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Shindo Y, Ioka T, Tokumitsu Y, Matsui H, Nakajima M, Kimura Y, Watanabe Y, Tomochika S, Nakagami Y, Tsunedomi R, Iida M, Takahashi H, Nagano H. Safety and Feasibility of Neoadjuvant-Modified FOLFIRINOX in Elderly Patients with Pancreatic Cancer. Cancers (Basel) 2024; 16:2522. [PMID: 39061162 PMCID: PMC11275028 DOI: 10.3390/cancers16142522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/01/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
The optimal treatment strategy for neoadjuvant chemotherapy in elderly patients with pancreatic cancer (PC) remains unclear. Hence, this study was aimed at evaluating the safety and feasibility of neoadjuvant-modified FOLFIRINOX (mFOLFIRINOX) in elderly patients with PC. We retrospectively collected data from 62 patients who received neoadjuvant mFOLFIRINOX between May 2015 and October 2023 and comparatively analyzed the clinicopathological data and outcomes between the non-elderly group (age: <75 years) and elderly group (age: >75 years). The non-elderly and elderly groups comprised 39 and 23 patients, respectively. Although elevated levels of aspartate aminotransferase (p = 0.0173) and alanine aminotransferase (p = 0.0378) and nausea (p = 0.0177) were more frequent in the elderly group, the incidence of severe adverse events was similar between the groups. Intergroup differences in resection rate (p = 0.3381), postoperative severe complication rates (p = 0.2450), and postoperative hospital stay (p = 0.3496) were not significant. Furthermore, no significant intergroup differences were found in survival in either the whole or the resection cohorts. The perioperative and postoperative outcomes of elderly patients treated with neoadjuvant mFOLFIRINOX were comparable with those of non-elderly patients. Neoadjuvant mFOLFIRINOX should be considered a feasible option for elderly patients with PC.
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Affiliation(s)
- Yoshitaro Shindo
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
| | - Tatsuya Ioka
- Department of Oncology Center, Yamaguchi University Hospital, Ube 755-8505, Yamaguchi, Japan;
| | - Yukio Tokumitsu
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
| | - Hiroto Matsui
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
| | - Masao Nakajima
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
| | - Yuta Kimura
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
| | - Yusaku Watanabe
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
| | - Shinobu Tomochika
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
| | - Yuki Nakagami
- Department of Data Science, Shimonoseki City University, Shimonoseki 751-8510, Yamaguchi, Japan;
| | - Ryouichi Tsunedomi
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
| | - Michihisa Iida
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
| | - Hidenori Takahashi
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
| | - Hiroaki Nagano
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Yamaguchi, Japan; (Y.S.); (Y.T.); (H.M.); (M.N.); (Y.K.); (Y.W.); (S.T.); (R.T.); (M.I.); (H.T.)
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Kotecha K, Tree K, Ziaziaris WA, McKay SC, Wand H, Samra J, Mittal A. Centralization of Pancreaticoduodenectomy: A Systematic Review and Spline Regression Analysis to Recommend Minimum Volume for a Specialist Pancreas Service. Ann Surg 2024; 279:953-960. [PMID: 38258578 DOI: 10.1097/sla.0000000000006208] [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: 01/24/2024]
Abstract
OBJECTIVE Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center. BACKGROUND The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable. MATERIALS AND METHODS Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a "zero-crossing" technique was used, which produced "first and second derivatives" to identify volume thresholds. RESULTS Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df 5.154 ( P <0.001) and 8.254 ( P <0.001), respectively. The threshold value for mortality was ~45 PDs/year (model 9.219 ( P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost ( edf =2, P =0.989) and length of stay ( edf =2.04, P =0.099). CONCLUSIONS There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year.
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Affiliation(s)
- Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Tree
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - William A Ziaziaris
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Siobhan C McKay
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Cancer and Genomic Science, University of Birmingham, Edgbaston, Birmingham United Kingdom
| | - Handan Wand
- Kirby Institute (formerly National Center in HIV Epidemiology and Clinical Research), University of New South Wales, Sydney, NSW
| | - Jaswinder Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Center, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Center, Sydney, Australia
- University of Notre Dame, Sydney
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Non-Surgical Interventions for the Prevention of Clinically Relevant Postoperative Pancreatic Fistula-A Narrative Review. Cancers (Basel) 2023; 15:5865. [PMID: 38136409 PMCID: PMC10741911 DOI: 10.3390/cancers15245865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is the leading cause of morbidity and mortality after pancreatic surgery. Post-pancreatectomy acute pancreatitis (PPAP) has been increasingly understood as a precursor and exacerbator of CR-POPF. No longer believed to be the consequence of surgical technique, the solution to preventing CR-POPF may lie instead in non-surgical, mainly pharmacological interventions. Five databases were searched, identifying eight pharmacological preventative strategies, including neoadjuvant therapy, somatostatin and its analogues, antibiotics, analgesia, corticosteroids, protease inhibitors, miscellaneous interventions with few reports, and combination strategies. Two further non-surgical interventions studied were nutrition and fluids. New potential interventions were also identified from related surgical and experimental contexts. Given the varied efficacy reported for these interventions, numerous opportunities for clarifying this heterogeneity remain. By reducing CR-POPF, patients may avoid morbid sequelae, experience shorter hospital stays, and ensure timely delivery of adjuvant therapy, overall aiding survival where prognosis, particularly in pancreatic cancer patients, is poor.
