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Justo Alonso I, Marcacuzco Quinto A, Caso Maestro O, Alonso Murillo L, Rioja Conde P, Fernández Fernández C, Jiménez Romero C. Whipple's cephalic pancreaticoduodenectomy versus pyloric-preserving pancreaticoduodenectomy. Retrospective study. Cir Esp 2024; 102:265-274. [PMID: 38493929 DOI: 10.1016/j.cireng.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/07/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Controversy exists in the literature as to the best technique for pancreaticoduodenectomy (PD), whether pyloric preservation (PP-CPD) or Whipple's technique (with antrectomy [W-CPD]), the former being associated with a higher frequency of delayed gastric emptying (DGE). METHODS Retrospective and comparative study between PP-CPD technique (n = 124 patients) and W-CPD technique (n = 126 patients), in patients who were operated for tumors of the pancreatic head and periampullary region between the period 2012 and 2023. RESULTS Surgical time was longer, although not significant, with the W-CPD technique. Pancreatic and peripancreatic tumor invasion (p = 0.031) and number of lymph nodes resected (p < 0.0001) reached statistical significance in W-CPD, although there was no significant difference between the groups in terms of lymph node tumor invasion. Regarding postoperative morbimortality (medical complications, postoperative pancreatic fistula [POPF], hemorrhage, RVG, re-interventions, in-hospital mortality, Clavien-Dindo complications), ICU and hospital stay, no statistically significant differences were observed between the groups. During follow-up, no significant differences were observed between the groups for morbidity and mortality at 90 days and survival at 1, 3 and 5 years. Binary logistic regression analysis for DGE showed that binary relevant POPF grade B/C was a significant risk factor for DGE. CONCLUSIONS Postoperative morbidity and mortality and long-term survival were not significantly different with PP-CPD and W-CPD, but POPF grade B/C was a risk factor for DGE grade C.
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Affiliation(s)
- Iago Justo Alonso
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Alberto Marcacuzco Quinto
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Oscar Caso Maestro
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Laura Alonso Murillo
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Paula Rioja Conde
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Clara Fernández Fernández
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Carlos Jiménez Romero
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain.
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Russell TB, Labib PL, Denson J, Streeter A, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Croagh D, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh BA, Serrablo A, Aroori S. Postoperative complications after pancreatoduodenectomy for malignancy: results from the Recurrence After Whipple's (RAW) study. BJS Open 2023; 7:zrad106. [PMID: 38036696 PMCID: PMC10689345 DOI: 10.1093/bjsopen/zrad106] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 08/04/2023] [Accepted: 08/27/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is associated with significant postoperative morbidity. Surgeons should have a sound understanding of the potential complications for consenting and benchmarking purposes. Furthermore, preoperative identification of high-risk patients can guide patient selection and potentially allow for targeted prehabilitation and/or individualized treatment regimens. Using a large multicentre cohort, this study aimed to calculate the incidence of all PD complications and identify risk factors. METHOD Data were extracted from the Recurrence After Whipple's (RAW) study, a retrospective cohort study of PD outcomes (29 centres from 8 countries, 2012-2015). The incidence and severity of all complications was recorded and potential risk factors for morbidity, major morbidity (Clavien-Dindo grade > IIIa), postoperative pancreatic fistula (POPF), post-pancreatectomy haemorrhage (PPH) and 90-day mortality were investigated. RESULTS Among the 1348 included patients, overall morbidity, major morbidity, POPF, PPH and perioperative death affected 53 per cent (n = 720), 17 per cent (n = 228), 8 per cent (n = 108), 6 per cent (n = 84) and 4 per cent (n = 53), respectively. Following multivariable tests, a high BMI (P = 0.007), an ASA grade > II (P < 0.0001) and a classic Whipple approach (P = 0.005) were all associated with increased overall morbidity. In addition, ASA grade > II patients were at increased risk of major morbidity (P < 0.0001), and a raised BMI correlated with a greater risk of POPF (P = 0.001). CONCLUSION In this multicentre study of PD outcomes, an ASA grade > II was a risk factor for major morbidity and a high BMI was a risk factor for POPF. Patients who are preoperatively identified to be high risk may benefit from targeted prehabilitation or individualized treatment regimens.
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Affiliation(s)
- Thomas B Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Peter L Labib
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jemimah Denson
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Adam Streeter
- Department of Medical Statistics, University of Muenster, Muenster, Germany
- Department of Medical Statistics, University of Plymouth, Plymouth, UK
| | - Fabio Ausania
- Department of HPB Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Elizabeth Pando
- Department of HPB Surgery, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Keith J Roberts
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ambareen Kausar
- Department of HPB Surgery, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Vasileios K Mavroeidis
- Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Department of HPB Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Gabriele Marangoni
- Department of HPB Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | | | - Adam E Frampton
- Department of HPB Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Pavlos Lykoudis
- Department of HPB Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Manuel Maglione
- Department of HPB Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nassir Alhaboob
- Department of HPB Surgery, Ibn Sina Specialized Hospital, Khartoum, Sudan
| | - Hassaan Bari
- Department of HPB Surgery, Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | - Andrew M Smith
- Department of HPB Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Duncan Spalding
- Department of HPB Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Parthi Srinivasan
- Department of HPB Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Brian R Davidson
- Department of HPB Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Ricky H Bhogal
- Department of HPB Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Daniel Croagh
- Department of HPB Surgery, Monash Medical Centre, Melbourne, Australia
| | - Ismael Dominguez
- Department of HPB Surgery, Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Department of HPB Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dhanny Gomez
- Department of HPB Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Department of HPB Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Pierfrancesco Lapolla
- Department of HPB Surgery, Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Andrea Mingoli
- Department of HPB Surgery, Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Department of HPB Surgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Department of HPB Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- Department of HPB Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bilal A Al-Sarrieh
- Department of HPB Surgery, Swansea Bay University Health Board, Swansea, UK
| | - Alejandro Serrablo
- Department of HPB Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Gorji L, Beal EW. Surgical Treatment of Distal Cholangiocarcinoma. Curr Oncol 2022; 29:6674-6687. [PMID: 36135093 PMCID: PMC9498206 DOI: 10.3390/curroncol29090524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 12/03/2022] Open
Abstract
Distal cholangiocarcinoma (dCCA) is a rare malignancy arising from the epithelial cells of the distal biliary tract and has a poor prognosis. dCCA is often clinically silent and patients commonly present with locally advanced and/or distant disease. For patients identified with early stage, resectable disease, surgical resection with negative margins remains the only curative treatment strategy available. However, despite appropriate treatment and diligent surveillance, risk of recurrence remains high with nearly 50% of patients experiencing recurrence at 5 years subsequent to surgical resection; therefore, it is prudent to continue to optimize neoadjuvant and adjuvant therapies in order to reduce the risk of recurrence and improve overall survival. In this review, we discuss the clinical presentation, workup and surgical treatment of dCCA.
