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Famularo S, Russolillo N, Donadon M, Cipriani F, Ardito F, Perri P, Giani A, De Stefano F, Lai Q, Molfino S, Zanello M, Iaria M, La Barba G, Pinotti E, Germani P, Conci S, Ferrari C, Fumagalli L, Romano M, Antonucci A, Zimmitti G, Troci A, Floridi A, Ferraro V, Patauner S, Frena A, Memeo R, Crespi M, Hilal MA, Zanus G, Chiarelli M, Percivale A, Ruzzenente A, Tarchi P, Zago M, Ercolani G, Dalla Valle R, Jovine E, Baiocchi GL, Rossi M, Maestri M, Romano F, Grazi GL, Giuliante F, Aldrighetti L, Ferrero A, Torzilli G. Benchmarking postoperative outcomes after open liver surgery for cirrhotic patients with hepatocellular carcinoma in a national cohort. HPB (Oxford) 2022; 24:1365-1375. [PMID: 35293320 DOI: 10.1016/j.hpb.2022.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/17/2022] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Benchmark analysis for open liver surgery for cirrhotic patients with hepatocellular carcinoma (HCC) is still undefined. METHODS Patients were identified from the Italian national registry HE.RC.O.LE.S. The Achievable Benchmark of Care (ABC) method was employed to identify the benchmarks. The outcomes assessed were the rate of complications, major comorbidities, post-operative ascites (POA), post-hepatectomy liver failure (PHLF), 90-day mortality. Benchmarking was stratified for surgical complexity (CP1, CP2 and CP3). RESULTS A total of 978 of 2698 patients fulfilled the inclusion criteria. 431 (44.1%) patients were treated with CP1 procedures, 239 (24.4%) with CP2 and 308 (31.5%) with CP3 procedures. Patients submitted to CP1 had a worse underlying liver function, while the tumor burden was more severe in CP3 cases. The ABC for complications (13.1%, 19.2% and 28.1% for CP1, CP2 and CP3 respectively), major complications (7.6%, 11.1%, 12.5%) and 90-day mortality (0%, 3.3%, 3.6%) increased with the surgical difficulty, but not POA (4.4%, 3.3% and 2.6% respectively) and PHLF (0% for all groups). CONCLUSION We propose benchmarks for open liver resections in HCC cirrhotic patients, stratified for surgical complexity. The difference between the benchmark values and the results obtained during everyday practice reflects the room for potential growth, with the aim to encourage constant improvement among liver surgeons.
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Affiliation(s)
- Simone Famularo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Nadia Russolillo
- Department of General and Oncological Surgery, Mauriziano Hospital "Umberto I", Turin, Italy
| | - Matteo Donadon
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Pasquale Perri
- Division of Hepatobiliarypancreatic Unit, IRCCS - Regina Elena National Cancer Institute, Rome, Italy
| | - Alessandro Giani
- School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Francesca De Stefano
- Unit of General Surgery 1, University of Pavia and Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Quirino Lai
- Hepato-Biliary Surgery and Organ Transplantation Unit, Sapienza University of Rome, Umberto I Polyclinic of Rome, Rome, Italy
| | - Sarah Molfino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Matteo Zanello
- Alma Mater Studiorum, University of Bologna, AOU Sant'Orsola Malpighi, IRCCS at Maggiore Hospital, Bologna, Italy
| | - Maurizio Iaria
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giuliano La Barba
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Enrico Pinotti
- Department of Surgery, Ponte San Pietro Hospital, Bergamo, Italy
| | - Paola Germani
- Surgical Clinics, University Hospital of Trieste, Trieste, Italy
| | - Simone Conci
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | | | - Luca Fumagalli
- Department of Emergency and Robotic Surgery, ASST Lecco, Lecco, Italy
| | - Maurizio Romano
- Department of Surgical, Oncological and Gastroenterological Science (DISCOG), University of Padua, Hepatobiliary and Pancreatic Surgery Unit - Treviso Hospital, Italy
| | | | - Giuseppe Zimmitti
- Department of General Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Albert Troci
- Department of Surgery, L. Sacco Hospital, Milan, Italy
| | | | - Valentina Ferraro
- Department of Hepato-Pancreatic-Biliary Surgery, Miulli Hospital, Bari, Italy
| | - Stefan Patauner
- Department of General and Pediatric Surgery, Bolzano Central Hospital, Bolzano, Italy
| | - Antonio Frena
- Department of General and Pediatric Surgery, Bolzano Central Hospital, Bolzano, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreatic-Biliary Surgery, Miulli Hospital, Bari, Italy
| | | | - Mohammed A Hilal
- Department of General Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Giacomo Zanus
- Department of Surgical, Oncological and Gastroenterological Science (DISCOG), University of Padua, Hepatobiliary and Pancreatic Surgery Unit - Treviso Hospital, Italy
| | - Marco Chiarelli
- Department of Emergency and Robotic Surgery, ASST Lecco, Lecco, Italy
| | | | - Andrea Ruzzenente
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Paola Tarchi
- Surgical Clinics, University Hospital of Trieste, Trieste, Italy
| | - Mauro Zago
- Department of Surgery, Ponte San Pietro Hospital, Bergamo, Italy; Department of Emergency and Robotic Surgery, ASST Lecco, Lecco, Italy
| | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | | | - Elio Jovine
- Alma Mater Studiorum, University of Bologna, AOU Sant'Orsola Malpighi, IRCCS at Maggiore Hospital, Bologna, Italy
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Massimo Rossi
- Hepato-Biliary Surgery and Organ Transplantation Unit, Sapienza University of Rome, Umberto I Polyclinic of Rome, Rome, Italy
| | - Marcello Maestri
- Unit of General Surgery 1, University of Pavia and Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabrizio Romano
- School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Gian Luca Grazi
- Division of Hepatobiliarypancreatic Unit, IRCCS - Regina Elena National Cancer Institute, Rome, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Mauriziano Hospital "Umberto I", Turin, Italy
| | - Guido Torzilli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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van Beek DJ, Takkenkamp TJ, Wong-Lun-Hing EM, de Kleine RHJ, Walenkamp AME, Klaase JM, Nijkamp MW, Valk GD, Molenaar IQ, Hagendoorn J, van Santvoort HC, Borel Rinkes IHM, Hoogwater FJH, Vriens MR. Risk factors for complications after surgery for pancreatic neuroendocrine tumors. Surgery 2022; 172:127-136. [PMID: 35341591 DOI: 10.1016/j.surg.2022.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/03/2022] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgical resection is the only potentially curative treatment for pancreatic neuroendocrine tumors. The choice for the type of procedure is influenced by the expected oncological benefit and the anticipated risk of procedure-specific complications. Few studies have focused on complications in these patients. This cohort study aimed to assess complications and risk factors after resections of pancreatic neuroendocrine tumors. METHODS Patients undergoing resection of a pancreatic neuroendocrine tumor were identified within 2 centers of excellence. Complications were assessed according to the Clavien-Dindo classification and the comprehensive complication index. Logistic regression was performed to compare surgical procedures with adjustment for potential confounders (Clavien-Dindo ≥3). RESULTS The cohort comprised 123 patients, including 12 enucleations, 50 distal pancreatectomies, 51 pancreatoduodenectomies, and 10 total/combined pancreatectomies. Mortality was 0.8%, a severe complication occurred in 41.5%, and the failure-to-rescue rate was 2.0%. The median comprehensive complication index was 22.6 (0-100); the comprehensive complication index increased after more extensive resections. After adjustment, a pancreatoduodenectomy, as compared to a distal pancreatectomy, increased the risk for a severe complication (odds ratio 3.13 [95% confidence interval 1.32-7.41]). Of the patients with multiple endocrine neoplasia type 1 or von Hippel-Lindau, 51.9% developed a severe complication vs 38.5% with sporadic disease. After major resections, morbidity was significantly higher in patients with multiple endocrine neoplasia type 1/von Hippel-Lindau (comprehensive complication index 45.1 vs 28.9, P = .029). CONCLUSION Surgery for pancreatic neuroendocrine tumors is associated with a high rate of complications but low failure-to-rescue in centers of excellence. Complications are procedure-specific. Major resections in patients with multiple endocrine neoplasia type 1/von Hippel-Lindau appear to increase the risk of complications.
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Affiliation(s)
- Dirk-Jan van Beek
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tim J Takkenkamp
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Edgar M Wong-Lun-Hing
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ruben H J de Kleine
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annemiek M E Walenkamp
- Department of Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joost M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten W Nijkamp
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Inne H M Borel Rinkes
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Frederik J H Hoogwater
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Menno R Vriens
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.
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Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis. Langenbecks Arch Surg 2022; 407:2801-2810. [PMID: 35752718 DOI: 10.1007/s00423-022-02599-1] [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: 01/11/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications. METHODS Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed. RESULTS A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations. CONCLUSIONS Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.
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Aleotti F, Crippa S, Belfiori G, Tamburrino D, Partelli S, Longo E, Palumbo D, Pecorelli N, Lena MS, Capurso G, Arcidiacono PG, Falconi M. Pancreatic resections for benign intraductal papillary mucinous neoplasms: Collateral damages from friendly fire. Surgery 2022; 172:1202-1209. [PMID: 35667898 DOI: 10.1016/j.surg.2022.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/05/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Surgical resection of intraductal papillary mucinous neoplasms is based on preoperative high-risk stigmata/worrisome features, but the risk of overtreatment remains high. The aim of this study was to evaluate surgical indications and perioperative and long-term complications in patients with low-grade intraductal papillary mucinous neoplasms. METHODS Patients who underwent surgical resection between 2009 and 2018 with a final histology of low-grade intraductal papillary mucinous neoplasms were included. Surgical indications, type of surgery, and short- and long-term outcomes were evaluated. RESULTS A significant decrease in the rate of patients resected for low-grade intraductal papillary mucinous neoplasms was observed (43.6% in 2009-2012 vs 27.8% in 2013-2018; P = .003), and 133 patients were finally included (62 women, median age: 68 years). Of these, 24.1% had 1 worrisome feature, 39.8% had ≥2 worrisome features, 18.8% had ≥1 high-risk stigmata, and 15.8% had ≥1 worrisome features + 1 high-risk stigmata. Overall surgical morbidity was 55.6%, 15.8% had Clavien-Dindo ≥3 complications, reoperation rate was 3.8%, and 90-day postoperative mortality was 1.5%. After a median follow-up of 60 months, 13 patients (11.5%) had a recurrence of benign intraductal papillary mucinous neoplasm in the pancreatic remnant, and 2 patients (1.8%) developed pancreatic ductal adenocarcinoma. After partial pancreatectomy, 51.3% of patients were taking pancreatic enzyme replacement therapy. Among nondiabetics, 26% developed diabetes after partial pancreatectomy, of which 38% were insulin-dependent. Eighteen patients (13.7%) developed incisional hernia. CONCLUSION Given the rates of morbidity and long-term complications after pancreatic resections, surgeons should attentively balance the true risks of intraductal papillary mucinous neoplasm degeneration with the risks of surgical resection in each patient.