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Affiliation(s)
- Nadya Rykina-Tameeva
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
| | - Jaswinder S. Samra
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Sumit Sahni
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Anubhav Mittal
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
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Schouten TJ, Henry AC, Smits FJ, Besselink MG, Bonsing BA, Bosscha K, Busch OR, van Dam RM, van Eijck CH, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IHJT, Kazemier G, Liem MSL, de Meijer VE, Patijn GA, Roos D, Schreinemakers JMJ, Stommel MWJ, Wit F, Daamen LA, Molenaar IQ, van Santvoort HC. Risk Models for Developing Pancreatic Fistula After Pancreatoduodenectomy: Validation in a Nationwide Prospective Cohort. Ann Surg 2023; 278:1001-1008. [PMID: 36804843 DOI: 10.1097/sla.0000000000005824] [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: 02/22/2023]
Abstract
OBJECTIVE To evaluate the performance of published fistula risk models by external validation, and to identify independent risk factors for postoperative pancreatic fistula (POPF). BACKGROUND Multiple risk models have been developed to predict POPF after pancreatoduodenectomy. External validation in high-quality prospective cohorts is, however, lacking or only performed for individual models. METHODS A post hoc analysis of data from the stepped-wedge cluster cluster-randomized Care After Pancreatic Resection According to an Algorithm for Early Detection and Minimally Invasive Management of Pancreatic Fistula versus Current Practice (PORSCH) trial was performed. Included were all patients undergoing pancreatoduodenectomy in the Netherlands (January 2018-November 2019). Risk models on POPF were identified by a systematic literature search. Model performance was evaluated by calculating the area under the receiver operating curves (AUC) and calibration plots. Multivariable logistic regression was performed to identify independent risk factors associated with clinically relevant POPF. RESULTS Overall, 1358 patients undergoing pancreatoduodenectomy were included, of whom 341 patients (25%) developed clinically relevant POPF. Fourteen risk models for POPF were evaluated, with AUCs ranging from 0.62 to 0.70. The updated alternative fistula risk score had an AUC of 0.70 (95% confidence intervals [CI]: 0.69-0.72). The alternative fistula risk score demonstrated an AUC of 0.70 (95% CI: 0.689-0.71), whilst an AUC of 0.70 (95% CI: 0.699-0.71) was also found for the model by Petrova and colleagues. Soft pancreatic texture, pathology other than pancreatic ductal adenocarcinoma or chronic pancreatitis, small pancreatic duct diameter, higher body mass index, minimally invasive resection and male sex were identified as independent predictors of POPF. CONCLUSION Published risk models predicting clinically relevant POPF after pancreatoduodenectomy have a moderate predictive accuracy. Their clinical applicability to identify high-risk patients and guide treatment strategies is therefore questionable.
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Affiliation(s)
- Thijs J Schouten
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Anne Claire Henry
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Francina J Smits
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center, Amsterdam, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, The Netherlands
- Department of General and Visceral Surgery, University Hospital Aachen, Aachen, Germany
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Ignace H J T de Hingh
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Geert Kazemier
- Cancer Center, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Hospital, Delft, The Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans, Heerenveen, The Netherlands
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Lois A Daamen
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
- Imaging Division, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Izaak Q Molenaar
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
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Perri G, van Hilst J, Li S, Besselink MG, Hogg ME, Marchegiani G. Teaching modern pancreatic surgery: close relationship between centralization, innovation, and dissemination of care. BJS Open 2023; 7:zrad081. [PMID: 37698977 PMCID: PMC10496870 DOI: 10.1093/bjsopen/zrad081] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Pancreatic surgery is increasingly moving towards centralization in high-volume centres, supported by evidence on the volume-outcome relationship. At the same time, minimally invasive pancreatic surgery is becoming more and more established worldwide, and interest in new techniques, such as robotic pancreatoduodenectomy, is growing. Such recent innovations are reshaping modern pancreatic surgery, but they also represent new challenges for surgical training in its current form. METHODS This narrative review presents a chosen selection of literature, giving a picture of the current state of training in pancreatic surgery, together with the authors' own views, and in the context of centralization and innovation towards minimally invasive techniques. RESULTS Centralization of pancreatic surgery at high-volume centres, volume-outcome relationships, innovation through minimally invasive technologies, learning curves in both traditional and minimally invasive surgery, and standardized training paths are the different, but deeply interconnected, topics of this article. Proper training is essential to ensure quality of care, but innovation and centralization may represent challenges to overcome with new training models. CONCLUSION Innovations in pancreatic surgery are introduced with the aim of increasing the quality of care. However, their successful implementation is deeply dependent on dissemination and standardization of surgical training, adapted to fit in the changing landscape of modern pancreatic surgery.