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Affiliation(s)
- Leva Gorji
- Department of Surgery, Kettering Health Dayton, Dayton, OH 45405, USA
| | - Eliza W. Beal
- Departments of Oncology and Surgery, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 48201, USA
- Correspondence:
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Busquets J, Martín S, Secanella L, Sorribas M, Cornellà N, Altet J, Peláez N, Bajen M, Carnaval T, Videla S, Fabregat J. Delayed gastric emptying after classical Whipple or pylorus-preserving pancreatoduodenectomy: a randomized clinical trial (QUANUPAD). Langenbecks Arch Surg 2022; 407:2247-2258. [PMID: 35786739 PMCID: PMC9468034 DOI: 10.1007/s00423-022-02583-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 06/04/2022] [Indexed: 10/29/2022]
Abstract
PURPOSE Pylorus-preserving pancreatoduodenectomy (PPPD) has been the gold standard for pancreatic head lesion resection for several years. Some studies have noted that it involves more delayed gastric emptying (DGE) than classical Whipple (i.e., pancreatoduodenectomy with antrectomy). Our working hypothesis was that the classical Whipple has a lower incidence of DGE. We aimed to compare the incidence of DGE among pancreatoduodenectomy techniques. METHODS This pragmatic, randomized, open-label, single-center clinical trial involved patients who underwent classical Whipple (study group) or PPPD (control group). Gastric emptying was clinically evaluated using scintigraphy. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria. The secondary endpoints were postoperative morbidity, length of hospital stay, anthropometric measurements, and nutritional status. RESULTS A total of 84 patients were randomized (42 per group). DGE incidence was 50% (20/40, 95% confidence interval (95% CI): 35-65%) in the study group and 62% (24/39, 95% CI: 46-75%) in the control group (p = 0.260). No differences were observed between both groups regarding postoperative morbidity or length of hospital stay. Anthropometric measurements at 6 months post-surgery: triceps fold measurements were 12 mm and 16 mm (p = 0.021). At 5 weeks post-surgery, triceps fold measurements were 13 mm and 16 mm (p = 0.020) and upper arm circumferences were 26 cm and 28 cm (p = 0.030). No significant differences were observed in nutritional status. CONCLUSION DGE incidence and severity did not differ between classical Whipple and PPPD. Some anthropometric measurements may indicate a better recovery with PPPD. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03984734.
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Affiliation(s)
- J Busquets
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain. .,Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain.
| | - S Martín
- General and Digestive Surgery Service, Viladecans Hospital, Viladecans, Spain
| | - Ll Secanella
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - M Sorribas
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - N Cornellà
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - J Altet
- General and Digestive Surgery Service, Mar Hospital, Barcelona, Spain
| | - N Peláez
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - M Bajen
- Department of Nuclear Medicine, Bellvitge University Hospital, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - T Carnaval
- Clinical Research Support Unit (HUB·IDIBELL), Clinical Pharmacology Department, Bellvitge University Hospital, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - S Videla
- Clinical Research Support Unit (HUB·IDIBELL), Clinical Pharmacology Department, Bellvitge University Hospital, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain.,Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - J Fabregat
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain.,Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain
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Barreto SG. Classical or pylorus-preserving pancreatoduodenectomy in pancreatic and periampullary cancer: "The jury is still out!". Indian J Med Paediatr Oncol 2021; 37:209-210. [PMID: 28144083 PMCID: PMC5234153 DOI: 10.4103/0971-5851.195747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Savio George Barreto
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta - The Medicity, Sector 38, Gurgaon, Haryana, India. E-mail:
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Deo KB, Kulkarni AA, Kumar-M P, Krishnamurthy G, Shenvi S, Rana SS, Kapoor R, Gupta R. Impact of diabetes mellitus on morbidity and survival after pancreaticoduodenectomy for malignancy. Ann Hepatobiliary Pancreat Surg 2021; 25:230-241. [PMID: 34053926 PMCID: PMC8180397 DOI: 10.14701/ahbps.2021.25.2.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/17/2021] [Accepted: 02/01/2021] [Indexed: 11/22/2022] Open
Abstract
Backgrounds/Aims Diabetes mellitus (DM) is a known risk factor for morbidity, length of hospital stay, or mortality after surgery, however, its impact on postoperative course and long-term survival after pancreaticoduodenectomy (PD) is not clear. Methods This is a retrospective analysis of prospectively maintained database of 141 patients with periampullary and pancreatic head adenocarcinoma operated between January 2001 and March 2019. Clinico-pathological records and follow-up data were retrieved and analyzed. Cumulative hazard was computed for comparing the survival between DM and non-DM. Results DM was present in 31/141 (21.9%) patients, while 16/31 (51.6%). were new-onset DM (NODM). Tumor size, lymphovascular & perineural invasion, type of surgery, lymph node positivity and R0 resection rate were comparable between diabetic and non-diabetic. There was no significant difference in postoperative pancreatic fistula, delayed gastric emptying, infectious complication, hospital stay and mortality between DM and nondiabetics. Patients with DM had worse survival at 3 years (OS: HR, 3.11 [1.43-6.76] p=0.004, DFS: HR, 2.61 [1.23-5.53] p=0.01) and 5 years (OS: HR, 3.32 [1.46-7.53] p=0.004, DFS: HR, 2.87 [1.29-6.41] p=0.009). On multivariate analysis, DM (3 year OS: HR, 2.61 [1.14-5.98] p=0.022, DFS: HR, 2.19; p=0.058) (5 year OS: HR, 2.55; p=0.04, DFS: HR, 2.25; p=0.068) and pylorus resecting surgery were significantly associated with worse survival at 3 and 5 years. Conclusions Preoperative DM has no significant effect on postoperative course but has negative impact on 3-year and 5-year OS and DFS after PD for pancreatic and periampullary adenocarcinoma.
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Affiliation(s)
- Kunal Bikram Deo
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.,Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Aditya Atul Kulkarni
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.,Department of Surgical Gastroenterology, D Y Patil Medical College, Pune, India
| | - Praveen Kumar-M
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Gautham Krishnamurthy
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.,Department of Surgical Gastroenterology, SRM Institutes for Medical Science, Chennai, India
| | - Sunil Shenvi
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.,Department of Liver Transplantation and Hepatobiliary Surgery, Gleneagles Global Hospital, Bangalore, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rakesh Kapoor
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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147 Pancreatoduodenectomies: a Single Center's Perspective into the Epidemiology and Surgical Outcomes of Periampullary and Pancreatic Cancers in South India. J Gastrointest Cancer 2020; 52:1035-1045. [PMID: 33051795 DOI: 10.1007/s12029-020-00534-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is the only curative procedure for resectable periampullary cancers. This study aims to survey the various outcome variables of the procedure at our institute, which is in the early process of evolving into a high-volume center for PDs. METHODS Data of patients, who underwent PDs, was collected retrospectively from January 2010 to December 2017 and prospectively from January 2018 to December 2019. Various preoperative, intraoperative, and histopathological parameters were compared with the outcome variables-morbidity and mortality rates. RESULTS A total of 147 patients underwent PDs over the last decade. From January 2010 to December 2014 (period A), 29 patients underwent PD, while 118 patients underwent PD from January 2015 to December 2019 (period B). Clinically relevant (CR) delayed gastric emptying (44.8% vs 23.7%), CR post-pancreatectomy hemorrhage (37.9% vs 18.6%), and blood loss (850 ml (400-5300 ml) vs 600 ml (150-2500 ml)) improved in period B with no improvement in CR postoperative pancreatic fistula (20.7% vs 28.8%). The rates of SSI (63.6%), pulmonary complications (29.9%), and mean postoperative stay (19.87 ± 11.59 days) were found to be higher than most of the major centers. Mortality rates decreased significantly from 27.6% in period A to 10.2% in period B (p = 0.029). Median overall survival was 30 months (95% CI 20.76-39.23 months) CONCLUSION: Over the last decade, there has been a significant improvement in the mortality rate, but morbidity remains high and must be looked into as the department enters the new decade as a young high-volume center.