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Affiliation(s)
- Francesca Aleotti
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Giulio Belfiori
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy. http://www.twitter.com/spartelli
| | - Enrico Longo
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Diego Palumbo
- Division of Radiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy. http://www.twitter.com/nicpecorelli
| | - Marco Schiavo Lena
- Department of Pathology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Capurso
- Pancreas-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy. http://www.twitter.com/lelecapurso
| | - Paolo Giorgio Arcidiacono
- Pancreas-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Smits FJ, Henry AC, Besselink MG, Busch OR, van Eijck CH, Arntz M, Bollen TL, van Delden OM, van den Heuvel D, van der Leij C, van Lienden KP, Moelker A, Bonsing BA, Borel Rinkes IH, Bosscha K, van Dam RM, Derksen WJM, den Dulk M, Festen S, Groot Koerkamp B, de Haas RJ, Hagendoorn J, van der Harst E, de Hingh IH, Kazemier G, van der Kolk M, Liem M, Lips DJ, Luyer MD, de Meijer VE, Mieog JS, Nieuwenhuijs VB, Patijn GA, Te Riele WW, Roos D, Schreinemakers JM, Stommel MWJ, Wit F, Zonderhuis BA, Daamen LA, van Werkhoven CH, Molenaar IQ, van Santvoort HC. Algorithm-based care versus usual care for the early recognition and management of complications after pancreatic resection in the Netherlands: an open-label, nationwide, stepped-wedge cluster-randomised trial. Lancet 2022; 399:1867-1875. [PMID: 35490691 DOI: 10.1016/s0140-6736(22)00182-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Early recognition and management of postoperative complications, before they become clinically relevant, can improve postoperative outcomes for patients, especially for high-risk procedures such as pancreatic resection. METHODS We did an open-label, nationwide, stepped-wedge cluster-randomised trial that included all patients having pancreatic resection during a 22-month period in the Netherlands. In this trial design, all 17 centres that did pancreatic surgery were randomly allocated for the timing of the crossover from usual care (the control group) to treatment given in accordance with a multimodal, multidisciplinary algorithm for the early recognition and minimally invasive management of postoperative complications (the intervention group). Randomisation was done by an independent statistician using a computer-generated scheme, stratified to ensure that low-medium-volume centres alternated with high-volume centres. Patients and investigators were not masked to treatment. A smartphone app was designed that incorporated the algorithm and included the daily evaluation of clinical and biochemical markers. The algorithm determined when to do abdominal CT, radiological drainage, start antibiotic treatment, and remove abdominal drains. After crossover, clinicians were trained in how to use the algorithm during a 4-week wash-in period; analyses comparing outcomes between the control group and the intervention group included all patients other than those having pancreatic resection during this wash-in period. The primary outcome was a composite of bleeding that required invasive intervention, organ failure, and 90-day mortality, and was assessed by a masked adjudication committee. This trial was registered in the Netherlands Trial Register, NL6671. FINDINGS From Jan 8, 2018, to Nov 9, 2019, all 1805 patients who had pancreatic resection in the Netherlands were eligible for and included in this study. 57 patients who underwent resection during the wash-in phase were excluded from the primary analysis. 1748 patients (885 receiving usual care and 863 receiving algorithm-centred care) were included. The primary outcome occurred in fewer patients in the algorithm-centred care group than in the usual care group (73 [8%] of 863 patients vs 124 [14%] of 885 patients; adjusted risk ratio [RR] 0·48, 95% CI 0·38-0·61; p<0·0001). Among patients treated according to the algorithm, compared with patients who received usual care there was a decrease in bleeding that required intervention (47 [5%] patients vs 51 [6%] patients; RR 0·65, 0·42-0·99; p=0·046), organ failure (39 [5%] patients vs 92 [10%] patients; 0·35, 0·20-0·60; p=0·0001), and 90-day mortality (23 [3%] patients vs 44 [5%] patients; 0·42, 0·19-0·92; p=0·029). INTERPRETATION The algorithm for the early recognition and minimally invasive management of complications after pancreatic resection considerably improved clinical outcomes compared with usual care. This difference included an approximate 50% reduction in mortality at 90 days. FUNDING The Dutch Cancer Society and UMC Utrecht.
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Affiliation(s)
- F Jasmijn Smits
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Mark Arntz
- Department of Radiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Thomas L Bollen
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Otto M van Delden
- Department of Radiology, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Daniel van den Heuvel
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Krijn P van Lienden
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Inne H Borel Rinkes
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Wouter J M Derksen
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Robbert J de Haas
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven and GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Mike Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven and GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - J Sven Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - Wouter W Te Riele
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Hospital, Delft, Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, Netherlands
| | - Babs A Zonderhuis
- Department of Surgery, Cancer Centre Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - C Henri van Werkhoven
- Julius Centre for Health Sciences and Primary Care, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands.
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Real-world study of surgical treatment of pancreatic cancer in China: Annual Report of China Pancreas Data Center (2016–2020). JOURNAL OF PANCREATOLOGY 2022. [DOI: 10.1097/jp9.0000000000000086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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126
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van Dongen JC, Suker M, Versteijne E, Bonsing BA, Mieog JSD, de Vos-Geelen J, van der Harst E, Patijn GA, de Hingh IH, Festen S, Ten Tije AJ, Busch OR, Besselink MG, van Tienhoven G, Koerkamp BG, van Eijck CHJ. Surgical Complications in a Multicenter Randomized Trial Comparing Preoperative Chemoradiotherapy and Immediate Surgery in Patients With Resectable and Borderline Resectable Pancreatic Cancer (PREOPANC Trial). Ann Surg 2022; 275:979-984. [PMID: 33201120 DOI: 10.1097/sla.0000000000004313] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the effect of preoperative chemoradiotherapy on surgical complications in patients after pancreatic resection for (borderline-)resectable pancreatic cancer. SUMMARY OF BACKGROUND DATA Preoperative chemoradiotherapy is increasingly used in patients with (borderline-)resectable pancreatic cancer. concerns have been raised about the potential harmful effect of any preoperative therapy on the surgical complication rate after pancreatic resection. METHODS An observational analysis was performed within the multicenter randomized controlled PREOPANC trial (April 2013-July 2017). The trial randomly assigned (1:1) patients to preoperative chemoradiotherapy followed by surgery and the remaining adjuvant chemotherapy or to immediate surgery, followed by adjuvant chemotherapy. The main analysis consisted of a per-protocol approach. The endpoints of the present analyses were the rate of postoperative complications. RESULTS This study included 246 patients from 16 centers, of whom 66 patients underwent resection after preoperative therapy and 98 patients after immediate surgery. No differences were found regarding major complications (37.9% vs 30.6%, P=0.400), postpancreatectomy hemorrhage (9.1% vs 5.1%, P=0.352), delayed gastric emptying (21.2% vs 22.4%, P=0.930), bile leakage (4.5% vs 3.1%, P=0.686), intra-abdominal infections (12.1% vs 10.2%, P=0.800), and mortality (3.0% vs 4.1%, P=1.000). There was a significant lower incidence of postoperative pancreatic fistula in patients who received preoperative chemoradiotherapy (0% vs 9.2%, P=0.011). CONCLUSIONS Preoperative chemoradiotherapy did not increase the incidence of surgical complications or mortality and reduced the rate of postoperative pancreatic fistula after resection in patients with (borderline-)resectable pancreatic cancer.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala Oncology Center, Zwolle, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Albert J Ten Tije
- Department of Medical Oncology, Amphia Hospital, Breda, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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Kawabata Y, Tajima Y. Comment on "Perihilar cholangiocarcinoma-novel benchmark values for surgical and oncological outcomes from 24 expert centers". Hepatobiliary Surg Nutr 2022; 11:314-316. [PMID: 35464282 PMCID: PMC9023826 DOI: 10.21037/hbsn-21-560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/15/2022] [Indexed: 08/30/2023]
Affiliation(s)
- Yasunari Kawabata
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Yoshitsugu Tajima
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
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Muzzolini M, Araujo RLC, Kingham TP, Peschaud F, Paye F, Lupinacci RM. Incidence and risk factors for Chyle leak after pancreatic surgery for cancer: A comprehensive systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:707-717. [PMID: 34887165 PMCID: PMC8995357 DOI: 10.1016/j.ejso.2021.11.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/25/2021] [Accepted: 11/29/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chyle leak (CL) is a clinically relevant complication after pancreatectomy. Its incidence and the associated risk factors are ill defined, and various treatments options have been described. There is no consensus, however, regarding optimal management. The present study aims to systematically review the literature on CL after pancreatectomy. METHODS A systematic review from PubMed, Scopus and Embase database was performed. Studies using a clear definition for CL and published from January 2000 to January 2021 were included. The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score was used to assess methodological quality. RESULTS Literature search found 361 reports, 99 of which were duplicates. The titles and abstracts of 262 articles were finally screened. The references from the remaining 181 articles were manually assessed. After the exclusions, 43 articles were thoroughly assessed. A total of 23 articles were ultimately included for this review. The number of patients varied from 54 to 3532. Incidence of post pancreatectomy CL varied from 1.3% to 22.1%. Main risk factors were the extent of the surgery and early oral or enteral feeding. CL dried up spontaneously or after conservative management within 14 days in 53% to 100% of the cases. CONCLUSIONS The extent of surgery is the most common predictor of risk of CL. Conservative treatment has been shown to be effective in most cases and can be considered the treatment of choice. We propose a management algorithm based on the current available evidence.