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Affiliation(s)
- Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Shen Li
- Department of Surgical Oncology, University of Chicago, Chicago, Illinois, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Melissa E Hogg
- Department of HPB Surgery, NorthShore Health System, Evanston, Illinois, USA
| | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
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Sahakyan MA, Brudvik KW, Angelsen JH, Dille-Amdam RG, Sandvik OM, Edwin B, Nymo LS, Lassen K. Preoperative Inflammatory Markers in Liver Resection for Colorectal Liver Metastases: A National Registry-Based Study. World J Surg 2023; 47:2213-2220. [PMID: 37140610 PMCID: PMC10387457 DOI: 10.1007/s00268-023-07035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Preoperative inflammatory markers were shown to be associated with prognosis following surgery for hepato-pancreato-biliary cancer. Yet little evidence exists about their role in patients with colorectal liver metastases (CRLM). This study aimed to examine the association between selected preoperative inflammatory markers and outcomes of liver resection for CRLM. METHODS Data from the Norwegian National Registry for Gastrointestinal Surgery (NORGAST) was used to capture all liver resections performed in Norway within the study period (November 2015-April 2021). Preoperative inflammatory markers were Glasgow prognostic score (GPS), modified Glasgow prognostic score (mGPS) and C-reactive protein to albumin ratio (CAR). The impact of these on postoperative outcomes, as well as on survival were studied. RESULTS Liver resections for CRLM were performed in 1442 patients. Preoperative GPS ≥ 1 and mGPS ≥ 1 were present in 170 (11.8%) and 147 (10.2%) patients, respectively. Both were associated with severe complications but became non-significant in the multivariable model. GPS, mGPS, CAR were significant predictors for overall survival in the univariable analysis, but only CAR remained such in the multivariable model. When stratified by the type of surgical approach, CAR was a significant predictor for survival after open but not laparoscopic liver resections. CONCLUSIONS GPS, mGPS and CAR have no impact on severe complications after liver resection for CRLM. CAR outperforms GPS and mGPS in predicting overall survival in these patients, especially following open resections. The prognostic significance of CAR in CRLM should be tested against other clinical and pathology parameters relevant for prognosis.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.
- Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia.
| | | | - Jon-Helge Angelsen
- Department of Acute and Digestive Surgery, Haukeland University Hospital, Bergen, Norway
| | - Rachel G Dille-Amdam
- Department of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Oddvar M Sandvik
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Bjørn Edwin
- The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, UiT, the Arctic University of Norway, Tromsø, Norway
| | - Kristoffer Lassen
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, UiT, the Arctic University of Norway, Tromsø, Norway
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7
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Boggi U, Donisi G, Napoli N, Partelli S, Esposito A, Ferrari G, Butturini G, Morelli L, Abu Hilal M, Viola M, Di Benedetto F, Troisi R, Vivarelli M, Jovine E, Ferrero A, Bracale U, Alfieri S, Casadei R, Ercolani G, Moraldi L, Molino C, Dalla Valle R, Ettorre G, Memeo R, Zanus G, Belli A, Gruttadauria S, Brolese A, Coratti A, Garulli G, Romagnoli R, Massani M, Borghi F, Belli G, Coppola R, Falconi M, Salvia R, Zerbi A. Prospective minimally invasive pancreatic resections from the IGOMIPS registry: a snapshot of daily practice in Italy on 1191 between 2019 and 2022. Updates Surg 2023; 75:1439-1456. [PMID: 37470915 PMCID: PMC10435655 DOI: 10.1007/s13304-023-01592-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
This retrospective analysis of the prospective IGOMIPS registry reports on 1191 minimally invasive pancreatic resections (MIPR) performed in Italy between 2019 and 2022, including 668 distal pancreatectomies (DP) (55.7%), 435 pancreatoduodenectomies (PD) (36.3%), 44 total pancreatectomies (3.7%), 36 tumor enucleations (3.0%), and 8 central pancreatectomies (0.7%). Spleen-preserving DP was performed in 109 patients (16.3%). Overall incidence of severe complications (Clavien-Dindo ≥ 3) was 17.6% with a 90-day mortality of 1.9%. This registry analysis provided some important information. First, robotic assistance was preferred for all MIPR but DP with splenectomy. Second, robotic assistance reduced conversion to open surgery and blood loss in comparison to laparoscopy. Robotic PD was also associated with lower incidence of severe postoperative complications and a trend toward lower mortality. Fourth, the annual cut-off of ≥ 20 MIPR and ≥ 20 MIPD improved selected outcome measures. Fifth, most MIPR were performed by a single surgeon. Sixth, only two-thirds of the centers performed spleen-preserving DP. Seventh, DP with splenectomy was associated with higher conversion rate when compared to spleen-preserving DP. Eighth, the use of pancreatojejunostomy was the prevalent reconstruction in PD. Ninth, final histology was similar for MIPR performed at high- and low-volume centers, but neoadjuvant chemotherapy was used more frequently at high-volume centers. Finally, this registry analysis raises important concerns about the reliability of R1 assessment underscoring the importance of standardized pathology of pancreatic specimens. In conclusion, MIPR can be safely implemented on a national scale. Further analyses are required to understand nuances of implementation of MIPR in Italy.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