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Deng Y, He S, Cheng Y, Cheng N, Gong J, Gong J, Zeng Z, Zhao L. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. Cochrane Database Syst Rev 2020; 3:CD009621. [PMID: 32157697 PMCID: PMC7064369 DOI: 10.1002/14651858.cd009621.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants have been used in some centers to reduce postoperative pancreatic fistula. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2018. OBJECTIVES To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. SEARCH METHODS We searched trial registers and the following biomedical databases: the Cochrane Library (2019, Issue 2), MEDLINE (1946 to 13 March2019), Embase (1980 to 11 March 2019), Science Citation Index Expanded (1900 to 13 March 2019), and Chinese Biomedical Literature Database (CBM) (1978 to 13 March 2019). SELECTION CRITERIA We included all randomised controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). MAIN RESULTS We included 12 studies involving 1604 participants in the review. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included seven studies involving 860 participants: 428 were randomised to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence) or length of hospital stay (MD 0.99 days, 95% CI -1.83 to 3.82; 371 participants; two studies; very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included four studies involving 393 participants: 186 were randomised to the fibrin sealant group and 207 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (16.7% versus 11.7%; RR 1.14, 95% CI 0.28 to 4.69; 199 participants; two studies; very low-quality evidence). We are uncertain whether fibrin sealants reduce postoperative mortality (0.5% versus 2.4%; Peto OR 0.26, 95% CI 0.05 to 1.32; 393 participants; four studies; low-quality evidence) or length of hospital stay (MD 0.01 days, 95% CI -3.91 to 3.94; 323 participants; three studies; very low-quality evidence). There is probably little or no difference in overall postoperative morbidity (52.6% versus 50.3%; RR 1.04, 95% CI 0.87 to 1.24; 323 participants; three studies; moderate-quality evidence) between the groups. We are uncertain whether fibrin sealants reduce reoperation rate (5.2% versus 7.7%; RR 0.74, 95% CI 0.33 to 1.66; 323 participants; three studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two studies involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (median 16 to 17 days versus 17 days; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study (169 participants; low-quality evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness. AUTHORS' CONCLUSIONS Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Yilei Deng
- The First Affiliated Hospital of Zhengzhou UniversityDepartment of Hepatopancreatobiliary SurgeryNo. 1, Jianshe East RoadZhengzhouHenan ProvinceChina450000
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo. 1 Yixue RoadChongqingChina450000
| | - Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryNo. 74, Lin Jiang Road, ChongqingChongqingChina400010
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryNo. 74, Lin Jiang Road, ChongqingChongqingChina400010
| | - Junhua Gong
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingYunnanChina650032
| | - Zhong Zeng
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingYunnanChina650032
| | - Longshuan Zhao
- The First Affiliated Hospital of Zhengzhou UniversityDepartment of Hepatopancreatobiliary SurgeryNo. 1, Jianshe East RoadZhengzhouHenan ProvinceChina450000
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9
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Cheng Y, He S, Xia J, Ding X, Liu Z, Gong J. Duct-to-mucosa pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Hippokratia 2019. [DOI: 10.1002/14651858.cd013462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Sirong He
- Chongqing Medical University; Department of Immunology, College of Basic Medicine; No. 1 Yixue Road Chongqing China 450000
| | - Jie Xia
- Chongqing Medical University; The Key Laboratory of Molecular Biology on Infectious Diseases; Chongqing China 450000
| | - Xiong Ding
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
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10
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Hu Y, Johnston LE, Shami VM, Bauer TW, Adams RB, Stukenborg GJ, Zaydfudim VM. Comparative Effectiveness of Resection vs Surveillance for Pancreatic Branch Duct Intraductal Papillary Mucinous Neoplasms With Worrisome Features. JAMA Surg 2019; 153:225-232. [PMID: 29167899 DOI: 10.1001/jamasurg.2017.4587] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Yinin Hu
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - Lily E. Johnston
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - Vanessa M. Shami
- Department of Gastroenterology, University of Virginia School of Medicine, Charlottesville
| | - Todd W. Bauer
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - Reid B. Adams
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - George J. Stukenborg
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville,Surgical Outcomes Research Center, University of Virginia School of Medicine, Charlottesville
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia School of Medicine, Charlottesville,Surgical Outcomes Research Center, University of Virginia School of Medicine, Charlottesville
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11
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Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains a dismal prognosis and surgery is the only chance for cure. However, only few of the patients have localized tumor eligible for curative complete resection. Preoperative management and well-staging of the disease are the cornerstone for appropriate surgery and major issues to define the best therapeutic strategy. This review focuses on the surgical and optimal perioperative management of PDAC and summarizes updates data on the subject.