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Affiliation(s)
- Milena Muzzolini
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France
| | - Raphael L C Araujo
- Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Frédérique Peschaud
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France; Versailles St-Quentin-en-Yvelines/Paris Saclay University, UFR des Sciences de la Santé Simone Veil, 78180, Montigny-le-Bretonneux, France
| | - François Paye
- Department of Surgery, Saint Antoine Hospital, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France; Sorbonne Université, 75013, 91-105, Bd de l'Hôpital, Paris, France
| | - Renato M Lupinacci
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France; Versailles St-Quentin-en-Yvelines/Paris Saclay University, UFR des Sciences de la Santé Simone Veil, 78180, Montigny-le-Bretonneux, France.
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Müller PC, Kuemmerli C, Cizmic A, Sinz S, Probst P, de Santibanes M, Shrikhande SV, Tschuor C, Loos M, Mehrabi A, Z’graggen K, Müller-Stich BP, Hackert T, Büchler MW, Nickel F. Learning Curves in Open, Laparoscopic, and Robotic Pancreatic Surgery: A Systematic Review and Proposal of a Standardization. ANNALS OF SURGERY OPEN 2022; 3:e111. [PMID: 37600094 PMCID: PMC10431463 DOI: 10.1097/as9.0000000000000111] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 10/30/2021] [Indexed: 12/31/2022] Open
Abstract
Objective To depict and analyze learning curves for open, laparoscopic, and robotic pancreatoduodenectomy (PD) and distal pancreatectomy (DP). Background Formal training is recommended for safe introduction of pancreatic surgery but definitions of learning curves vary and have not been standardized. Methods A systematic search on PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in pancreatic surgery. Primary outcome was the number needed to reach the learning curve as defined by the included studies. Secondary outcomes included endpoints defining learning curves, methods of analysis (statistical/arbitrary), and classification of learning phases. Results Out of 1115 articles, 66 studies with 14,206 patients were included. Thirty-five studies (53%) based the learning curve analysis on statistical calculations. Most often used parameters to define learning curves were operative time (n = 51), blood loss (n = 17), and complications (n = 10). The number of procedures to surpass a first phase of learning curve was 30 (20-50) for open PD, 39 (11-60) for laparoscopic PD, 25 (8-100) for robotic PD (P = 0.521), 16 (3-17) for laparoscopic DP, and 15 (5-37) for robotic DP (P = 0.914). In a three-phase model, intraoperative parameters improved earlier (first to second phase: operating time -15%, blood loss -29%) whereas postoperative parameters improved later (second to third phase: complications -46%, postoperative pancreatic fistula -48%). Studies with higher sample sizes showed higher numbers of procedures needed to overcome the learning curve (rho = 0.64, P < 0.001). Conclusions This study summarizes learning curves for open-, laparoscopic-, and robotic pancreatic surgery with different definitions, analysis methods, and confounding factors. A standardized reporting of learning curves and definition of phases (competency, proficiency, mastery) is desirable and proposed.
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Affiliation(s)
- P. C. Müller
- From the Department of Surgery, Clinic Beau-Site, Bern, Switzerland
| | - C. Kuemmerli
- Clarunis, University Center for Gastrointestinal and Liver Disorders, University Hospital Basel, Basel, Switzerland
| | - A. Cizmic
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - S. Sinz
- Department of General Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - P. Probst
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M. de Santibanes
- Department of Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - S. V. Shrikhande
- Department of GI and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - C. Tschuor
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M. Loos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - A. Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - K. Z’graggen
- From the Department of Surgery, Clinic Beau-Site, Bern, Switzerland
| | - B. P. Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - T. Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M. W. Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - F. Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Yang Y, Fu X, Zhu S, Cai Z, Qiu Y, Mao L. Vater's ampullary carcinoma increases the risk of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis. BMC Gastroenterol 2022; 22:51. [PMID: 35125104 PMCID: PMC8818205 DOI: 10.1186/s12876-022-02128-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a frequent complication after pancreaticoduodenectomy (PD). This study aimed to investigate the impact of Vater's ampullary carcinoma (VAC) on clinically relevant POPF (CR-POPF) in patients undergoing PD. METHODS Clinical data were gathered retrospectively from January 2018 to December 2020 for all patients undergoing PD. The univariate and multivariate analysis were used to identify independent risk factors of CR-POPF. A propensity score-matched (PSM) analysis at a ratio of 1:1 was performed to minimize bias from baseline characteristics between VAC and non-VAC groups. Main postoperative complications were compared between the two groups after PSM. RESULTS In 263 patients, 94 (35.7%) patients were diagnosed as VAC. CR-POPF occurred in 99 (37.6%) patients and VAC was identified as an independent risk factor of CR-POPF in multivariate logistic regression analysis (OR = 0.548, 95% CI = 0.327-0.920, P = 0.023). After PSM, there were similar baseline characteristics between the VAC and non-VAC group. Moreover, VAC group had a higher rate of CR-POPF (P = 0.025) and intra-abdominal infection (P = 0.015) compared to the non-VAC group. CONCLUSIONS In patients undergoing PD, VAC increases the risk of CR-POPF and several other postoperative complications.
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Affiliation(s)
- Yifei Yang
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Xu Fu
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Saisai Zhu
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Zhenghua Cai
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Yudong Qiu
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Liang Mao
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China.
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131
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Schlegel A, van Reeven M, Croome K, Parente A, Dolcet A, Widmer J, Meurisse N, De Carlis R, Hessheimer A, Jochmans I, Mueller M, van Leeuwen OB, Nair A, Tomiyama K, Sherif A, Elsharif M, Kron P, van der Helm D, Borja-Cacho D, Bohorquez H, Germanova D, Dondossola D, Olivieri T, Camagni S, Gorgen A, Patrono D, Cescon M, Croome S, Panconesi R, Carvalho MF, Ravaioli M, Caicedo JC, Loss G, Lucidi V, Sapisochin G, Romagnoli R, Jassem W, Colledan M, De Carlis L, Rossi G, Di Benedetto F, Miller CM, van Hoek B, Attia M, Lodge P, Hernandez-Alejandro R, Detry O, Quintini C, Oniscu GC, Fondevila C, Malagó M, Pirenne J, IJzermans JNM, Porte RJ, Dutkowski P, Taner CB, Heaton N, Clavien PA, Polak WG, Muiesan P. A multicentre outcome analysis to define global benchmarks for donation after circulatory death liver transplantation. J Hepatol 2022; 76:371-382. [PMID: 34655663 DOI: 10.1016/j.jhep.2021.10.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/17/2021] [Accepted: 10/04/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The concept of benchmarking is established in the field of transplant surgery; however, benchmark values for donation after circulatory death (DCD) liver transplantation are not available. Thus, we aimed to identify the best possible outcomes in DCD liver transplantation and to propose outcome reference values. METHODS Based on 2,219 controlled DCD liver transplantations, collected from 17 centres in North America and Europe, we identified 1,012 low-risk, primary, adult liver transplantations with a laboratory MELD score of ≤20 points, receiving a DCD liver with a total donor warm ischemia time of ≤30 minutes and asystolic donor warm ischemia time of ≤15 minutes. Clinically relevant outcomes were selected and complications were reported according to the Clavien-Dindo-Grading and the comprehensive complication index (CCI). Corresponding benchmark cut-offs were based on median values of each centre, where the 75th-percentile was considered. RESULTS Benchmark cases represented between 19.7% and 75% of DCD transplantations in participating centres. The 1-year retransplant and mortality rates were 4.5% and 8.4% in the benchmark group, respectively. Within the first year of follow-up, 51.1% of recipients developed at least 1 major complication (≥Clavien-Dindo-Grade III). Benchmark cut-offs were ≤3 days and ≤16 days for ICU and hospital stay, ≤66% for severe recipient complications (≥Grade III), ≤16.8% for ischemic cholangiopathy, and ≤38.9 CCI points 1 year after transplant. Comparisons with higher risk groups showed more complications and impaired graft survival outside the benchmark cut-offs. Organ perfusion techniques reduced the complications to values below benchmark cut-offs, despite higher graft risk. CONCLUSIONS Despite excellent 1-year survival, morbidity in benchmark cases remains high. Benchmark cut-offs targeting morbidity parameters offer a valid tool to assess the protective value of new preservation technologies in higher risk groups and to provide a valid comparator cohort for future clinical trials. LAY SUMMARY The best possible outcomes after liver transplantation of grafts donated after circulatory death (DCD) were defined using the concept of benchmarking. These were based on 2,219 liver transplantations following controlled DCD donation in 17 centres worldwide. Donor and recipient combinations with higher risk had significantly worse outcomes. However, the use of novel organ perfusion technology helped high-risk patients achieve similar outcomes as the benchmark cohort.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom; Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Marjolein van Reeven
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Surgery, Division of Hepato-Pancreato-Biliary and Transplant Surgery, Rotterdam, the Netherlands
| | - Kristopher Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 United States
| | - Alessandro Parente
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom
| | - Annalisa Dolcet
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Jeannette Widmer
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; HPB Surgery and Liver Transplantation, Royal Free Hospital London, United Kingdom
| | - Nicolas Meurisse
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Amelia Hessheimer
- General & Digestive Surgery, Hospital Clínic Barcelona, Barcelona, Spain; CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ina Jochmans
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; Abdominal Transplant Surgery, Department of Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Matteo Mueller
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Otto B van Leeuwen
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Amit Nair
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA; Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY, USA
| | - Koji Tomiyama
- Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY, USA
| | - Ahmed Sherif
- Department of Transplant Surgery, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, United Kingdom
| | - Mohamed Elsharif
- HPB and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | - Philipp Kron
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; HPB and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | - Danny van der Helm
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Daniel Borja-Cacho
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Humberto Bohorquez
- Multi-Organ Transplant Institute, University of Queensland School and the Ochsner Clinical School, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Desislava Germanova
- Department of abdominal surgery, Unit of hepato-biliary surgery and abdominal transplantation, CUB Erasme Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan 20122, Italy
| | - Tiziana Olivieri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefania Camagni
- Department of Organ Failure and Transplantation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Andre Gorgen
- Multi-Organ Transplant Program, Division of General Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sarah Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 United States
| | - Rebecca Panconesi
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | | | - Matteo Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Juan Carlos Caicedo
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - George Loss
- Multi-Organ Transplant Institute, University of Queensland School and the Ochsner Clinical School, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Valerio Lucidi
- Department of abdominal surgery, Unit of hepato-biliary surgery and abdominal transplantation, CUB Erasme Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | | | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Michele Colledan
- Department of Organ Failure and Transplantation, Papa Giovanni XXIII Hospital, Bergamo, Italy; Università di Milano-Bicocca, Milano, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giorgio Rossi
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan 20122, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Charles M Miller
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Magdy Attia
- HPB and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | - Peter Lodge
- HPB and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | | | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium
| | - Cristiano Quintini
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gabriel C Oniscu
- Department of Transplant Surgery, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, United Kingdom
| | - Constantino Fondevila
- General & Digestive Surgery, Hospital Clínic Barcelona, Barcelona, Spain; CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Massimo Malagó
- HPB Surgery and Liver Transplantation, Royal Free Hospital London, United Kingdom
| | - Jacques Pirenne
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; Abdominal Transplant Surgery, Department of Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jan N M IJzermans
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Surgery, Division of Hepato-Pancreato-Biliary and Transplant Surgery, Rotterdam, the Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 United States
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Wojciech G Polak
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Surgery, Division of Hepato-Pancreato-Biliary and Transplant Surgery, Rotterdam, the Netherlands
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom; Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan 20122, Italy.