| | - Greta Donisi
- Pancreatic Surgery Unit, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, OSR ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Esposito
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Giovanni Ferrari
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Luca Morelli
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Massimo Viola
- Department of Surgery, Ospedale Card. G. Panico, Tricase, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Troisi
- Division of HPB Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Elio Jovine
- Department of General Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, "Umberto I" Mauriziano Hospital, Turin, Italy
| | - Umberto Bracale
- Department Clinical Medicine and Surgery, Federico II University of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Sergio Alfieri
- Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, Department of Internal Medicine and Surgery (DIMEC), IRCCS, Azienda Ospedaliero Universitaria di Bologna Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giorgio Ercolani
- General and Oncology Surgery, Morgagni-Pierantoni Hospital, Forli, Italy
| | - Luca Moraldi
- Division of Oncologic Surgery and Robotics, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Carlo Molino
- Department of Oncological Surgery Team 1, "Antonio Cardarelli" Hospital, Naples, Italy
| | - Raffaele Dalla Valle
- Hepatobiliary Surgery Unit Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giuseppe Ettorre
- Transplantation Department, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreatic-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva Delle Fonti, Bari, Italy
| | - Giacomo Zanus
- 4th Surgery Unit, Azienda ULSS2 Marca Trevigiana, Treviso, Italy
| | - Andrea Belli
- Division of Hepatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, Naples, Italy
| | | | - Alberto Brolese
- Department of General Surgery and HPB Unit, Santa Chiara Hospital, Trento, Italy
| | - Andrea Coratti
- USL Toscana Sud Est, Misericordia Hospital, Grosseto, Italy
| | | | - Renato Romagnoli
- Liver Transplant Center-General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marco Massani
- Department of Surgery, Regional Hospital of Treviso, Treviso, Italy
| | | | | | - Roberto Coppola
- Department of Surgery, University Campus Bio-Medico of Rome, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, OSR ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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Robertson FP, Spiers HVM, Lim WB, Loveday B, Roberts K, Pandanaboyana S. Intraoperative pancreas stump perfusion assessment during pancreaticoduodenectomy: A systematic scoping review. World J Gastrointest Surg 2023; 15:1799-1807. [PMID: 37701689 PMCID: PMC10494594 DOI: 10.4240/wjgs.v15.i8.1799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/23/2023] [Accepted: 06/11/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is the primary cause of morbidity following pancreaticoduodenectomy. Rates of POPF have remained high despite well known risk factors. The theory that hypoperfusion of the pancreatic stump leads to anastomotic failure has recently gained interest. AIM To define the published literature with regards to intraoperative pancreas perfusion assessment and its correlation with POPF. METHODS A systematic search of available literature was performed in November 2022. Data extracted included study characteristics, method of assessment of pancreas stump perfusion, POPF and other post-pancreatic surgery specific complications. RESULTS Five eligible studies comprised two prospective non-randomised studies and three case reports, total 156 patients. Four studies used indocyanine green fluorescence angiography to assess the pancreatic stump, with the remaining study assessing pancreas perfusion by visual inspection of arterial bleeding of the pancreatic stump. There was significant heterogeneity in the definition of POPF. Studies had a combined POPF rate of 12%; intraoperative perfusion assessment revealed hypoperfusion was present in 39% of patients who developed POPF. The rate of POPF was 11% in patients with no evidence of hypoperfusion and 13% in those with evidence of hypoperfusion, suggesting that not all hypoperfusion gives rise to POPF and further analysis is required to analyse if there is a clinically relevant cut off. Significant variance in practice was seen in the pancreatic stump management once hypoperfusion was identified. CONCLUSION The current published evidence around pancreas perfusion during pancreaticoduodenectomy is of poor quality. It does not support a causative link between hypoperfusion and POPF. Further well-designed prospective studies are required to investigate this.