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12
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Gong J, He S, Cheng Y, Cheng N, Gong J, Zeng Z. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. Cochrane Database Syst Rev 2018; 6:CD009621. [PMID: 29934987 PMCID: PMC6513198 DOI: 10.1002/14651858.cd009621.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2016. OBJECTIVES To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. SEARCH METHODS We searched trial registers and the following biomedical databases: the Cochrane Library (2018, Issue 4), MEDLINE (1946 to 12 April 2018), Embase (1980 to 12 April 2018), Science Citation Index Expanded (1900 to 12 April 2018), and Chinese Biomedical Literature Database (CBM) (1978 to 12 April 2018). SELECTION CRITERIA We included all randomized controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). MAIN RESULTS We included 11 studies involving 1462 participants in the review.Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomyWe included seven studies involving 860 participants: 428 were randomized to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence). There is probably little or no difference in length of hospital stay between the groups (12.1 days versus 11.4 days; MD 0.32 days, 95% CI -1.06 to 1.70; 755 participants; four studies; moderate-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomyWe included three studies involving 251 participants: 115 were randomized to the fibrin sealant group and 136 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (1.6% versus 6.2%; RR 0.25, 95% CI 0.01 to 5.06; 57 participants; one study; very low-quality evidence). Fibrin sealants may lead to little or no difference in postoperative mortality (0.1% versus 0.7%; Peto OR 0.15, 95% CI 0.00 to 7.76; 251 participants; three studies; low-quality evidence) or length of hospital stay (12.8 days versus 14.8 days; MD -1.58 days, 95% CI -3.96 to 0.81; 181 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (33.7% versus 34.7%; RR 0.97, 95% CI 0.65 to 1.45; 181 participants; two studies; very low-quality evidence), or reoperation rate (7.6% versus 9.2%; RR 0.83, 95% CI 0.33 to 2.11; 181 participants; two studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomyWe included two studies involving 351 participants: 188 were randomized to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (17.0 days versus 16.5 days; MD 0.58 days, 95% CI -5.74 to 6.89; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study: more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness. AUTHORS' CONCLUSIONS Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Junhua Gong
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingChina650032
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo. 1 Yixue RoadChongqingChina450000
| | - Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduChina610041
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Zhong Zeng
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingChina650032
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13
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Zhao R, Chang Y, Wang X, Zhang P, Zhang C, Lian P. Pylorus-preserving pancreaticoduodenectomy versus standard pancreaticoduodenectomy in the treatment of duodenal papilla carcinoma. Oncol Lett 2018; 15:6368-6376. [PMID: 29725396 PMCID: PMC5920278 DOI: 10.3892/ol.2018.8156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 12/29/2017] [Indexed: 12/15/2022] Open
Abstract
It is not known whether pylorus-preserving pancreaticoduodenectomy (PPPD) is as effective as the standard pancreaticoduodenectomy (SPD) in the treatment of duodenal papilla carcinoma (DPC). A retrospective cohort trial was undertaken to compare the results of these two procedures. Clinical data, histological findings, short-term results, survival and quality of life of all patients who had undergone surgery for primary DPC between January 2003 and February 2010 were analyzed. According to the inclusion criteria and the surgical methods, 116 patients were divided into the PPPD group (n=43) and the SPD group (n=73). There were no significant differences in various indices, including surgery duration, extent of intraoperative hemorrhage and postoperative pathological indexes. The incidence of postoperative complications, including pancreatic fistula and delayed gastric emptying, were also similar between the two groups (20.9 vs. 21.9%; P=0.900 and 11.6 vs. 5.4%; P=0.402). Long-term survival and quality of life were identical following a median follow-up of 45.6 months (range, 4-144 months). Within 6 months, there was a decreased loss of appetite following the pylorus-preserving procedure (26.9 vs. 49.3; P=0.003). The procedures were equally effective for the treatment of DPC. PPPD offers minor advantages in the early postoperative period but not in the long term.
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Affiliation(s)
- Rui Zhao
- Department of Hepatobiliary Surgery, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Yuan Chang
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Xianqiang Wang
- Department of Hepatobiliary Surgery, The People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Peng Zhang
- Department of Hepatobiliary Surgery, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Cheng Zhang
- Department of Hepatobiliary Surgery, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Peilong Lian
- Department of Hepatobiliary Surgery, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
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14
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Major pancreatic resections: normal postoperative findings and complications. Insights Imaging 2018; 9:173-187. [PMID: 29450852 PMCID: PMC5893491 DOI: 10.1007/s13244-018-0595-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 01/03/2018] [Accepted: 01/05/2018] [Indexed: 12/11/2022] Open
Abstract
Objectives (1) To illustrate and describe the main types of pancreatic surgery; (2) to discuss the normal findings after pancreatic surgery; (3) to review the main complications and their radiological findings. Background Despite the decreased postoperative mortality, morbidity still remains high resulting in longer hospitalisations and greater costs. Imaging findings following major pancreatic resections can be broadly divided into “normal postoperative alterations” and real complications. The former should regress within a few months whereas complications may be life-threatening and should be promptly identified and treated. Imaging findings CT is the most effective postoperative imaging technique. MRI and fluoroscopy are used less often and only in specific cases such as assessing the gastro-intestinal function or the biliary tree. The most common normal postoperative findings are pneumobilia, perivascular cuffing, fluid collections, lymphadenopathy, acute anastomotic oedema and stranding of the peri-pancreatic/mesenteric fat. Imaging depicts the anastomoses and the new postoperative anatomy. It can also demonstrate early and late complications: pancreatic fistula, haemorrhage, delayed gastric emptying, hepatic infarction, acute pancreatitis of the remnant, porto-mesenteric thrombosis, abscess, biliary anastomotic leaks, anastomotic stenosis and local recurrence. Conclusions Radiologists should be aware of surgical procedures, postoperative anatomy and normal postoperative imaging findings to better detect complications and recurrent disease. Teaching Points • Morbidity after pancreatic resections is high. • CT is the most effective postoperative imaging technique. • Imaging depicts the anastomoses and the new postoperative anatomy. • Pancreatic fistula is the most common complication after partial pancreatic resection.
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15
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Panwar R, Pal S. The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy. Hepatobiliary Pancreat Dis Int 2017; 16:353-363. [PMID: 28823364 DOI: 10.1016/s1499-3872(17)60037-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 02/03/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND A number of definitions have been used for delayed gastric emptying (DGE) after pancreatoduodenectomy and the reported rates varied widely. The International Study Group of Pancreatic Surgery (ISGPS) definition is the current standard but it is not used universally. In this comprehensive review, we aimed to determine the acceptance rate of ISGPS definition of DGE, the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence. DATA SOURCE We searched PubMed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition, DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles. RESULTS Out of 435 search results, 178 were selected for data extraction. The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7% (range: 0-100%; median: 18.7%) and 14.3% (range: 1.8%-58.2%; median: 13.6%), respectively. Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates. Although pyloric dilatation, Braun's entero-enterostomy and Billroth II reconstruction were associated with significantly lower DGE rates, pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies. CONCLUSIONS ISGPS definition of DGE has been used in majority of studies published after 2010. Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications. Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.
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Affiliation(s)
- Rajesh Panwar
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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16
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Zijah R, Jasmin H, Amra M, Emir A, Amir T, Goran I. http://www.ijhpd.com/archive/2016-archive/100060IJHPDRZ2016-zijah/100060IJHPDRZ2016-zijah-full-text.php. INTERNATIONAL JOURNAL OF HEPATOBILIARY AND PANCREATIC DISEASES 2017. [DOI: 10.5348/ijhpd-2016-59-oa-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Aims: The most demanding anastomosis of cephalic pancreaticoduodenectomy is pancreaticojejunostomy. In order to reduce the number of complications of pancreatico- jejunostomy, we worked to improve the technique of creating the anastomosis by modification of several aspects of the already standardized technique of creating a pancreaticojejunostomy.
Materials and Methods: Observational cohort study was conducted on 50 patients who had undergone a cephalic pancreaticoduo-denectomy due to a periampullary carcinoma in the period from January 2011 to March 2016. We analyzed the effect of the presented technique on postoperative morbidity and mortality.