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Kuemmerli C, Tschuor C, Kasai M, Alseidi AA, Balzano G, Bouwense S, Braga M, Coolsen M, Daniel SK, Dervenis C, Falconi M, Hwang DW, Kagedan DJ, Kim SC, Lavu H, Liang T, Nussbaum D, Partelli S, Passeri MJ, Pecorelli N, Pillai SA, Pillarisetty VG, Pucci MJ, Su W, Sutcliffe RP, Tingstedt B, van der Kolk M, Vrochides D, Wei A, Williamsson C, Yeo CJ, Zani S, Zouros E, Abu Hilal M. Impact of enhanced recovery protocols after pancreatoduodenectomy: meta-analysis. Br J Surg 2022; 109:256-266. [PMID: 35037019 DOI: 10.1093/bjs/znab436] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This individual-patient data meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenectomy. METHODS The Cochrane Library, MEDLINE, Embase, Scopus, and Web of Science were searched systematically for articles reporting outcomes of ERAS after pancreatoduodenectomy published up to August 2020. Comparative studies were included. Main outcomes were postoperative functional recovery elements, postoperative morbidity, duration of hospital stay, and readmission. RESULTS Individual-patient data were obtained from 17 of 31 eligible studies comprising 3108 patients. Time to liquid (mean difference (MD) -3.23 (95 per cent c.i. -4.62 to -1.85) days; P < 0.001) and solid (-3.84 (-5.09 to -2.60) days; P < 0.001) intake, time to passage of first stool (MD -1.38 (-1.82 to -0.94) days; P < 0.001) and time to removal of the nasogastric tube (3.03 (-4.87 to -1.18) days; P = 0.001) were reduced with ERAS. ERAS was associated with lower overall morbidity (risk difference (RD) -0.04, 95 per cent c.i. -0.08 to -0.01; P = 0.015), less delayed gastric emptying (RD -0.11, -0.22 to -0.01; P = 0.039) and a shorter duration of hospital stay (MD -2.33 (-2.98 to -1.69) days; P < 0.001) without a higher readmission rate. CONCLUSION ERAS improved postoperative outcome after pancreatoduodenectomy. Implementation should be encouraged.
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Affiliation(s)
- Christoph Kuemmerli
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Department of Surgery, Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Clarunis-University Centre for Gastrointestinal and Liver Diseases Basle, Basle, Switzerland
| | - Christoph Tschuor
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, Hyogo, Japan
| | - Adnan A Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marco Braga
- Department of Surgery, Monza Hospital, University of Milano Bicocca, Monza, Italy
| | - Mariëlle Coolsen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sara K Daniel
- Hepatopancreatobiliary Surgery, University of Washington, Seattle, Washington, USA
| | - Christos Dervenis
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Daniel Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Michael J Passeri
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Sastha Ahanatha Pillai
- Department of Surgery, Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai, India
| | - Venu G Pillarisetty
- Hepatopancreatobiliary Surgery, University of Washington, Seattle, Washington, USA
| | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Wei Su
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Robert P Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Dionisios Vrochides
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
| | - Alice Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Efstratios Zouros
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - Mohammed Abu Hilal
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Department of Surgery, Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Gero D, Muller X, Staiger RD, Gutschow CA, Vonlanthen R, Bueter M, Clavien PA, Puhan MA. How to Establish Benchmarks for Surgical Outcomes?: A Checklist Based on an International Expert Delphi Consensus. Ann Surg 2022; 275:115-120. [PMID: 32398485 DOI: 10.1097/sla.0000000000003931] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To define a standardized methodology for establishing benchmarks for relevant outcomes in surgery. SUMMARY BACKGROUND DATA Benchmarking is an established tool to improve quality in industry and economics, and is emerging in assessing outcome values in surgery. Despite a recent 10-step approach to identify such benchmark values, a standardized and more widely agreed-on approach is still lacking. METHODS A multinational web-based Delphi survey with a focus on methodological requirements for establishing benchmarks for surgical outcomes was performed. Participants were selected among internationally renowned specialists in abdominal, vascular, and thoracic surgery. Consensus was defined as ≥70% agreement and results were used to develop a checklist to establish benchmarks in surgery. RESULTS Forty-one surgical opinion leaders from 19 countries and 5 continents were involved. Experts' response rates were 98% and 80% in rounds 1 and 2, respectively. Upon completion of the final Delphi round, consensus was successfully achieved for 26 of 36 items covering the following areas: center eligibility, validation of databases, patient cohort selection, procedure selection, duration of follow-up, statistical analysis, and publication requirements regarding center-specific outcomes. CONCLUSIONS This multinational Delphi survey represents the first expert-led process for developing a standardized approach for establishing benchmarks for relevant outcome measures in surgery. The provided consensual checklist customizes the methodology of outcome reporting in surgery and thus improves reproducibility and comparability of data and should ultimately serve to improve quality of care.
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Affiliation(s)
- Daniel Gero
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Roxane D Staiger
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christian A Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - René Vonlanthen
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Marco Bueter
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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134
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Drexler R, Ben-Haim S, Bien CG, Borger V, Cardinale F, Carpentier A, Cendes F, Chandra S, Clusmann H, Colon A, de Curtis M, Delev D, Didato G, Dührsen L, Farah JO, Guenot M, Ghatan S, Haegelen C, Hamer H, Hauptmann JS, Jeffree RL, Kalbhenn T, Kegele J, Krayenbühl N, Lang J, Mathon B, Naros G, Onken J, Panov F, Raftopoulos C, Ricklefs FL, Rijkers K, Rizzi M, Rössler K, Schijns O, Schneider UC, Spyrantis A, Strzelczyk A, Stodieck S, Tripathi M, Vadera S, Alonso-Vanegas MA, Vaz JGR, Wellmer J, Wehner T, Westphal M, Sauvigny T. Enhancing Safety in Epilepsy Surgery (EASINESS): Study Protocol for a Retrospective, Multicenter, Open Registry. Front Neurol 2021; 12:782666. [PMID: 34966349 PMCID: PMC8710656 DOI: 10.3389/fneur.2021.782666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/05/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction: Optimizing patient safety and quality improvement is increasingly important in surgery. Benchmarks and clinical quality registries are being developed to assess the best achievable results for several surgical procedures and reduce unwarranted variation between different centers. However, there is no clinical database from international centers for establishing standardized reference values of patients undergoing surgery for mesial temporal lobe epilepsy. Design: The Enhancing Safety in Epilepsy Surgery (EASINESS) study is a retrospectively conducted, multicenter, open registry. All patients undergoing mesial temporal lobe epilepsy surgery in participating centers between January 2015 and December 2019 are included in this study. The patient characteristics, preoperative diagnostic tools, surgical data, postoperative complications, and long-term seizure outcomes are recorded. Outcomes: The collected data will be used for establishing standardized reference values (“benchmarks”) for this type of surgical procedure. The primary endpoints include seizure outcomes according to the International League Against Epilepsy (ILAE) classification and defined postoperative complications. Discussion: The EASINESS will define robust and standardized outcome references after amygdalohippocampectomy for temporal lobe epilepsy. After the successful definition of benchmarks from an international cohort of renowned centers, these data will serve as reference values for the evaluation of novel surgical techniques and comparisons among centers for future clinical trials. Clinical trial registration: This study is indexed at clinicaltrials.gov (NT 04952298).