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Affiliation(s)
- Francis P Robertson
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, United Kingdom
| | - Harry V M Spiers
- Department of HPB Surgery, Addenbrookes Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Wei Boon Lim
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, United Kingdom
| | - Benjamin Loveday
- Department of General Surgery, Royal Melbourne Hospital, Melbourne VIC 3050, Australia
| | - Keith Roberts
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham BG15 2GW, United Kingdom
| | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, United Kingdom
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Sahakyan MA, Kleive D, Dille-Amdam RG, Kjeseth T, Waardal K, Edwin B, Nymo LS, Lassen K. The Role of Preoperative Inflammatory Markers in Pancreatectomy: a Norwegian Nationwide Cohort Study. J Gastrointest Surg 2023; 27:1650-1659. [PMID: 37322265 PMCID: PMC10412490 DOI: 10.1007/s11605-023-05726-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/27/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND PURPOSE Preoperative inflammatory markers, such as Glasgow prognostic score, modified Glasgow prognostic score and C-reactive protein to albumin ratio, were shown to be associated with prognosis in patients undergoing pancreatectomy for cancer. However, little is known about their predictive role in a Western population. METHODS The Norwegian National Registry for Gastrointestinal Surgery (NORGAST) was used to capture all pancreatectomies performed within the study period (November 2015-April 2021). The association between the preoperative inflammatory markers and postoperative outcomes was studied. Their impact on survival was examined in patients operated for pancreatic ductal adenocarcinoma. RESULTS A total of 1554 patients underwent pancreatectomy in this period. Glasgow prognostic score, modified Glasgow prognostic score and C-reactive protein to albumin ratio were associated with severe complications (Accordion grade ≥ III) in the univariable but not in the multivariable analysis. C-reactive protein to albumin ratio, but not Glasgow prognostic score and modified Glasgow prognostic score, was linked to survival following pancreatectomy for ductal adenocarcinoma. In the multivariable model, age, neoadjuvant chemotherapy, ECOG score, C-reactive protein to albumin ratio and total pancreatectomy correlated with survival. Also, preoperative C-reactive protein to albumin ratio was significantly associated with survival after pancreatoduodenectomy. CONCLUSIONS Preoperative Glasgow prognostic score, modified Glasgow prognostic score and C-reactive protein to albumin ratio have no role in predicting the complications after pancreatectomy. C-reactive protein to albumin ratio is a significant predictor for survival in ductal adenocarcinoma, yet its clinical relevance should be explored in conjunction with the pathology parameters and adjuvant therapy.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia.
| | - Dyre Kleive
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Rachel G Dille-Amdam
- Department of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Trond Kjeseth
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Kim Waardal
- Department of Acute and Digestive Surgery, Haukeland University Hospital, Bergen, Norway
| | - Bjørn Edwin
- The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, UiT, the Arctic University of Norway, Tromsø, Norway
| | - Kristoffer Lassen
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, UiT, the Arctic University of Norway, Tromsø, Norway
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10
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Elshami M, Hue JJ, Ahmed FA, Kakish H, Hoehn RS, Rothermel LD, Hardacre JM, Ammori JB, Winter JM, Ocuin LM. Defining Facility Volume Threshold for Optimization of Short- and Long-Term Outcomes in Patients Undergoing Resection of Perihilar Cholangiocarcinoma. J Gastrointest Surg 2022; 27:730-740. [PMID: 36138311 DOI: 10.1007/s11605-022-05465-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/10/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND We determined the minimum threshold (Tmin) of annual facility case volume to optimize outcomes for patients with resected perihilar cholangiocarcinoma. METHODS We identified patients with localized perihilar cholangiocarcinoma who underwent resection within the National Cancer Database (2010-2017). We used marginal structural logistic regression models to estimate the average treatment effect of receiving care in facilities meeting/exceeding Tmin on 90-day mortality and other postoperative outcomes. RESULTS A total of 2471 patients underwent resection for perihilar cholangiocarcinoma at 471 facilities. There was no effect of total hepatopancreatobiliary, surgical hepatopancreatobiliary, total hepatobiliary, surgical hepatobiliary, or total perihilar cholangiocarcinoma case volume on 90-day mortality. A Tmin of seven perihilar cholangiocarcinoma resections/year resulted in lower odds of 90-day mortality (IP-weighted OR = 0.49, 95% CI: 0.66-0.87). A total of two facilities met the Tmin. Patients receiving treatment at Tmin facilities had lower odds of length of stay ≥ 7 days (IP-weighted OR = 0.85, 95% CI: 0.75-0.97) and positive surgical resection margins (IP-weighted OR = 0.40, 95% CI: 0.47-0.55). Additionally, undergoing surgery at Tmin facilities resulted in higher (≥ 4 nodes) lymph node yields (IP-weighted OR = 1.94, 95% CI: 1.21-3.11) but no change in the odds of nodal positivity. There was no effect of undergoing surgery at Tmin facilities on 30-day mortality or re-admission. CONCLUSIONS Resection of perihilar cholangiocarcinoma is infrequently performed at a high number of facilities. A Tmin of ≥ 7 resections/year resulted in lower 90-day mortality and improved postoperative outcomes. Our data suggest that regionalization of care for patients with perihilar cholangiocarcinoma could potentially improve outcomes in the USA.
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Affiliation(s)
- Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Fasih Ali Ahmed
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Hanna Kakish
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Richard S Hoehn
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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Abstract
Mortality after pancreatoduodenectomy has improved over time. This progress is likely related to advancements in failure to rescue (FTR-the percentage of patients who die after developing a major complication). Several factors associated with FTR include patient-specific risks, development of certain postoperative complications, surgeon-specific factors, hospital-specific factors, rescue techniques, and regional differences. Efforts should be made to explore additional factors such as the influence of safety culture in the postoperative setting. Improvement in FTR may be better explored through randomized controlled postoperative management trials. In stable patients, management of complications by interventional radiology is preferred over reoperation.