Results: Of the 50 surgical patients, 31 (62%) were male. The mean age of the surgical patients was 58.8±10.08 years. Postoperative morbidity of 28% was lower than figures from literatures, which range from 35–43% (p > 0.05). Postoperative mortality was 6%, and in line with the figures from literature. Postoperative pancreatic fistula occurred in 6% of patients, which is also lower than 12.9% found in literature (p > 0.05).
Conclusion: Postoperative morbidity in patients in whom a pancreaticojejunostomy was created with presented technique, including the incidence of a postoperative pancreatic fistula, was lower, although the difference was not statistically significant.
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Affiliation(s)
- Rifatbegović Zijah
- MD, University Clinical Centre Tuzla, Department of Surgery, Tuzla, Bosnia and Herzegovina
| | - Hasanović Jasmin
- MD, University Clinical Centre Tuzla, Department of Surgery, Tuzla, Bosnia and Herzegovina
| | - Meštrić Amra
- MD, University of Tuzla, School of Medicine, Tuzla, Bosnia and Herzegovina
| | - Ahmetašević Emir
- MD, University Clinical Centre Tuzla, Department of Surgery, Tuzla, Bosnia and Herzegovina
| | - Tursunović Amir
- MD, University Clinical Centre Tuzla, Department of Surgery, Tuzla, Bosnia and Herzegovina
| | - Imamović Goran
- MD, University of Tuzla, School of Medicine, Tuzla, Bosnia and Herzegovina
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17
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Gastroduodenal and pancreatic surgeries: indications, surgical techniques, and imaging features. Abdom Radiol (NY) 2017; 42:2054-2068. [PMID: 28493073 DOI: 10.1007/s00261-017-1165-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This review article focuses on gastroduodenal and pancreatic surgeries with the goal of identifying radiologic findings that translate to important surgical considerations. The topics covered include partial gastrectomy with reconstruction techniques, total gastrectomy, pancreaticoduodenectomy, and pancreaticojejunostomy. Indications, contraindications, surgical techniques, and postoperative imaging are described within each of these topics. Knowledge of these surgical techniques is extremely helpful for the interpreting radiologists to identify expected postoperative anatomy and related complications that would remain clinically relevant to our surgical colleagues and direct timely patient management.
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18
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Plagemann S, Welte M, Izbicki JR, Bachmann K. Surgical Treatment for Chronic Pancreatitis: Past, Present, and Future. Gastroenterol Res Pract 2017; 2017:8418372. [PMID: 28819358 PMCID: PMC5551531 DOI: 10.1155/2017/8418372] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/02/2017] [Accepted: 07/05/2017] [Indexed: 02/07/2023] Open
Abstract
The pancreas was one of the last explored organs in the human body. The first surgical experiences were made before fully understanding the function of the gland. Surgical procedures remained less successful until the discovery of insulin, blood groups, and finally the possibility of blood donation. Throughout the centuries, the surgical approach went from radical resections to minimal resections or only drainage of the gland in comparison to an adequate resection combined with drainage procedures. Today, the well-known and standardized procedures are considered as safe due to the high experience of operating surgeons, the centering of pancreatic surgery in specialized centers, and optimized perioperative treatment. Although surgical procedures have become safer and more efficient than ever, the overall perioperative morbidity after pancreatic surgery remains high and management of postoperative complications stagnates. Current research focuses on the prevention of complications, optimizing the patient's general condition preoperatively and finding the appropriate timing for surgical treatment.
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Affiliation(s)
- Stephanie Plagemann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Maria Welte
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Jakob R. Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Kai Bachmann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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Mima K, Nakagawa S, Sawayama H, Ishimoto T, Imai K, Iwatsuki M, Hashimoto D, Baba Y, Yamashita YI, Yoshida N, Chikamoto A, Baba H. The microbiome and hepatobiliary-pancreatic cancers. Cancer Lett 2017; 402:9-15. [PMID: 28527946 DOI: 10.1016/j.canlet.2017.05.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 04/29/2017] [Accepted: 05/11/2017] [Indexed: 02/07/2023]
Abstract
The human intestinal microbiome encompasses at least 100 trillion microorganisms that can influence host immunity and disease conditions, including cancer. Hepatobiliary and pancreatic cancers have been associated with poor prognosis owing to their high level of tumor invasiveness, distant metastasis, and resistance to conventional treatment options, such as chemotherapy. Accumulating evidence from animal models suggests that specific microbes and microbial dysbiosis can potentiate hepatobiliary-pancreatic tumor development by damaging DNA, activating oncogenic signaling pathways, and producing tumor-promoting metabolites. Emerging evidence suggests that the gut microbiota may influence not only the efficacy of cancer chemotherapies and novel targeted immunotherapies such as anti-CTLA4 and anti-CD274 therapies but also the occurrence of postoperative complications after hepatobiliary and pancreatic surgery, which have been associated with tumor recurrence and worse patient survival in hepatobiliary-pancreatic cancers. Hence, a better understanding of roles of the gut microbiota in the development and progression of hepatobiliary-pancreatic tumors may open opportunities to develop new prevention and treatment strategies for patients with hepatobiliary-pancreatic cancer through manipulating the gut microbiota by diet, lifestyle, antibiotics, and pro- and prebiotics.
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Affiliation(s)
- Kosuke Mima
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Sawayama
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Takatsugu Ishimoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Daisuke Hashimoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Yo-Ichi Yamashita
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan.
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Abstract
The pylorus preserving pancreatoduodenectomy (PPPD) is a surgical procedure for the treatment of pancreatic head cancer, distal bile duct tumors and malignancies of the duodenum. This surgical technique can also be applied to treat chronic pancreatitis. The perioperative mortality rate ranges between 3% and 5%. The procedure is performed in a standardized way. It begins with the exploration phase to clarify resectability of the tumor. Subsequently it is divided into a structured resection and reconstruction phase. Malignant tumors require a systematic lymphadenectomy of the hepatoduodenal ligament. Since the complication rate is not negligible, complication management plays an important role. Most frequently, delayed gastric emptying and pancreatic fistulas occur. We present an accompanying video of this operation online, where the PPPD procedure is performed to treat duodenal polyps in familial adenomatous polyposis after failure of endoscopic ablation.
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Seo JW, Hwang HK, Lee M, Kim KW, Kang CM, Kim MJ, Chung YE. Normal Postoperative Computed Tomography Findings after a Variety of Pancreatic Surgeries. Korean J Radiol 2017; 18:299-308. [PMID: 28246510 PMCID: PMC5313518 DOI: 10.3348/kjr.2017.18.2.299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/14/2016] [Indexed: 12/12/2022] Open
Abstract
Pancreatic surgery remains the only curative treatment for pancreatic neoplasms, and plays an important role in the management of medically intractable diseases. Since the original Whipple operation in the 20th century, surgical techniques have advanced, resulting in decreased postoperative complications and better clinical outcomes. Normal postoperative imaging findings vary greatly depending on the surgical technique used. Radiologists are required to be familiar with the normal postoperative imaging findings, in order to distinguish from postoperative complications or tumor recurrence. In this study, we briefly review a variety of surgical techniques for the pancreas, and present the normal postoperative computed tomography findings.