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sharona Ben-Haim
- Department of Neurosurgery, University of California San Diego, San Diego, CA, United States
| | | | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | | | - Fernando Cendes
- Department of Neurology, University of Campinas, Campinas, Brazil
| | | | - Hans Clusmann
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Albert Colon
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (UM), Maastricht, Netherlands
| | - Marco de Curtis
- Epilepsy Unit, IRCCS "C. Besta" Neurological Institute Foundation, Milan, Italy
| | - Daniel Delev
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Giuseppe Didato
- Epilepsy Unit, IRCCS "C. Besta" Neurological Institute Foundation, Milan, Italy
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Marc Guenot
- Department of Functional Neurosurgery, P. Wertheimer Hospital, Hospices Civils de Lyon, Lyon, France.,Department for Neurosurgery, University of Lyon, Lyon, France
| | - Saadi Ghatan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Claire Haegelen
- Department of Functional Neurosurgery, P. Wertheimer Hospital, Hospices Civils de Lyon, Lyon, France.,Department for Neurosurgery, University of Lyon, Lyon, France
| | - Hajo Hamer
- Epilepsy Center, Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Jason S Hauptmann
- Department of Neurosurgery, University of Washington, Seattle, WA, United States
| | - Rosalind L Jeffree
- Department of Neurosurgery, Royal Brisbane and Womens Hospital, Brisbane, QLD, Australia.,Herston Clinical School, University of Queensland, Brisbane, QLD, Australia
| | - Thilo Kalbhenn
- Department of Neurosurgery (Evangelisches Klinikum Bethel), Bielefeld University, Medical School, Bielefeld, Germany
| | - Josua Kegele
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tubingen, Tubingen, Germany
| | - Niklaus Krayenbühl
- Division of Pediatric Neurosurgery, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Johannes Lang
- Epilepsy Center, Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Bertrand Mathon
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Georgios Naros
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tubingen, Tubingen, Germany
| | - Julia Onken
- Department of Neurosurgery, Universitätsmedizin Charité-Berlin, Berlin, Germany
| | - Fedor Panov
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Christian Raftopoulos
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kim Rijkers
- Department of Neurosurgery, Academic Center for Epileptology UMC Maastricht, Maastricht, Netherlands
| | - Michele Rizzi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Karl Rössler
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Olaf Schijns
- Department of Neurosurgery, Academic Center for Epileptology UMC Maastricht, Maastricht, Netherlands.,School for Mental Health and Neuroscience (MHeNS), University Maastricht (UM), Maastricht, Netherlands
| | - Ulf C Schneider
- Department of Neurosurgery, Universitätsmedizin Charité-Berlin, Berlin, Germany
| | - Andrea Spyrantis
- Department of Neurosurgery and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Frankfurt, Germany
| | - Adam Strzelczyk
- Department of Neurosurgery and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Frankfurt, Germany
| | - Stefan Stodieck
- Hamburg Epilepsy Center, Protestant Hospital Alsterdorf, Department of Neurology and Epileptology, Hamburg, Germany
| | | | - Sumeet Vadera
- Department of Neurological Surgery, University of California Irvine, Irvine, CA, United States
| | - Mario A Alonso-Vanegas
- National Institute of Neurology and Neurosurgery, Manuel Velasco Suarez, Mexico City, Mexico
| | - José Géraldo Ribero Vaz
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Jörg Wellmer
- Ruhr - Epileptology, Department of Neurology, University Hospital Knappschafts-Krankenhaus, Ruhr - University Bochum, Bochum, Germany
| | - Tim Wehner
- Ruhr - Epileptology, Department of Neurology, University Hospital Knappschafts-Krankenhaus, Ruhr - University Bochum, Bochum, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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135
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Chinikar R, Patricio D, Gosse J, Ickx B, Delhaye M, Closset J, El Moussaoui I, Hites M, Navez J. Perioperative antimicrobial prophylaxis in patients undergoing pancreatoduodenectomy: retrospective analysis of bacteriological profile and susceptibility. Acta Chir Belg 2021:1-8. [PMID: 34779697 DOI: 10.1080/00015458.2021.2006887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pancreatic tumours are frequently associated with obstructive jaundice requiring preoperative biliary drainage (PBD) before pancreatoduodenectomy (PD), exposing patients to infectious complications. This study aims to compare postoperative complications after PD with or without PBD and to analyse bile bacteriology and antibiotic susceptibility. METHODS All patients undergoing PD between 2014 and 2019 were retrospectively evaluated, and postoperative outcomes were compared according to PBD use. Prophylactic narrow-spectrum antibiotic therapy was given for 24 h, then adapted according to bacteriologic profile. Intraoperative bile cultures and antibiograms were collected. RESULTS Among 164 patients with intraoperative bile culture during PD (75 PBD+, 89 PBD-), an infected bile was observed in 95% and 70% of PBD + and PBD- groups, respectively (p < 0.001). Postoperative mortality and severe morbidity including infectious complications were similar between groups (5% and 15%). The median duration of antibiotherapy was longer in PBD + compared to PBD- groups (9 vs. 2 days, p = 0.009). Malignant indication and PBD were associated with bile contamination using univariate analysis, and PBD was significantly relevant at multivariate analysis. Most common pathogens identified in bile cultures were Escherichia coli, Klebsiella spp. and Enterobacter spp. Overall antibiotic susceptibility to commonly used antibiotics was decreased, including those used in our local guidelines. CONCLUSIONS PBD exposes nearly 100% of patients undergoing PD to bile infection and an increased duration of postoperative antimicrobial therapy, without increasing infectious complications in this study. Adaptation of antimicrobial prophylaxis should be further evaluated according to performance of PBD and local epidemiology, in order to avoid overuse of antibiotics.
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Affiliation(s)
- Reza Chinikar
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Cliniques Universitaires de Bruxelles (CUB)-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
- Department of Surgery, CHU Tivoli, La Louvière, Belgium
| | - Daniel Patricio
- Department of Anesthesiology, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Brigitte Ickx
- Department of Anesthesiology, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Myriam Delhaye
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Cliniques Universitaires de Bruxelles (CUB)-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Closset
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Cliniques Universitaires de Bruxelles (CUB)-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Imad El Moussaoui
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Cliniques Universitaires de Bruxelles (CUB)-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maya Hites
- Department of Infectious Diseases, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Julie Navez
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Cliniques Universitaires de Bruxelles (CUB)-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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136
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Evolving pancreatic cancer treatment: From diagnosis to healthcare management. Crit Rev Oncol Hematol 2021; 169:103571. [PMID: 34923121 DOI: 10.1016/j.critrevonc.2021.103571] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
The prognosis of pancreatic ductal adenocarcinoma is still the worst among solid tumors. In this review, a panel of experts addressed the main unanswered questions about the clinical management of this disease, with the aim of providing practical decision support for physicians. On the basis of the evidence available from the literature, the main topics concerning pancreatic cancer are discussed: the diagnosis, as the need for a pathological characterization and the role for germ-line and somatic molecular profiling; the therapeutic management of resectable disease, as the role of upfront surgery or neoadjuvant chemotherapy, the post-operative restaging and the optimal timing foradjuvant chemotherapy, the management of the borderline resectable and locally advanced disease; the metastatic disease and the role of surgery for the management of patients with isolated metastasis and the use of biomarkers of metastatic potential; the role of supportive care and the healthcare management of pancreatic ductal adenocarcinoma.
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137
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Francken MFG, van Roessel S, Swijnenburg RJ, Erdmann JI, Busch OR, Dijkgraaf MGW, Besselink MG. Hospital costs of delayed gastric emptying following pancreatoduodenectomy and the financial headroom for novel prophylactic treatment strategies. HPB (Oxford) 2021; 23:1865-1872. [PMID: 34144889 DOI: 10.1016/j.hpb.2021.04.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/23/2021] [Accepted: 04/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common complications following pancreatoduodenectomy (PD). In-hospital costs of DGE are unknown as well as the financial headroom for novel prophylactic treatments. This retrospective study aims to estimate the hospital costs of DGE and model the financial headroom per patient for new prophylactic treatment strategies within budget. METHODS Retrospective analysis of a single-center prospective database including patients after PD (2010-2017). In-hospital costs for clinically relevant DGE (ISGPS grade B/C) were calculated by comparing patient groups with and without DGE or other complications. The financial headroom per patient was modelled for potential reductions (0-100%) of empirical DGE baseline risks (15-30%). RESULTS Overall, DGE was present in 156 (26.9%) of 581 patients after PD. Costs for patients with isolated DGE (n = 90) were €10,295 higher than for patients without complications (n = 333). Costs for patients with other complications including DGE (n = 66) were €9008 higher than for patients with other complications without DGE (n = 92). The financial headroom for a novel prophylactic treatment per patient undergoing PD was €975 per 10% absolute decrease of DGE risk. CONCLUSION Hospital costs of DGE after PD are substantial. The financial headroom per patient for new DGE prophylactic treatments can be easily calculated via www.pancreascalculator.com.
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Affiliation(s)
- Michiel F G Francken
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - Stijn van Roessel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - Joris I Erdmann
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
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138
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Yau HCV, Lester L, Johansson M. Transitioning to a high volume centre for Whipple pancreaticoduodenectomy in Western Australia: a single centre experience. ANZ J Surg 2021; 92:86-91. [PMID: 34791763 DOI: 10.1111/ans.17367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/28/2021] [Accepted: 10/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a curative resection for peri-ampullary tumours associated with high rates of peri-operative mortality and morbidity. The global trend is towards the establishment of high volume centres to reduce this. Australia faces geographical and population distribution challenges. Western Australia has centralized PD to two centres and we present the results of our institution in transitioning to a high volume centre. METHODS This was a prospective database of all PDs performed at our institution from 1 January 2005 to 2 April 2020. Mortality outcomes included peri-operative, 30 day and 90 day mortality. Complications, readmission and reinterventions at 90 days were recorded. The annual volume exceeded 20 from 2015. Outcomes prior to this were compared to characterize the transition to a high volume centre. RESULTS One hundred and twenty eight PDs were performed in Period 1 (1 January 2005-31 December 2014) and 170 in the high volume Period 2 (1 January 2015-2 April 2020). There was a non-statistically significant reduction in 90 day mortality in Period 2 (4.69% versus 1.18%, p = 0.06). There was a reduction in clinically significant post-operative pancreatic fistulas (31.25% versus 11.76%, p < 0.05), delayed gastric emptying (39.84% versus 22.35%, p < 0.05) and transfusion requirements (56.25% versus 17.65%, p < 0.05). Severe complications (Clavien-Dindo III or greater) were reduced (30.47% versus 18.24%, p < 0.05). CONCLUSION Since establishing a high volume service, there was a reduction in post-operative complications and 90 day mortality. This is in line with outcomes from international centres and demonstrates the improvements that can be made.