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Affiliation(s)
- Elizabeth M Gleeson
- University of Edinburgh and Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland UK.
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey and Robert Wood Johnson University Hospital, 195 Little Albany Street, ET 834, New Brunswick, NJ 09083, USA
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12
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Huhta H, Nortunen M, Meriläinen S, Helminen O, Kauppila JH. Hospital volume and outcomes of pancreatic cancer: a Finnish population-based nationwide study. HPB (Oxford) 2022; 24:841-847. [PMID: 34824013 DOI: 10.1016/j.hpb.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/13/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic cancer surgery is associated with high incidence of short- and long-term morbidity and mortality. The aim of this study was to assess whether the hospital volume of pancreatic surgery is associated with better survival in a population-based setting. METHODS All patients who underwent pancreatic resection for cancer in Finland during 1997-2016 were identified from nationwide registries. The follow-up ended on 31 December 2019. Patients were divided into quintiles based on annual hospital volume (4-year moving average): ≤4, 5-9, 10-18, 19-36 and ≥ 37 resections per year. Cox regression provided hazard ratios (HR) and 95% confidence intervals (CI), adjusted for age, sex, comorbidity and year of surgery. RESULTS The number of diagnosed pancreatic cancers was 22,724. Of these, 1514 underwent pancreatic surgery due to pancreatic ductal adenocarcinoma. The 5-year survival ranged from 12% to 28%, increasing with higher annual operative volume. Adjusted 5-year mortality was higher in all other quintiles compared to the highest annual volume quintile (HR 1.43, 95% CI 1.16-1.75). Thirty and 90-day mortality were higher in the three lowest volume, compared to the highest quintile. CONCLUSION Higher annual hospital volume of pancreatic surgery for pancreatic ductal adenocarcinoma is associated with improved short- and long-term survival.
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Affiliation(s)
- Heikki Huhta
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland.
| | - Minna Nortunen
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland
| | - Sanna Meriläinen
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland
| | - Olli Helminen
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland
| | - Joonas H Kauppila
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland; Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
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13
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Smits FJ, Henry AC, Besselink MG, Busch OR, van Eijck CH, Arntz M, Bollen TL, van Delden OM, van den Heuvel D, van der Leij C, van Lienden KP, Moelker A, Bonsing BA, Borel Rinkes IH, Bosscha K, van Dam RM, Derksen WJM, den Dulk M, Festen S, Groot Koerkamp B, de Haas RJ, Hagendoorn J, van der Harst E, de Hingh IH, Kazemier G, van der Kolk M, Liem M, Lips DJ, Luyer MD, de Meijer VE, Mieog JS, Nieuwenhuijs VB, Patijn GA, Te Riele WW, Roos D, Schreinemakers JM, Stommel MWJ, Wit F, Zonderhuis BA, Daamen LA, van Werkhoven CH, Molenaar IQ, van Santvoort HC. Algorithm-based care versus usual care for the early recognition and management of complications after pancreatic resection in the Netherlands: an open-label, nationwide, stepped-wedge cluster-randomised trial. Lancet 2022; 399:1867-1875. [PMID: 35490691 DOI: 10.1016/s0140-6736(22)00182-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Early recognition and management of postoperative complications, before they become clinically relevant, can improve postoperative outcomes for patients, especially for high-risk procedures such as pancreatic resection. METHODS We did an open-label, nationwide, stepped-wedge cluster-randomised trial that included all patients having pancreatic resection during a 22-month period in the Netherlands. In this trial design, all 17 centres that did pancreatic surgery were randomly allocated for the timing of the crossover from usual care (the control group) to treatment given in accordance with a multimodal, multidisciplinary algorithm for the early recognition and minimally invasive management of postoperative complications (the intervention group). Randomisation was done by an independent statistician using a computer-generated scheme, stratified to ensure that low-medium-volume centres alternated with high-volume centres. Patients and investigators were not masked to treatment. A smartphone app was designed that incorporated the algorithm and included the daily evaluation of clinical and biochemical markers. The algorithm determined when to do abdominal CT, radiological drainage, start antibiotic treatment, and remove abdominal drains. After crossover, clinicians were trained in how to use the algorithm during a 4-week wash-in period; analyses comparing outcomes between the control group and the intervention group included all patients other than those having pancreatic resection during this wash-in period. The primary outcome was a composite of bleeding that required invasive intervention, organ failure, and 90-day mortality, and was assessed by a masked adjudication committee. This trial was registered in the Netherlands Trial Register, NL6671. FINDINGS From Jan 8, 2018, to Nov 9, 2019, all 1805 patients who had pancreatic resection in the Netherlands were eligible for and included in this study. 57 patients who underwent resection during the wash-in phase were excluded from the primary analysis. 1748 patients (885 receiving usual care and 863 receiving algorithm-centred care) were included. The primary outcome occurred in fewer patients in the algorithm-centred care group than in the usual care group (73 [8%] of 863 patients vs 124 [14%] of 885 patients; adjusted risk ratio [RR] 0·48, 95% CI 0·38-0·61; p<0·0001). Among patients treated according to the algorithm, compared with patients who received usual care there was a decrease in bleeding that required intervention (47 [5%] patients vs 51 [6%] patients; RR 0·65, 0·42-0·99; p=0·046), organ failure (39 [5%] patients vs 92 [10%] patients; 0·35, 0·20-0·60; p=0·0001), and 90-day mortality (23 [3%] patients vs 44 [5%] patients; 0·42, 0·19-0·92; p=0·029). INTERPRETATION The algorithm for the early recognition and minimally invasive management of complications after pancreatic resection considerably improved clinical outcomes compared with usual care. This difference included an approximate 50% reduction in mortality at 90 days. FUNDING The Dutch Cancer Society and UMC Utrecht.
