[Survival, mortality and quality of life after pylorus-preserving or classical Whipple operation. A systematic review with meta-analysis]

Is endocrine and exocrine function improved following duodenal preserving pancreatic head resection over whipple for chronic pancreatitis?

BACKGROUND

The aim of our study was to evaluate the rates of treatment for post-operative exocrine pancreatic insufficiency (EPI) and diabetes mellites (DM) between Duodenal Preserving Pancreatic Head Resections (DPPHR) and Pancreaticoduodenectomy (PD) from a prospectively maintained database of patients with chronic pancreatitis.

METHODS

104 patients were identified for inclusion, 62 of whom underwent DPPHR and 42 underwent PD. Study endpoints included changes in treatment for EPI and DM.

RESULTS

In the DPPHR group, the vast majority (n = 55) received a Frey procedure, with a small minority of patients undergoing a Beger procedure (n = 4) or Berne modification (n = 3). Patients in the DPPHR group had a lower rate of new persistent treatment for EPI post-operatively compared to patients who underwent PD (28.0% vs. 76.5%, p = 0.002). There was no difference in the rate of new onset DM, with low rates of new insulin dependent diabetics in both groups. Both groups had equal efficacy in terms of pain control, with 67.7% of the DPPHR group and 61.9% of the PD group remaining opioid free at long-term follow-up (p = 0.539).

CONCLUSION

In patients with head-predominant chronic pancreatitis, DPPHR was associated with reduced rates of new EPI treatment and similar endocrine function compared with PD.

Cholangiocarcinoma

Cholangiocarcinoma (CCA) is a highly lethal adenocarcinoma of the hepatobiliary system, which can be classified as intrahepatic, perihilar and distal. Each anatomic subtype has distinct genetic aberrations, clinical presentations and therapeutic approaches. In endemic regions, liver fluke infection is associated with CCA, owing to the oncogenic effect of the associated chronic biliary tract inflammation. In other regions, CCA can be associated with chronic biliary tract inflammation owing to choledocholithiasis, cholelithiasis, or primary sclerosing cholangitis, but most CCAs have no identifiable cause. Administration of the anthelmintic drug praziquantel decreases the risk of CCA from liver flukes, but reinfection is common and future vaccination strategies may be more effective. Some patients with CCA are eligible for potentially curative surgical options, such as resection or liver transplantation. Genetic studies have provided new insights into the pathogenesis of CCA, and two aberrations that drive the pathogenesis of non-fluke-associated intrahepatic CCA, fibroblast growth factor receptor 2 fusions and isocitrate dehydrogenase gain-of-function mutations, can be therapeutically targeted. CCA is a highly desmoplastic cancer and targeting the tumour immune microenvironment might be a promising therapeutic approach. CCA remains a highly lethal disease and further scientific and clinical insights are needed to improve patient outcomes.

Peri-operative, long-term, and quality of life outcomes after pancreaticoduodenectomy in the elderly: greater justification for periampullary cancer compared to pancreatic head cancer

BACKGROUND

Pancreaticoduodenectomy (PD) is more challenging in the elderly.

METHODS

Data of patients undergoing PD above 70 years of age was analysed to study short and long-term outcomes along with the quality of life parameters (QOL).

RESULTS

Out of 1271 PDs performed, 94 (7%) patients were 70 years or more. American Society of Anaesthesiology (ASA) scores were higher in comparison to patients below 70 years (ASA 1;20% vs. 54% and ASA 2&3;80% vs. 46%, p < 0.001). The postoperative 90-day mortality rate of 5.3% and morbidity (Clavein Grade III and IV of 27%) was higher but non-significant compared to 3.9% (p = 0.50) and 20% (p = 0.11) in patients less than 70 years. The median survival of 40 months was significantly better for periampullary carcinoma when compared to 15 months in pancreatic ductal adenocarcinoma (PDAC) (p < 0.0001). Patients, less than 70 years had significantly better 3-year survival; 64% vs 43% with periampullary etiology (p < 0.01) and 29% vs 0% with PDAC (p < 0.0001). QLQ-PAN 26 questionnaire responses were suggestive of good long term QOL in these patients.

CONCLUSION

Although PD is safe and feasible in the elderly population with good long-term QOL, postoperative morbidity and mortality can be slightly higher and long-term survival significantly lower.

Comparison of Quality of Life before and after pancreaticoduodenectomy: a prospective study

Background

Pancreatic cancer is an aggressive malignancy, and surgical resection is the only therapeutic option with pancreaticoduodenectomy being considered the standard of care. It is essential to take into account the patients’ Quality of Life after the resection, in order to make more informed decisions about treatment options.

Objective

The aim of the study was to determine perceived Quality of Life levels among patients who undergo pancreaticoduodenectomy, in a period of six months after surgery.

Methods

This prospective study was conducted on all patients (n=40) who underwent pancreaticoduodenectomy in Attikon University General Hospital in Athens, Greece, from January 2013 to June 2015. The Quality of Life was assessed by use of EORTC QLQ-C30 and EORTC QOL-PAN26 questionnaires at four phases: First, after admission at the hospital preoperatively, and then one month, three months, and six months postoperatively. Repeated measurements analysis of variance (ANOVA) was used in order to evaluate changes in Quality of Life measures during the follow-up (postoperative) period. Data analysis was conducted using SPSS version 19. A p-value of less than or equal to 0.05 was set as the level of significance.