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Affiliation(s)
- Ho-Cing Victor Yau
- Department of General Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Leanne Lester
- School of Human Science, University of Western Australia, Perth, Western Australia, Australia
| | - Mikael Johansson
- Department of General Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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139
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Birrer DL, Golcher H, Casadei R, Haile SR, Fritsch R, Hussung S, Brunner TB, Fietkau R, Meyer T, Grützmann R, Merkel S, Ricci C, Ingaldi C, Di Marco M, Guido A, Serra C, Minni F, Pestalozzi B, Petrowsky H, DeOliveira M, Bechstein WO, Bruns CJ, Oberkofler CE, Puhan M, Lesurtel M, Heinrich S, Clavien PA. Neoadjuvant Therapy for Resectable Pancreatic Cancer: A New Standard of Care. Pooled Data From 3 Randomized Controlled Trials. Ann Surg 2021; 274:713-720. [PMID: 34334656 DOI: 10.1097/sla.0000000000005126] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to pool data from randomized controlled trials (RCT) limited to resectable pancreatic ductal adenocarcinoma (PDAC) to determine whether a neoadjuvant therapy impacts on disease-free survival (DFS) and surgical outcome. SUMMARY BACKGROUND DATA Few underpowered studies have suggested benefits from neoadjuvant chemo (± radiation) for strictly resectable PDAC without offering conclusive recommendations. METHODS Three RCTs were identified comparing neoadjuvant chemo (± radio) therapy vs. upfront surgery followed by adjuvant therapy in all cases. Data were pooled targeting DFS as primary endpoint, whereas overall survival (OS), postoperative morbidity, and mortality were investigated as secondary endpoints. Survival endpoints DFS and OS were compared using Cox proportional hazards regression with study-specific baseline hazards. RESULTS A total of 130 patients were randomized (56 in the neoadjuvant and 74 in the control group). DFS was significantly longer in the neoadjuvant treatment group compared to surgery only [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.4-0.9] (P = 0.01). Furthermore, DFS for the subgroup of R0 resections was similarly longer in the neoadjuvant treated group (HR 0.6, 95% CI 0.35-0.9, P = 0.045). Although postoperative complications (Comprehensive Complication Index, CCI®) occurred less frequently (P = 0.008), patients after neoadjuvant therapy experienced a higher toxicity, but without negative impact on oncological or surgical outcome parameters. CONCLUSION Neoadjuvant therapy can be offered as an acceptable standard of care for patients with purely resectable PDAC. Future research with the advances of precision oncology should now focus on the definition of the optimal regimen.
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Affiliation(s)
- Dominique L Birrer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Henriette Golcher
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Sarah R Haile
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Ralph Fritsch
- Department of Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Saskia Hussung
- Department of Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas B Brunner
- Department of Radiation Oncology, University Hospital Magdeburg, Magdeburg, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Thomas Meyer
- Department of Surgery, Hospital Ansbach, Ansbach, Germany
| | - Robert Grützmann
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Claudio Ricci
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Mariacristina Di Marco
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
- Medical Oncology, IRCCS Azienda Ospedaliero, University of Bologna, Bologna, Italy
| | - Alessandra Guido
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Carla Serra
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Francesco Minni
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Michelle DeOliveira
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Wolf O Bechstein
- Department of General, Visceral- and Transplantation Surgery, University Hospital Frankfurt am Main, Frankfurt, Germany
| | - Christiane J Bruns
- Department of General and Transplantation Surgery, University Hospital Cologne, Köln, Germany
| | - Christian E Oberkofler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Milo Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, University Lyon I, Lyon, France
| | - Stefan Heinrich
- Department of General, Visceral and Transplantation Surgery, University Hospital of Mainz, Mainz, Germany
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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Gero D, Vannijvel M, Okkema S, Deleus E, Lloyd A, Lo Menzo E, Tadros G, Raguz I, San Martin A, Kraljević M, Mantziari S, Frey S, Gensthaler L, Sammalkorpi H, Garcia-Galocha JL, Zapata A, Tatarian T, Wiggins T, Bardisi E, Goreux JP, Seki Y, Vonlanthen R, Widmer J, Thalheimer A, Kasama K, Himpens J, Hollyman M, Welbourn R, Aggarwal R, Beekley A, Sepulveda M, Torres A, Juuti A, Salminen P, Prager G, Iannelli A, Suter M, Peterli R, Boza C, Rosenthal R, Higa K, Lannoo M, Hazebroek EJ, Dillemans B, Clavien PA, Puhan M, Raptis DA, Bueter M. Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures. Ann Surg 2021; 274:821-828. [PMID: 34334637 DOI: 10.1097/sla.0000000000005117] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To define "best possible" outcomes for secondary bariatric surgery (BS). BACKGROUND Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. METHODS Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years. RESULTS The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ± 10 years, 8.4 ± 5.3 years after primary BS, with a BMI 35.2 ± 7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. CONCLUSION Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.
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Affiliation(s)
- Daniel Gero
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Marie Vannijvel
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium
| | - Sietske Okkema
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, The Netherlands
| | - Ellen Deleus
- Department of General Surgery, University Hospital Leuven, Leuven, Belgium
| | - Aaron Lloyd
- Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, California
| | - Emanuele Lo Menzo
- The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - George Tadros
- The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Ivana Raguz
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Andres San Martin
- Bariatric and Metabolic Center, Department of Surgery, Clinica Las Condes, Las Condes, Santiago, Chile
| | - Marko Kraljević
- Department of Visceral Surgery, Clarunis: St.Clara Hosptital, Basel, Switzerland
| | - Styliani Mantziari
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
| | - Sebastien Frey
- Digestive Surgery and Liver Transplantation Unit, University Hospital Nice, University Côte d'Azur, Nice, France
| | - Lisa Gensthaler
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Henna Sammalkorpi
- Department ofGastroenterological Surgery, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - José Luis Garcia-Galocha
- Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain
| | - Amalia Zapata
- Bariatric and Metabolic Surgery Center, Dipreca Hospital, Las Condes, Santiago, Chile
| | - Talar Tatarian
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Tom Wiggins
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, UK
| | - Ekhlas Bardisi
- Department of Surgery, St Blasius Hospital, Dendermonde, Belgium
| | | | - Yosuke Seki
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - René Vonlanthen
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jeannette Widmer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Thalheimer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Kazunori Kasama
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Jacques Himpens
- Department of Surgery, St Blasius Hospital, Dendermonde, Belgium
- Department of Surgery, Delta CHIREC Hospital, Brussels, Belgium
- The European School of Laparoscopic Surgery, St Pierre University Hospital, Brussels, Belgium
| | - Marianne Hollyman
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, UK
| | - Richard Welbourn
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, UK
| | - Rajesh Aggarwal
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Alec Beekley
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Matias Sepulveda
- Bariatric and Metabolic Surgery Center, Dipreca Hospital, Las Condes, Santiago, Chile
| | - Antonio Torres
- Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain
| | - Anne Juuti
- Department ofGastroenterological Surgery, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | | | - Gerhard Prager
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Antonio Iannelli
- Digestive Surgery and Liver Transplantation Unit, University Hospital Nice, University Côte d'Azur, Nice, France
| | - Michel Suter
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
- Department of Surgery, Riviera-Chablais Hospital, Rennaz, Switzerland
| | - Ralph Peterli
- Department of Visceral Surgery, Clarunis: St.Clara Hosptital, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Camilo Boza
- Bariatric and Metabolic Center, Department of Surgery, Clinica Las Condes, Las Condes, Santiago, Chile
| | - Raul Rosenthal
- The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Kelvin Higa
- Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, California
| | - Matthias Lannoo
- Department of General Surgery, University Hospital Leuven, Leuven, Belgium
| | - Eric J Hazebroek
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, The Netherlands
| | - Bruno Dillemans
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Milo Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Dimitri A Raptis
- Department of Hepatobiliary and Pancreas Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Marco Bueter
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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Probst P, Hüttner FJ, Meydan Ö, Abu Hilal M, Adham M, Barreto SG, Besselink MG, Busch OR, Bockhorn M, Del Chiaro M, Conlon K, Castillo CFD, Friess H, Fusai GK, Gianotti L, Hackert T, Halloran C, Izbicki J, Kalkum E, Kelemen D, Kenngott HG, Kretschmer R, Landré V, Lillemoe KD, Miao Y, Marchegiani G, Mihaljevic A, Radenkovic D, Salvia R, Sandini M, Serrablo A, Shrikhande S, Shukla PJ, Siriwardena AK, Strobel O, Uzunoglu FG, Vollmer C, Weitz J, Wolfgang CL, Zerbi A, Bassi C, Dervenis C, Neoptolemos J, Büchler MW, Diener MK. Evidence Map of Pancreatic Surgery-A living systematic review with meta-analyses by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2021; 170:1517-1524. [PMID: 34187695 DOI: 10.1016/j.surg.2021.04.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 04/11/2021] [Accepted: 04/19/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pancreatic surgery is associated with considerable morbidity and, consequently, offers a large and complex field for research. To prioritize relevant future scientific projects, it is of utmost importance to identify existing evidence and uncover research gaps. Thus, the aim of this project was to create a systematic and living Evidence Map of Pancreatic Surgery. METHODS PubMed, the Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for all randomized controlled trials and systematic reviews on pancreatic surgery. Outcomes from every existing randomized controlled trial were extracted, and trial quality was assessed. Systematic reviews were used to identify an absence of randomized controlled trials. Randomized controlled trials and systematic reviews on identical subjects were grouped according to research topics. A web-based evidence map modeled after a mind map was created to visualize existing evidence. Meta-analyses of specific outcomes of pancreatic surgery were performed for all research topics with more than 3 randomized controlled trials. For partial pancreatoduodenectomy and distal pancreatectomy, pooled benchmarks for outcomes were calculated with a 99% confidence interval. The evidence map undergoes regular updates. RESULTS Out of 30,860 articles reviewed, 328 randomized controlled trials on 35,600 patients and 332 systematic reviews were included and grouped into 76 research topics. Most randomized controlled trials were from Europe (46%) and most systematic reviews were from Asia (51%). A living meta-analysis of 21 out of 76 research topics (28%) was performed and included in the web-based evidence map. Evidence gaps were identified in 11 out of 76 research topics (14%). The benchmark for mortality was 2% (99% confidence interval: 1%-2%) for partial pancreatoduodenectomy and <1% (99% confidence interval: 0%-1%) for distal pancreatectomy. The benchmark for overall complications was 53% (99%confidence interval: 46%-61%) for partial pancreatoduodenectomy and 59% (99% confidence interval: 44%-80%) for distal pancreatectomy. CONCLUSION The International Study Group of Pancreatic Surgery Evidence Map of Pancreatic Surgery, which is freely accessible via www.evidencemap.surgery and as a mobile phone app, provides a regularly updated overview of the available literature displayed in an intuitive fashion. Clinical decision making and evidence-based patient information are supported by the primary data provided, as well as by living meta-analyses. Researchers can use the systematic literature search and processed data for their own projects, and funding bodies can base their research priorities on evidence gaps that the map uncovers.