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Affiliation(s)
- F Jasmijn Smits
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Mark Arntz
- Department of Radiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Thomas L Bollen
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Otto M van Delden
- Department of Radiology, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Daniel van den Heuvel
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Krijn P van Lienden
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Inne H Borel Rinkes
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Wouter J M Derksen
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Robbert J de Haas
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven and GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Mike Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven and GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - J Sven Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - Wouter W Te Riele
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Hospital, Delft, Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, Netherlands
| | - Babs A Zonderhuis
- Department of Surgery, Cancer Centre Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - C Henri van Werkhoven
- Julius Centre for Health Sciences and Primary Care, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands.
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14
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Valbekmo AG, Mo L, Gjøsund G, Håland E, Melby L. Exploring wait time variations in a prostate cancer patient pathway—A qualitative study. Int J Health Plann Manage 2022; 37:2122-2134. [PMID: 35347768 PMCID: PMC9543572 DOI: 10.1002/hpm.3454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 02/11/2022] [Accepted: 02/23/2022] [Indexed: 11/10/2022] Open
Abstract
Norwegian health authorities emphasise that all citizens should have equal access to healthcare and implement cancer patient pathways (CPPs) to ensure medical care for all patients within the same time frame and to avoid unwanted variation. Statistics regarding prostate cancer indicate longer wait times for patients from a local hospital compared to patients from a university hospital. This study describes which health system‐related factors influence variations in wait times. Eighteen healthcare workers participated in qualitative individual interviews conducted using a semi‐structured interview guide. Transcripts were analysed by systematic text condensation, which is a cross‐case method for the thematic analysis of qualitative data. The analysis unveiled four categories describing possible health system‐related factors causing variation in times spent on diagnostics for patients in the local hospital and in university hospital, respectively: (a) capacity and competence, (b) logistics and efficiency, (c) need for highly specialised investigations, and (d) need for extra consultations. Centralisation of surgical treatment necessitated the transfer of patients, with extra steps indicated in the CPP for patients transferring from the local hospital to the university hospital for surgery. The local hospital seemed to lack capacity more frequently than the university hospital. Possible factors explaining variations in wait time between the two hospitals concern both internal conditions at the hospitals in organising CPPs and the implications of transferring patients between hospitals. Differences in hospitals' capacity can cause variations in wait time. The extra steps involved in transferring patients between hospitals can lead to additional time spent in CPP. Centralisation of surgical treatment necessitated the transfer of patients The extra steps involved in transferring patients between hospitals can lead to additional time spent in cancer patient pathway It can be a demanding exercise to comply with the authorities' requirements for specific wait times and simultaneously centralise treatment Politicians and health authorities should have these implications of contradictory quality indicators in mind when designing patient pathways
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Affiliation(s)
| | - Lise Mo
- St. Olavs Hospital Regional Center for Health Care Improvement (RSHU) Trondheim Trøndelag Norway
| | - Gudveig Gjøsund
- Department of Social Research Norwegian University of Science and Technology Trondheim Trøndelag Norway
| | - Erna Håland
- Department of Education and Lifelong Learning Norwegian University of Science and Technology Trondheim Norway
| | - Line Melby
- Department of Health Research SINTEF Trondheim Norway
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15
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Nymo LS, Myklebust TÅ, Hamre H, Møller B, Lassen K. Treatment and survival of patients with pancreatic ductal adenocarcinoma: 15-year national cohort. BJS Open 2022; 6:zrac004. [PMID: 35257140 PMCID: PMC8902330 DOI: 10.1093/bjsopen/zrac004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 12/05/2021] [Accepted: 01/08/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Improvement in survival from pancreatic ductal adenocarcinoma (PDAC) has been reported in trial settings but is less explored in unselected cohorts. The aim of this study was to assess trends in provision of treatments and survival in Norway over a 15-year period following the implementation of hepato-pancreato-biliary (HPB) multidisciplinary teams, centralization of surgery, and implementation of modern chemotherapy (CTx) regimens. METHODS A population-based observational study was conducted by analysing all patients diagnosed with PDAC between 2004 and 2018 using coupled data from the Cancer Registry of Norway and the National Patient Registry. RESULTS A total of 10 630 patients were identified, of whom 1492 (14.0 per cent) underwent surgical resection. The resection rate, median age of those resected, and provision of perioperative CTx all increased over time. Median overall survival after resection improved from 16.0 months in the period 2004 to 2008 to 25.1 months in the period 2014 to 2018 (P < 0.001). For non-resected patients there was a rise in the provision of palliative chemotherapy, but little survival gain over time (median overall survival for 2004 to 2008 was 3.2 months versus 4.2 months for 2014 to 2018; P < 0.001). The rate of patients who did not receive any tumour-directed treatment (neither CTx nor surgery) was 44.3 per cent (2481 of 5603 patients) and decreased from 52.9 per cent in 2010 to 37.9 per cent in 2018 (P < 0.001). The median overall survival for all patients with PDAC increased from 3.7 months for 2004 to 2008 to 5.8 months for 2014 to 2018 (P < 0.001). CONCLUSION Survival after resection increased substantially, as did national resection rates. Little development in the provision of CTx or survival was observed for non-resected patients.