Results

The study revealed a mixed image. Except for the nausea and vomiting scale, where indeed a symptom increase is initially reported and then gradually decreases below preoperative levels by 6 months, scoring in many symptom scales worsens postoperatively. From first to fourth assessment, fatigue (Mean from 23.61 to 38.72, p=0.005) and financial difficulties scoring (Mean from 5.98 to 42.42, p<0.001) consistently worsen. Functionality scales scoring also tends to get worse between first and fourth assessment, with statistically significant changes for physical (p<0.001), role (p<0.001) and social functioning (p<0.001). However, a slight improvement can be noted in many scales from third to fourth assessment, as in diarrhea (Mean from 32.38 to 29.29), pancreatic pain (Mean from 17.71 to 2.34), global health status (Mean from 50.48 to 52.53) and social functioning (Mean from 43.81 to 48.48) scales.

Conclusions

Quality of Life levels among patients who undergo pancreaticoduodenectomy are getting worse following surgery. However, the longitudinal study of these changes may improve patients’ postoperative life by formulating evidence-based interventions concerning symptoms treatment and psychological and social support.

Evidence-Based Surgical Treatments for Chronic Pancreatitis

BACKGROUND

If conservative treatment of chronic pancreatitis is unsuccessful, surgery is an option. The choice of the most suitable surgical method can be difficult, as the indications, advantages, and disadvantages of the available methods have not yet been fully documented with scientific evidence.

METHODS

In April 2015, we carried out a temporally unlimited systematic search for publications on surgery for chronic pancreatitis. The target parameters were morbidity, mortality, pain, endocrine and exocrine insuffi - ciency, weight gain, quality of life, length of hospital stay, and duration of urgery. Differences between surgical methods were studied with network meta-analysis, and duodenum-preserving operations were compared with partial duodenopancreatectomy with standard meta-analysis.

RESULTS

Among the 326 articles initially identified, 8 randomized controlled trials on a total of 423 patients were included in the meta-analysis. The trials were markedly heterogeneous in some respects. There was no significant difference among surgical methods with respect to perioperative morbidity, pain, endocrine and exocrine insufficiency, or quality of life. Duodenumpreserving procedures, compared to duodenopancreatectomy, were associated with a long-term weight gain that was 3 kg higher (p <0.001; three trials), a mean length of hospital stay that was 3 days shorter (p = 0.009; six trials), and a duration of surgery that was 2 hours shorter (p <0.001; five trials).

CONCLUSION

Duodenum-preserving surgery for chronic pancreatitis is superior to partial duodenopancreatectomy in multiple respects. Only limited recommendations can be given, however, on the basis of present data. The question of the best surgical method for the individual patient, in view of the clinical manifestations, anatomy, and diagnostic criteria, remains open.

Pylorus preservation pancreatectomy or not

Pancreaticoduodenectomy (PD) is the treatment of choice for various benign and malignant tumors of the pancreatic head or the periampullary region, and the only hope for cure in patients with cancer at this side. While it has been associated with high morbidity and mortality rates in the last century, its centralization in specialized institutions together with refinements in the operative technique and better management of postoperative complications have made PD a standardized, safe procedure. Besides the classic Whipple procedure including distal gastrectomy, two variations of PD with or without pylorus resection, but preservation of the entire stomach in either procedure exist today. Pylorus-preserving PD has gained wide acceptance as standard procedure and is being performed by an increasing number of pancreatic surgeons. After its oncological adequacy was questioned initially, pylorus-preserving PD was shown to be equivalent to the classic Whipple procedure regarding tumor recurrence and long-term survival. Moreover, operation time and blood loss were shown to be reduced in the pylorus-preserving procedure and benefits in nutritional status and quality of life were observed. However, preservation of the pylorus has been suggested to result in an increased incidence of postoperative delayed gastric emptying (DGE). In this context, pylorus-resecting PD has become popular especially in Japan with the aim to prevent DGE by removal of the pylorus but preservation of the stomach. In contrast to positive results from early studies, latest high-quality randomized controlled trial (RCT) data show that pylorus resection does not reduce DGE compared to the pylorus-preserving operation. Non-superiority of pylorus resection was also confirmed in current meta-analysis on this topic. This article summarizes the existing evidence on PD with or without pylorus preservation and derives recommendations for daily practice.

Quality of life and impact of bile reflux after retro colic retro gastric gastrojejunostomy in Whipple surgery

BACKGROUND

Delayed gastric emptying and bile reflux are common concerns in long-term survivors after Whipple surgery. The study was designed to assess modified retro colic retro gastric gastrojejunostomy in reducing macro and microscopic bile reflux and impact on dyspepsia related quality of life in long-term survivors.