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Affiliation(s)
- Ji Won Seo
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Ho Kyoung Hwang
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Minwook Lee
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Ki Whang Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Chang Moo Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Myeong-Jin Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Yong Eun Chung
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
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22
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Shahbazov R, Yoshimatsu G, Haque WZ, Khan OS, Saracino G, Lawrence MC, Kim PT, Onaca N, Naziruddin B, Levy MF. Clinical effectiveness of a pylorus-preserving procedure on total pancreatectomy with islet autotransplantation. Am J Surg 2016; 213:1065-1071. [PMID: 27760705 DOI: 10.1016/j.amjsurg.2016.09.051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The impact of pylorus preserving procedures (PP) on total pancreatectomy with islet autotransplantation (TPIAT) has not been examined. This study aimed to investigate the clinical impact of the PP on TPIAT. METHODS The Baylor Simmons Transplant Institute database was queried to identify seventy-three patients who underwent TPIAT from 2006 to 2014. All patients were investigated in postoperative complications, long-term nutritional status, and graft function. RESULTS Patients with PP did not face worse outcomes in terms of delayed gastric emptying and length of hospital stay. Also, nutritional status and metabolic outcome, such as body weight, serum albumin level, serum vitamin level, HbA1c level, graft survival rate and insulin independent rate, were similar between both groups. CONCLUSIONS Clinical results including the graft function indicated that patients undergoing TPIAT with PP did not amplify surgical complications such as delayed gastric emptying and showed no significant advantage of nutrition and metabolic outcome.
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Affiliation(s)
- Rauf Shahbazov
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Waqas Z Haque
- Islet Cell Laboratory, Baylor Research Institute, Dallas, TX, USA
| | - Omar S Khan
- Islet Cell Laboratory, Baylor Research Institute, Dallas, TX, USA
| | - Giovanna Saracino
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | | | - Peter T Kim
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Nicholas Onaca
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Bashoo Naziruddin
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
| | - Marlon F Levy
- Transplant Division, Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Søreide K, Labori KJ. Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review. Scand J Gastroenterol 2016; 51:1147-54. [PMID: 27216233 PMCID: PMC4975078 DOI: 10.3109/00365521.2016.1169317] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers. METHODS A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF. RESULTS A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained. CONCLUSIONS Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital,
Stavanger,
Norway,Department of Clinical Medicine, University of Bergen,
Bergen,
Norway,CONTACT Kjetil Søreide
Department of Gastrointestinal Surgery, Stavanger University Hospital, POB 8100,
N-4068Stavanger,
Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital,
Oslo,
Norway
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24
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Costi R, De Pastena M, Malleo G, Marchegiani G, Butturini G, Violi V, Salvia R, Bassi C. Poor Results of Pancreatoduodenectomy in High-Risk Patients with Endoscopic Stent and Bile Colonization are Associated with E. coli, Diabetes and Advanced Age. J Gastrointest Surg 2016; 20:1359-67. [PMID: 27170172 DOI: 10.1007/s11605-016-3158-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/22/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic stenting has spread as bridge management before pancreatoduedenectomy (PD) to resolve jaundice, but its role is nowadays challenged as it is reported to increase morbidity. Although bile sampling is increasingly performed, its clinical role is unclear. The objective of the study is to assess bile colonization's impact on outcome. METHODS Results of pancreatoduodenectomy after endoscopic stenting are analyzed in 61 high-risk patients presenting bacterial bile colonization. The impact of 11 demographic, clinical, infectious, and laboratory parameters and outcome, including pancreatic leakage, morbidity, and mortality, is analyzed. RESULTS All stented patients present bacterial bile colonization and PD mortality approaches 10 %. The presence of E. coli in the bile is significantly related to poor outcome, including 23.5 % mortality (p = 0.034), whereas age (≥70 years) and diabetes present borderline results (p < 0.070 and p < 0.066, respectively). E. coli (p = 0.002) and age (p = 0.017) are also related to grade C pancreatic fistula. CONCLUSIONS In high-risk patients undergoing PD, bile colonization inevitably occurs after endoscopic stenting and is a major risk factor of poor outcome, reaching its maximum in the case of E. coli colonization and elderly patients, where the indication to stent and/or to perform PD should be accurately evaluated. E. coli-targeted antibiotic prophylaxis should be administered.
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Affiliation(s)
- Renato Costi
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia. .,Service de Chirurgie Digestive et Cancérologique, Hôpital Lariboisière, AP-HP, Université Paris 7 "Diderot", Paris, France. .,Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Azienda Ospedaliero-Universitaria di Parma, Parma, Via Gramsci 14, 43100, Parma, Italia.
| | - Matteo De Pastena
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giuseppe Malleo
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giovanni Marchegiani
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giovanni Butturini
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia.,Unità Operativa di Chirurgia del Pancreas, Casa di Cura "Pederzoli", Peschiera sul Garda, Verona, Italia
| | - Vincenzo Violi
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Azienda Ospedaliero-Universitaria di Parma, Parma, Via Gramsci 14, 43100, Parma, Italia
| | - Roberto Salvia
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Claudio Bassi
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
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25
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Pancreaticogastrostomy versus pancreaticojejunostomy reconstruction for the prevention of pancreatic fistula following pancreaticoduodenectomy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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27
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Advances in the Surgical Management of Resectable and Borderline Resectable Pancreas Cancer. Surg Oncol Clin N Am 2016; 25:287-310. [PMID: 27013365 PMCID: PMC10181830 DOI: 10.1016/j.soc.2015.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Successful surgical resection offers the only chance for cure in patients with pancreatic cancer. However, pancreatic resection is feasible in less than 20% of the patients. In this review, the current state of surgical management of pancreatic cancer is discussed. The definition of resectability based on cross-sectional imaging and the technical aspects of surgery, including vascular resection and/or reconstruction, management of aberrant vascular anatomy and extent of lymphadenectomy, are appraised. Furthermore, common pancreatic resection-specific postoperative complications and their management are reviewed.