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Affiliation(s)
- Linn Såve Nymo
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
| | - Tor Åge Myklebust
- Department of Clinical and Registry-based Research, Cancer Registry of Norway, Oslo, Norway
| | - Hanne Hamre
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Bjørn Møller
- Department of Clinical and Registry-based Research, Cancer Registry of Norway, Oslo, Norway
| | - Kristoffer Lassen
- Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital Rikshospitalet, Oslo, Norway
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Bhandare MS, Mondal A, Chaudhari V, Bal M, Yadav S, Ramaswamy A, Ostwal V, Shetty N, Shrikhande SV. Factors influencing local and distant recurrence following resection of periampullary cancer. Br J Surg 2021; 108:427-434. [PMID: 33723577 DOI: 10.1093/bjs/znaa143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/27/2020] [Accepted: 11/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recurrence of periampullary cancer after pancreatoduodenectomy is common. The aim of this study was to investigate patterns of recurrence, incidence, and factors associated with local and distant recurrences. METHODS This retrospective, single-centre study included consecutive patients with periampullary cancer who underwent resection with curative intent from January 2012 to January 2018. Survival, patterns of recurrence, and factors associated with recurrences were analysed. RESULTS Median overall survival (OS) and disease-free survival among 398 included patients was 58.4 and 49.5 months respectively. Twenty-three patients (5.8 per cent) developed isolated local recurrences (LR), 50 (12.6 per cent) developed LR along with distant metastasis (DM), and 103 (25.9 per cent) developed isolated DM. Median OS was 40.4 months for patients with isolated LR versus 23 months for those with DM (P < 0.001). Tumour subtype (distal common bile duct (CBD): odds ratio (OR) 6.18, 95 per cent c.i. 2.19 to 17.46) and node-positive status (OR 2.36, 1.26 to 4.43) were independently associated with higher rates of LR. The most common site for isolated LR was along the superior mesenteric artery (12 of 23 patients). Tumour subtype (distal CBD: OR 2.86, 1.09 to 7.52), nodal positivity (OR 2.46, 1.53 to 3.94), and presence of perineural invasion (OR 1.80, 1.02 to 3.18) were independently associated with DM. CONCLUSION Isolated LR is associated with better survival than DM and occurs most commonly along the superior mesenteric artery.
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Affiliation(s)
- M S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - A Mondal
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - V Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - M Bal
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - S Yadav
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - A Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - V Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - N Shetty
- Department of Intervention Radiology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - S V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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Abstract
OBJECTIVE This analysis aimed to compare failure to rescue (FTR) after pancreatoduodenectomy across the Atlantic. SUMMARY BACKGROUND DATA FTR, or mortality after development of a major complication, is a quality metric originally created to compare hospital results. FTR has been studied in North American and Northern European patients undergoing pancreatoduodenectomy (PD). However, a direct comparison of FTR after PD between North America and Northern Europe has not been performed. METHODS Patients who underwent PD in North America, the Netherlands, Sweden and Germany (GAPASURG dataset) were identified from their respective registries (2014-17). Patients who developed a major complication defined as Clavien-Dindo ≥3 or developed a grade B/C postoperative pancreatic fistula (POPF) were included. Preoperative, intraoperative, and postoperative variables were compared between patients with and without FTR. Variables significant on univariable analysis were entered into a logistic regression for FTR. RESULTS Major complications occurred in 6188 of 22,983 patients (26.9%) after PD, and 504 (8.1%) patients had FTR. North American and Northern European patients with complications differed, and rates of FTR were lower in North America (5.4% vs 12%, P < 0.001). Fourteen factors from univariable analysis contributing to differences in patients who developed FTR were included in a logistic regression. On multivariable analysis, factors independently associated with FTR were age, American Society of Anesthesiology ≥3, Northern Europe, POPF, organ failure, life-threatening complication, nonradiologic intervention, and reoperation. CONCLUSIONS Older patients with severe systemic diseases are more difficult to rescue. Failure to rescue is more common in Northern Europe than North America. In stable patients, management of complications by interventional radiology is preferred over reoperation.
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