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Affiliation(s)
- Pascal Probst
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany; The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany.
| | - Felix J Hüttner
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany; The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany
| | - Ömer Meydan
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany
| | - Mohammed Abu Hilal
- HPB Department, Southampton General Hospital, Southampton, United Kingdom
| | | | - Savio G Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, Australia; College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Maximillian Bockhorn
- Department of General and Visceral Surgery, University Medical Center Oldenburg, Germany
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kevin Conlon
- Hepato-Pancreatico-Biliary Unit, Department of General Surgery, Trinity College Dublin, Tallaght Hospital, Ireland
| | | | - Helmut Friess
- Department of Hepato-Pancreato-Biliary Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Giuseppe Kito Fusai
- Institute for Liver and Digestive Health, University College London, United Kingdom
| | - Luca Gianotti
- Pancreatic Surgery Unit, School of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Christopher Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, United Kingdom
| | - Jakob Izbicki
- University Medical Center Hamburg-Eppendorf, Germany
| | - Eva Kalkum
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany
| | - Dezső Kelemen
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Hungary
| | - Hannes G Kenngott
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Rüdiger Kretschmer
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany
| | - Vincent Landré
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and the Harvard Medical School, Boston, MA
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, China
| | - Giovanni Marchegiani
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - André Mihaljevic
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany; The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany
| | - Dejan Radenkovic
- Department of Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Serbia
| | - Roberto Salvia
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Marta Sandini
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Alejandro Serrablo
- Hepatobiliopancreatic Surgery Unit, General and Digestive Surgery Service, Hospital Miguel Servet, Zaragoza, Spain
| | | | - Parul J Shukla
- Weill Cornell Medical College & New York Presbyterian Hospital, NY
| | - Ajith K Siriwardena
- Department of Surgery, Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, United Kingdom
| | - Oliver Strobel
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | | | - Charles Vollmer
- Department of Surgery, Penn Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jürgen Weitz
- Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | | | - Alessandro Zerbi
- Pancreatic Surgery, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy; Humanitas University, Pieve Emanuele (MI), Italy
| | - Claudio Bassi
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | | | - John Neoptolemos
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany; The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany. https://twitter.com/evidencemap
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Holmberg M, Ghorbani P, Gilg S, Del Chiaro M, Arnelo U, Löhr JM, Sparrelid E. Outcome after resection for invasive intraductal papillary mucinous neoplasia is similar to conventional pancreatic ductal adenocarcinoma. Pancreatology 2021; 21:1371-1377. [PMID: 34426077 DOI: 10.1016/j.pan.2021.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/31/2021] [Accepted: 07/31/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Resections for intraductal papillary mucinous neoplasm (IPMN) have increased last decades. Overall survival (OS) for conventional pancreatic ductal adenocarcinoma (PDAC) is well known but OS for invasive IPMN (inv-IPMN) is not as conclusive. This study aims to elucidate potential differences in clinicopathology and OS between these tumor types and to investigate if the raised number of resections have affected outcome. METHODS Consecutive patients ≥18 years of age resected for inv-IPMN and PDAC at Karolinska University Hospital between 2009 and 2018 were included. Clinicopathological variables were analyzed in multivariable regression models. Outcome was assessed calculating two-year OS, estimating OS using the Kaplan-Meier model and comparing survival functions with log-rank test. RESULTS 513 patients were included, 122 with inv-IPMN and 391 with PDAC. During the study period both the proportion resected inv-IPMN and two-year OS, irrespective of tumor type, increased (2.5%-45%; p < 0.001 and 44%-57%; p = 0.005 respectively). In Kaplan-Meier survival analysis inv-IPMN had more favorable median OS (mOS) compared to PDAC (33.6 months vs 19.3 months, p = 0.001). However, in multivariable Cox Regression analysis, tumor type was not a predictor for death, but so were resection period, tumor subtype and N-stage (all p < 0.001). CONCLUSION In this large single center observational cohort study, inv-IPMN seemed to have favorable survival outcome compared to PDAC, but after adjusting for predictors for death this benefit vanished. The combination of a pronounced increase in resected inv-IPMN and a concurrent hazard abatement for death within 2 years during the study period proved to be a principal factor.
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Affiliation(s)
- Marcus Holmberg
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden.
| | - Poya Ghorbani
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
| | - Stefan Gilg
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, USA
| | - Urban Arnelo
- Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden; Department of Surgical and Perioperative Sciences/Surgery, Umeå University, Umeå, Sweden
| | - J-Matthias Löhr
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
| | - Ernesto Sparrelid
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
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Beane JD, Borrebach JD, Zureikat AH, Kilbane EM, Thompson VM, Pitt HA. Optimal Pancreatic Surgery: Are We Making Progress in North America? Ann Surg 2021; 274:e355-e363. [PMID: 31663969 DOI: 10.1097/sla.0000000000003628] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Our aims were to assess North American trends in the management of patients undergoing pancreatoduodenectomy (PD) and distal pancreatectomy (DP), and to quantify the delivery of optimal pancreatic surgery. BACKGROUND Morbidity after pancreatectomy remains unacceptably high. Recent literature suggests that composite measures may more accurately define surgical quality. METHODS The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program Participant Use Files were queried to identify patients undergoing PD (N = 16,222) and DP (N = 7946). Patient, process, procedure, and 30-day postoperative outcome variables were analyzed over time. Optimal pancreatic surgery was defined as the absence of postoperative mortality, serious morbidity, percutaneous drainage, and reoperation while achieving a length of stay equal to or less than the 75th percentile (12 days for PD and 7 days for DP) with no readmissions. Risk-adjusted time-trend analyses were performed using logistic regression, and the threshold for statistical significance was P ≤ 0.05. RESULTS The use of minimally invasive PD did not change over time, but robotic PD increased (2.5 to 4.2%; P < 0.001) and laparoscopic PD decreased (5.8% to 4.3%; P < 0.02). Operative times decreased (P < 0.05) and fewer transfusions were administered (P < 0.001). The percentage of patients with a drain fluid amylase checked on postoperative day 1 increased (P < 0.001), and a greater percentage of surgical drains were removed by postoperative day 3 (P < 0.001). Overall morbidity (P < 0.02), mortality (P < 0.05), and postoperative length of stay (P = 0.002) decreased. Finally, the rate of optimal pancreatic surgery increased for PD (53.7% to 56.9%; P < 0.01) and DP (53.3% to 58.5%; P < 0.001), and alspo for patients with pancreatic cancer (P < 0.01). CONCLUSIONS From 2013 to 2017, pre, intra, and perioperative pancreatectomy processes have evolved, and multiple postoperative outcomes have improved. Thus, in 4 years, optimal pancreatic surgery in North America has increased by 3% to 5%.
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Affiliation(s)
- Joal D Beane
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | | | | | - Henry A Pitt
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA
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Open pancreaticoduodenectomy: setting the benchmark of time to functional recovery. Langenbecks Arch Surg 2021; 407:1083-1089. [PMID: 34557940 PMCID: PMC9151571 DOI: 10.1007/s00423-021-02333-3] [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: 06/09/2021] [Accepted: 09/14/2021] [Indexed: 12/02/2022]
Abstract
Purpose No accepted benchmarks for open pancreaticoduodenectomy (PD) exist. The study assessed the time to functional recovery after open PD and how this could be affected by the magnitude of midline incision (MI). Materials and methods Prospective snapshot study during 1 year. Time to functional recovery (TtFR) was assessed for the entire cohort. Further analyses were conducted after excluding patients developing a Clavien-Dindo ≥ 2 morbidity and after stratifying for the relative length of MI. Results The overall median TtFR was 7 days (n = 249), 6 days for uncomplicated patients (n = 124). A short MI (SMI, < 60% of xipho-pubic distance, n = 62) was compared to a long MI (LMI, n = 62) in uncomplicated patients. The choice of a SMI was not affected by technical issues and provided a significantly shorter TtFR (5 vs 6 days, p = 0.002) especially for pain control (4 vs. 5 days, p = 0.048) and oral food intake (5 vs. 6 days, p = 0.001). Conclusion Functional recovery after open PD with MI is achieved within 1 week from surgery in half of the patients. This should be the appropriate benchmark for comparison with minimally invasive PD. Moreover, PD with a SMI is feasible, safe, and associated with a faster recovery. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02333-3.