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28
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Hüttner FJ, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Büchler MW, Diener MK. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2016; 2:CD006053. [PMID: 26905229 PMCID: PMC8255094 DOI: 10.1002/14651858.cd006053.pub6] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic cancer is the fourth-leading cause of cancer death for both, men and women. The standard treatment for resectable tumours consists of a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of these procedures is more favourable in terms of survival, postoperative mortality, complications, and quality of life. OBJECTIVES The objective of this systematic review was to compare the effectiveness of CW and PPW techniques for surgical treatment of cancer of the pancreatic head and the periampullary region. SEARCH METHODS We conducted searches on 28 March 2006, 11 January 2011, 9 January 2014, and 18 August 2015 to identify all randomised controlled trials (RCTs), while applying no language restrictions. We searched the following electronic databases on 18 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) from the Cochrane Library (2015, Issue 8); MEDLINE (1946 to August 2015); and EMBASE (1980 to August 2015). We also searched abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010); we did not update this part of the search for the 2014 and 2015 updates because the prior searches did not contribute any additional information. We identified two additional trials through the updated search in 2015. SELECTION CRITERIA RCTs comparing CW versus PPW including participants with periampullary or pancreatic carcinoma. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included trials. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (ORs), pooled continuous outcomes using mean differences (MDs), and used hazard ratios (HRs) for meta-analysis of survival. Two review authors independently evaluated the methodological quality and risk of bias of included trials according to the standards of The Cochrane Collaboration. MAIN RESULTS We included eight RCTs with a total of 512 participants. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. Postoperative mortality (OR 0.64, 95% confidence interval (CI) 0.26 to 1.54; P = 0.32), overall survival (HR 0.84, 95% CI 0.61 to 1.16; P = 0.29), and morbidity showed no significant differences, except of delayed gastric emptying, which significantly favoured CW (OR 3.03, 95% CI 1.05 to 8.70; P = 0.04). Furthermore, we noted that operating time (MD -45.22 minutes, 95% CI -74.67 to -15.78; P = 0.003), intraoperative blood loss (MD -0.32 L, 95% CI -0.62 to -0.03; P = 0.03), and red blood cell transfusion (MD -0.47 units, 95% CI -0.86 to -0.07; P = 0.02) were significantly reduced in the PPW group. All significant results were associated with low-quality evidence based on GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. AUTHORS' CONCLUSIONS Current evidence suggests no relevant differences in mortality, morbidity, and survival between the two operations. However, some perioperative outcome measures significantly favour the PPW procedure. Given obvious clinical and methodological heterogeneity, future high-quality RCTs of complex surgical interventions based on well-defined outcome parameters are required.
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Affiliation(s)
- Felix J Hüttner
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermany69120
| | - Christina Fitzmaurice
- University of Washington/Fred Hutchinson Cancer Research CenterHematology‐Oncology1100 Fairview Ave N – D5‐100PO Box 19024SeattleWashington StateUSA98109‐1024
| | - Guido Schwarzer
- Medical Center ‐ University of FreiburgCenter for Medical Biometry and Medical InformaticsStefan‐Meier‐Str. 26FreiburgGermanyD‐79104
| | - Christoph M Seiler
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermany69120
| | - Gerd Antes
- Medical Center ‐ University of FreiburgCochrane GermanyBerliner Allee 29FreiburgGermany79110
| | - Markus W Büchler
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermany69120
| | - Markus K Diener
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermany69120
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Cheng Y, Ye M, Xiong X, Peng S, Wu HM, Cheng N, Gong J. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. Cochrane Database Syst Rev 2016; 2:CD009621. [PMID: 26876721 DOI: 10.1002/14651858.cd009621.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial. OBJECTIVES To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. SEARCH METHODS We searched The Cochrane Library (2015, Issue 7), MEDLINE (1946 to 26 August 2015), EMBASE (1980 to 26 August 2015), Science Citation Index Expanded (1900 to 26 August 2015), and Chinese Biomedical Literature Database (CBM) (1978 to 26 August 2015). SELECTION CRITERIA We included all randomized controlled trials that compared fibrin sealant group (fibrin glue or fibrin sealant patch) versus control group (no fibrin sealant or placebo) in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio for very rare outcomes), and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). MAIN RESULTS We included nine trials involving 1095 participants who were randomized to the fibrin sealant group (N = 550) and the control group (N = 545) after pancreatic surgery. All of the trials were at high risk of bias. There was no evidence of differences in overall postoperative pancreatic fistula (fibrin sealant 29.6%; control 31.0%; RR 0.93, 95% CI 0.71 to 1.21; P = 0.58; nine studies; low-quality evidence), postoperative mortality (3.1% versus 2.1%; Peto OR 1.29, 95% CI 0.59 to 2.82; P = 0.53; eight studies; very low-quality evidence), overall postoperative morbidity (29.6% versus 28.9%; RR 1.04, 95% CI 0.82 to 1.32; P = 0.77; five studies), reoperation rate (8.7% versus 10.7%; RR 0.80, 95% CI 0.53 to 1.21; P = 0.29; five studies), or length of hospital stay (12.9 days versus 13.1 days; MD -0.73 days, 95% CI -2.20 to 0.74; P = 0.331; six studies) between the groups. The proportion of postoperative pancreatic fistula that was clinically significant was not mentioned in most trials. On inclusion of trials that clearly distinguished clinically significant fistulas, there was inadequate evidence to establish the effect of fibrin sealants on clinically significant postoperative pancreatic fistula (9.4% versus 13.4%; RR 0.72, 95% CI 0.42 to 1.21; P = 0.21; three studies). Quality of life and cost effectiveness were not reported in any of the trials. AUTHORS' CONCLUSIONS Based on the current available evidence, fibrin sealants do not seem to prevent postoperative pancreatic fistula in people undergoing pancreatic surgery.
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Affiliation(s)
- Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, No. 74, Lin Jiang Road, Chongqing, Chongqing, China, 400010
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30
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Lin SR, Xiao WD. Current research status of organ preserving pancreatectomy. Shijie Huaren Xiaohua Zazhi 2015; 23:5318-5324. [DOI: 10.11569/wcjd.v23.i33.5318] [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] [Indexed: 02/06/2023] Open
Abstract
Classic pancreatectomy procedures usually require resection of the pancreas and surrounding organs, having disadvantages of major trauma, long hospital stay and high morbidity. In order to preserve organ function as much as possible, many types of organ preserving pancreatectomy have been widely used in the treatment of benign pancreatic tumors and low-grade malignant lesions, including tumor enucleation, pylorus preserving pancreaticoduodenectomy, duodenum-preserving pancreatic head resection, middle segmental pancreatectomy, and spleen-preserving distal pancreatectomy. With the development of minimally invasive techniques in recent years, laparoscopic and robotic techniques have been also safely applied in organ preserving pancreatectomy. This article will review the current research status of organ preserving pancreatectomy.
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Vallance AE, Young AL, Macutkiewicz C, Roberts KJ, Smith AM. Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review. HPB (Oxford) 2015; 17:1040-8. [PMID: 26456948 PMCID: PMC4605344 DOI: 10.1111/hpb.12503] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/16/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND A post-operative pancreatic fistula (POPF) is a major cause of morbidity and mortality after a pancreaticoduodenectomy (PD). This systematic review aimed to identify all scoring systems to predict POPF after a PD, consider their clinical applicability and assess the study quality. METHOD An electronic search was performed of Medline (1946-2014) and EMBASE (1996-2014) databases. Results were screened according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and quality assessed according to the QUIPS (quality in prognostic studies) tool. RESULTS Six eligible scoring systems were identified. Five studies used the International Study Group on Pancreatic Fistula (ISGPF) definition. The proposed scores feature between two and five variables and of the 16 total variables, the majority (12) featured in only one score. Three scores could be fully completed pre-operatively whereas 1 score included intra-operative and two studies post-operative variables. Four scores were internally validated and of these, two scores have been subject to subsequent multicentre review. The median QUIPS score was 38 out of 50 (range 16-50). CONCLUSION These scores show potential in calculating the individualized patient risk of POPF. There is, however, much variation in current scoring systems and further validation in large multicentre cohorts is now needed.
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Affiliation(s)
| | | | | | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation TrustBirmingham, UK
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Pancreatic Fistula and Delayed Gastric Emptying After Pancreatectomy: Where do We Stand? Indian J Surg 2015; 77:409-25. [PMID: 26722205 DOI: 10.1007/s12262-015-1366-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
Pancreatic resection has become a feasible treatment of pancreatic neoplasms, and with improvements in surgical techniques and perioperative management, mortality associated with pancreatic surgery has decreased considerably. Despite this improvement, a high rate of complications is still associated with these procedures. Among these complications, delayed gastric emptying (DGE) and postoperative pancreatic fistula (POPF) have a substantial impact on patient outcomes and burden our healthcare system. Technical modifications and postoperative approaches have been proposed to reduce rates of both POPF and DGE in patients undergoing pancreatectomy; however, to date, their rates have remained unchanged. In the present study, we summarize the findings of the most significant studies that have investigated these complications. In particular, several studies focused on technical modifications including extent of dissection, stent placement, nature of anastomosis, type of reconstruction, and application of biological or non-biological agents to site of anastomosis. Moreover, postoperatively, drain placement, duration of drain usage, postoperative feeding, and use of pharmacological agents were studied to reduce rates of POPF and DGE. In this review, we summarize the most relevant literature on this fundamental aspect of pancreatic surgery. Despite studies identifying the potential benefit of technical modifications and postoperative approaches, these findings remain controversial and suggest need for further extensive investigation. Most importantly, we recommend that all surgeons performing these procedures base their practice on the most updated and highest available level of evidence.
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Mitra A, D'Souza A, Goel M, Shrikhande SV. Surgery for Pancreatic and Periampullary Carcinoma. Indian J Surg 2015; 77:371-80. [PMID: 26722199 DOI: 10.1007/s12262-015-1358-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022] Open
Abstract
Surgical resection for pancreatic and periampullary cancer has evolved over several decades. The postoperative mortality for these resections has declined to less than 5 %. However, morbidity associated with these resections is still considerable. Various technical modifications like pylorus preservation, reconstruction techniques and methods to perform pancreaticoenteric anastomosis have been suggested to improve postoperative outcomes after pancreaticoduodenectomy. Surgical modifications to improve oncological clearance and decrease fistula rates after distal pancreatic resections have also been suggested. Dilemma still exists whether interventions like pancreatic duct stents, octreotide and drains help to improve postoperative outcomes. The role of extended lymph node dissection and extended resections for pancreatic and periampullary cancer is still controversial, as is the management of borderline resectable pancreatic cancer. In this review, we discuss the literature pertaining to various surgical aspects of pancreatic and periampullary carcinoma.
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Affiliation(s)
- Abhishek Mitra
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
| | - Ashwin D'Souza
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
| | - Mahesh Goel
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
| | - Shailesh V Shrikhande
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
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Popp FC, Weigt J, Kalinski T, Betzler C, Arend J, Garlipp B, Benckert C, Bruns CJ. [Papillary tumors - therapeutic concepts]. Chirurg 2015. [PMID: 26223666 DOI: 10.1007/s00104-015-0048-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Papillary tumors originate from the various structures of the ampulla of Vater; therefore, these rare tumors represent a heterogeneous group of tumor entities. Intestinal differentiated adenomas are the most common benign lesions, whereas intestinal differentiated papillary carcinomas are the most common malignant tumors. Carcinomas with pancreaticobiliary differentiation have a poorer prognosis. Mesenchymal and neuroendocrine tumors are among the least frequent papillary tumors. Diagnosis is performed by side-view upper endoscopy and biopsy. In cases of suspected malignancy a complete staging with computed tomography (CT) and endoscopic ultrasound scanning is indicated to determine local tumor spread.Adenomas are removed by endoscopic snare papillectomy whereas the therapy of choice for papillary carcinomas is pancreatic head resection with systematic lymphadenectomy. Patients with papillary carcinomas are most likely to benefit from adjuvant therapy, which should be determined in an interdisciplinary consensus conference considering the histological differentiation of the tumor.
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Affiliation(s)
- F C Popp
- Universitätsklinik für Allgemein-, Viszeral- und Gefäßchirurgie, Leipziger Str. 44, 39120, Magdeburg, Deutschland,
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Huang X, Liang B, Zhao XQ, Zhang FB, Wang XT, Dong JH. The effects of different preoperative biliary drainage methods on complications following pancreaticoduodenectomy. Medicine (Baltimore) 2015; 94:e723. [PMID: 25860221 PMCID: PMC4554051 DOI: 10.1097/md.0000000000000723] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The objective of this study was to investigate the effects of different preoperative biliary drainage (PBD) methods on complications in jaundiced patients following pancreaticoduodenectomy. We retrospectively analyzed 270 extrahepatic bile duct cancer patients who underwent pancreaticoduodenectomy. A total of 170 patients without PBD treatment were defined as the non-PBD group. According to different PBD methods, 45, 18, and 37 patients were classified into the percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD), and endoscopic retrograde biliary stent (ERBS) groups, respectively. Clinical characteristics and complications were compared among the 4 groups. Preoperative cholangitis occurred in 14 (8.2%) and 8 (21.6%) patients in the non-PBD and ERBS group, respectively (P = 0.04). Compared with the non-PBD group, delayed gastric emptying (DGE) and wound infection occurred significantly more often in the ERBS group. The incidence of severe complications was significantly lower in the PTBD group than the non-PBD group (P = 0.03). Postoperative hospital stay and complication rates were significantly higher in the ERBS group than the PTBD group. There were no significant differences in complications between ENBD and other groups. In conclusion, PTBD can improve surgical outcomes by reducing severe complication rate in jaundiced patients following pancreaticoduodenectomy. ERBS increased the rates of DGE and wound infection due to high incidence of cholangitis before operative intervention and should be avoided. ENBD carried no special effect on complications and needs further analysis.
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Affiliation(s)
- Xin Huang
- From the Department and Institute of Hepatobiliary Surgery (XH, BL, XQZ, FBZ, XTW, JHD), Chinese PLA General Hospital, Beijing, China; and School of Medicine (XH, FBZ, XTW), Nankai University, Tianjin, China
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