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Tjaden C, Sandini M, Mihaljevic AL, Kaiser J, Khristenko E, Mayer P, Hinz U, Gaida MM, Berchtold C, Diener MK, Schneider M, Mehrabi A, Müller-Stich BP, Strobel O, Hackert T, Büchler MW. Risk of the Watch-and-Wait Concept in Surgical Treatment of Intraductal Papillary Mucinous Neoplasm. JAMA Surg 2021; 156:818-825. [PMID: 34009233 DOI: 10.1001/jamasurg.2021.0950] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance The natural history of intraductal papillary mucinous neoplasms (IPMNs) remains uncertain. The inconsistencies among published guidelines preclude accurate decision-making. The outcomes and potential risks of a conservative watch-and-wait approach vs a surgical approach must be compared. Objective To provide an overview of the surgical management of IPMNs, focusing on the time of resection. Design, Setting, and Participants This cohort study was conducted in a single referral center; all patients with pathologically proven IPMN who received a pancreatic resection at the institution between October 2001 and December 2019 were analyzed. Preoperatively obtained images and the medical history were scrutinized for signs of progression and/or malignant features. The timeliness of resection was stratified into too early (adenoma and low-grade dysplasia), timely (intermediate-grade dysplasia and in situ carcinoma), and too late (invasive cancer). The perioperative characteristics and outcomes were compared between these groups. Exposures Timeliness of resection according to the final pathological findings. Main Outcomes and Measures The risk of malignant transformation at the final pathology. Results Of 1439 patients, 438 (30.4%) were assigned to the too early group, 504 (35.1%) to the timely group, and 497 (34.5%) to the too late group. Radiological criteria for malignant conditions were detected in 53 of 382 patients (13.9%), 149 of 432 patients (34.5%), and 341 of 385 patients (88.6%) in the too early, timely, and too late groups, respectively (P < .001). Patients in the too early group underwent more parenchyma-sparing resections (too early group, 123 of 438 [28.1%]; timely group, 40 of 504 [7.9%]; too late group, 5 of 497 [1.0%]; P < .001), while morbidity (too early group, 112 of 438 [25.6%]; timely group, 117 of 504 [23.2%]; too late group, 158 of 497 [31.8%]; P = .002) and mortality (too early group, 4 patients [0.9%]; timely, 4 [0.8%]; too late, 13 [2.6%]; P = .03) were highest in the too late group. Of the 497 patients in the too late group, 124 (24.9%) had a previous history of watch-and-wait care. Conclusions and Relevance Until the biology and progression patterns of IPMN are clarified and accurate guidelines established, a watch-and-wait policy should be applied with caution, especially in IPMN bearing a main-duct component. One-third of IPMNs reach the cancer stage before resection. At specialized referral centers, the risks of surgical morbidity and mortality are justifiable.
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Affiliation(s)
- Christine Tjaden
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Marta Sandini
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jörg Kaiser
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Philipp Mayer
- Department of Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias M Gaida
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany.,Institute for Pathology, University Medical Center, Mainz, Germany
| | - Christoph Berchtold
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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146
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van Dongen JC, Wismans LV, Suurmeijer JA, Besselink MG, de Wilde RF, Groot Koerkamp B, van Eijck CHJ. The effect of preoperative chemotherapy and chemoradiotherapy on pancreatic fistula and other surgical complications after pancreatic resection: a systematic review and meta-analysis of comparative studies. HPB (Oxford) 2021; 23:1321-1331. [PMID: 34099372 DOI: 10.1016/j.hpb.2021.04.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative chemo- or chemoradiotherapy is recommended for borderline-resectable pancreatic cancer. The aim of this study was to determine the impact of preoperative therapy on surgical complications in patients with resected pancreatic cancer. METHODS This systematic review and meta-analysis included studies reporting on the rate of surgical complications after preoperative chemo- or chemoradiotherapy versus immediate surgery in pancreatic cancer patients. The primary endpoint was the rate of grade B/C POPF. Pooled odds ratios were calculated using random-effects models. RESULTS Forty-one comparative studies including 25,389 patients were included. Vascular resections were more often performed after preoperative therapy (29.4% vs. 15.7%, p < 0.001). Preoperative therapy was associated with a lower rate of grade B/C POPF as compared to immediate surgery (pooled OR 0.47, 95%CI 0.38-0.58). This reduction was mostly obtained by preoperative chemoradiotherapy (OR 0.46, 95%CI 0.29-0.73), but not by preoperative chemotherapy alone (OR 0.83, 95%CI 0.59-1.16). No difference was demonstrated for major morbidity, mortality, postpancreatectomy haemorrhage, delayed gastric emptying and overall morbidity. CONCLUSION Preoperative chemo- and chemoradiotherapy in patients with pancreatic cancer appears to be safe with respect to POPF and other surgical complications as compared to immediate surgery. The reduced rate of POPF appears to be attributable to preoperative chemoradiation.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Leonoor V Wismans
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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147
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Giani A, Mazzola M, Morini L, Zironda A, Bertoglio CL, De Martini P, Magistro C, Ferrari G. Hepatic vascular anomalies during totally laparoscopic pancreaticoduodenectomy: challenging the challenge. Updates Surg 2021; 74:583-590. [PMID: 34406616 DOI: 10.1007/s13304-021-01152-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/11/2021] [Indexed: 12/18/2022]
Abstract
The presence of hepatic vascular anomalies may add challenges to an already difficult surgery such as pancreatoduodenectomy, particularly when performed laparoscopically. Thus, our aim was to assess the impact of an aberrant right hepatic artery (aRHA) on postoperative outcomes during laparoscopic pancreatoduodenectomy (LPD) . Data of patients who underwent LPD were prospectively gathered and retrospectively analyzed. Patients with types III, IV, VI, VII, VIII, and IX anomalies according to Michels' classification were included in the aRHA group and were compared with the remaining patients (nRHA group). 72 patients underwent LPD; 14 of these had an aRHA (19.4%). Except for BMI (p = 0.021), the two groups did not differ in terms of clinico-pathological characteristics. The two groups had similar postoperative complications (p = 0.123), pancreatic fistula (p = 0.790), biliary leakage (p = 0.209), postpancreatectomy hemorrhage (p = 0.790), reoperations (p = 0.416), and mortality (p = 0.312). The median number of lymph nodes harvested was higher in aRHA group (p = 0.032), while R0 resection rate was similar between groups (p = 0.635). At the multivariate analysis, only moderate/high FRS (OR 3.95, p = 0.039) was an independent predictor of postoperative complications. This study suggests that aRHA has no negative impact on surgical and oncological outcomes in patients undergoing LPD.
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Affiliation(s)
- Alessandro Giani
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy.
| | - Michele Mazzola
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Lorenzo Morini
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Andrea Zironda
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Camillo Leonardo Bertoglio
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Paolo De Martini
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Carmelo Magistro
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Giovanni Ferrari
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
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Mazzola M, Giani A, Crippa J, Morini L, Zironda A, Bertoglio CL, De Martini P, Magistro C, Ferrari G. Totally Laparoscopic Pancreaticoduodenectomy: Comparison Between Early and Late Phase of an Initial Single-Center Learning Curve. Indian J Surg Oncol 2021; 12:688-698. [DOI: 10.1007/s13193-021-01422-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 08/09/2021] [Indexed: 12/25/2022] Open
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149
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Perihilar Cholangiocarcinoma-Novel Benchmark Values for Surgical and Oncological Outcomes From 24 Expert Centers. Ann Surg 2021; 274:780-788. [PMID: 34334638 DOI: 10.1097/sla.0000000000005103] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to define robust benchmark values for the surgical treatment of perihilar cholangiocarcinomas (PHC) to enable unbiased comparisons. BACKGROUND Despite ongoing efforts, postoperative mortality and morbidity remains high after complex liver surgery for PHC. Benchmark data of best achievable results in surgical PHC treatment are however still lacking. METHODS This study analyzed consecutive patients undergoing major liver surgery for PHC in 24 high-volume centers in 3 continents over the recent 5-year period (2014-2018) with a minimum follow-up of 1 year in each patient. Benchmark patients were those operated at high volume centers (≥50 cases during the study period) without the need for vascular reconstruction due to tumor invasion, or the presence of significant co-morbidities such as severe obesity (body mass index >35), diabetes, or cardiovascular diseases. Benchmark cutoff values were derived from the 75th or 25th percentile of the median values of all benchmark centers. RESULTS Seven hundred eight (39%) of a total of 1829 consecutive patients qualified as benchmark cases. Benchmark cut-offs included: R0 resection ≥57%, postoperative liver failure (International Study Group of Liver Surgery): ≤35%; in-hospital and 3-month mortality rates ≤8% and ≤13%, respectively; 3-month grade 3 complications and the CCI: ≤70% and ≤30.5, respectively; bile leak-rate: ≤47% and 5-year overall survival of ≥39.7%. Centers operating mostly on complex cases disclosed better outcome including lower post-operative liver failure rates (4% vs 13%; P = 0.002). Centers from Asia disclosed better outcomes. CONCLUSION Surgery for PHC remains associated with high morbidity and mortality with now the availability of benchmark values covering 21 outcome parameters, which may serve as key references for comparison in any future analyses of individuals, group of patients or centers.
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150
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Lapisatepun W, Wongsa W, Chanthima P, Junrungsee S, Lapisatepun W. Higher cumulative fluid follows a pancreaticoduodenectomy as a single modifiable factor for post-operative pancreatic fistula: Risk factor analysis. Asian J Surg 2021; 45:401-406. [PMID: 34315667 DOI: 10.1016/j.asjsur.2021.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is one of the major complications after pancreaticoduodenectomy. There have been many studies into the risk factors determining POPF. Some studies have reported a higher peri-operative fluid balance associated with POPF, however, the pertinent findings remain controversial. The aims of this study were to determine risk factors of clinically relevant-post operative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy and an association between peri-operative fluid balance and the incidence of CR-POPF. MATERIALS AND METHODS This is a retrospective cohort study included all adult patients who underwent an elective open pancreaticoduodenectomy in our center from 2005 to 2018. Patients who did not have POPF related data were excluded from study. We divided patients into CR-POPF and no CR-POPF group. Peri-operative data including amount and type of fluid were compared between two groups. Logistic regression analysis was used to identify the independent risk factors of CR-POPF. RESULTS There were 223 pancreaticoduodenectomies done in our center during that period. The incidence of CR-POPF was 15.2 %. Patients in CR-POPF group had significant higher BMI, higher serum globulin level, smaller pancreatic duct diameter and higher cumulative fluid balance per body weight (FBPBW) at post-operative day 3. Multivariable analysis showed BMI >23 kg/m2, diagnosis other than pancreatic duct adenocarcinoma or chronic pancreatitis and higher cumulative FBPBW at post-operative day 3 were the independent risk factors for CR-POPF. CONCLUSIONS Post-operative fluid balance was the post-operative modifiable risk factor to reduce CR-POPF. Higher positive post-operative fluid balance should be avoided especially in higher CR-POPF risk patients.
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Affiliation(s)
- Warangkana Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Weerapong Wongsa
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Phuriphong Chanthima
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Sunhawit Junrungsee
- Division of Hepatobiliary and pancreatic surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Worakitti Lapisatepun
- Division of Hepatobiliary and pancreatic surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
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