METHODS

Out of 43 patients operated, 23 long-term survivors were included. All underwent gastroscopy and bile reflux was grouped as normal, yellowish bile lakes and presence of greenish bile lakes. Six standard gastric biopsies were taken. Microscopic bile reflux index (BRI) was calculated and a score more than 14 was considered significant. Validated Nepean dyspepsia index-short form (NDI-SF) was used to assess the severity of dyspepsia-related quality of life and compared with age and gender-matched control.

RESULTS

The median age was 48 (21-70) years. Median survival of the group was 37 months (6-40). Endoscopically, 20/23 (87%) had macroscopic bile reflux (74% yellowish bile lakes, 13% greenish bile lakes). None had stomal ulcers or macroscopic inflammation. Mean bile reflux index score was 9.7 (range 1.77-34). Mean NDI-SF score of Whipple group was 23.1 (SD 8.88). In controls, mean score was 19.9 (SD 8.23), showing no significant difference (p = 0.245).

CONCLUSIONS

Though there was macroscopic bile reflux, clinical symptoms and microscopic changes were minimal. The modified technique had good long-term results.

Pancreaticoduodenectomy in elderly adults: is it justified in terms of mortality, long-term morbidity, and quality of life?

OBJECTIVES

To evaluate long-term morbidity, mortality, and quality of life (QoL) after pancreaticoduodenectomy (PD) in elderly adults.

DESIGN

Retrospective cohort study.

SETTING

Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.

PARTICIPANTS

One hundred and sixty-eight individuals aged 70 and older who underwent PD between 1995 and 2010.

MEASUREMENTS

A prospective pancreatic surgery database was analyzed for postoperative morbidity; mortality; intensive care unit (ICU), hospital, and rehabilitation facility stay; and readmissions after surgery. QoL was assessed using a validated questionnaire completed 3, 6, and 12 months after surgery.

RESULTS

Seventy-two percent of the participants had an American Society of Anesthesiologists score of 3 or greater. There was no intraoperative death. Thirty- and 60-day postoperative mortality rates were 5.9% and 6.5%, respectively. Median ICU stay was 2 days, and median hospital stay was 22 days. Sixty-four participants (37.5%) were discharged to a rehabilitation facility. The first-year readmission rate was 31%. One- and 2-year overall survival rates were 58% and 36%, respectively. Global QoL scores 3 and 12 months after surgery were 68% and 73%, respectively. Scores were lower yet comparable with those of matched individuals undergoing laparoscopic cholecystectomy.

CONCLUSION

Most elderly adults with pancreatic cancer survive longer than 1 year after PD; 36% survive longer than 2 years. These individuals are likely to have acceptable long-term morbidity and overall good QoL, corresponding with their age.

The estimation of metaloproteinases and their inhibitors blood levels in patients with pancreatic tumors

Background

The aim of the study was to evaluate the concentration of proteolytic enzymes, MMP-2 and MMP-9, and their tissue inhibitors, TIMP-1 and TIMP-2, in the blood of patients with benign and malignant pancreatic tumors.

Methods

MMP-2, MMP-9, TIMP-1, and TIMP-2 were evaluated in the patients with benign and malignant pancreatic tumors before surgery and in the 30-day follow-up. The study covered 134 patients aged 54 to 76 years, who were divided into groups by TNM staging.

Results

Before the operation, the highest mean concentration of MMP-2 was found in patients with unresectable cancer, whereas the highest level of MMP-9 was in patients with resectable cancer. The highest level of TIMP-1 was noted in patients with inflammatory tumors. In 1 month following the operation, the highest level of MMP-2 was also in patients with unresectable cancer and the highest level of TIMP-2 in patients with inflammatory tumors.

Conclusions

The evaluation of the level of the studied cytokines in the pancreatic tumor patients can be diagnostically significant in the differentiation of benign and malignant changes. The changes in the levels of the studied enzymes and their inhibitors can have a prognostic value in the clinical severity of pancreatic cancer.

Partial pancreaticoduodenectomy can provide cure for duodenal gastrinoma associated with multiple endocrine neoplasia type 1

OBJECTIVE

To evaluate the outcome of pancreaticoduodenectomy (PD) versus non-PD resections for the treatment of gastrinoma in multiple endocrine neoplasia type 1.

BACKGROUND

Gastrinoma in MEN1 is considered a rarely curable disease and its management is highly controversial both for timing and extent of surgery.

METHODS

Clinical characteristics, complications and outcomes of 27 prospectively collected MEN1 patients with biochemically proven gastrinoma, who underwent surgery, were analyzed with special regard to the gastrinoma type and the initial operative procedure.

RESULTS

Twenty-two (81%) patients with gastrinoma in MEN1 had duodenal gastrinomas and 5 patients (19%) had pancreatic gastrinomas. At the time of diagnosis, 21 (77%) gastrinomas were malignant (18 duodenal, 3 pancreatic), but distant metastases were only present in 4 (15%) patients. Patients with pancreatic gastrinomas underwent either distal pancreatic resections or gastrinoma enucleation with lymphadenectomy, 2 patients also had synchronous resections of liver metastases. One of these patients was biochemically cured after a median of 136 (77-312) months. Thirteen patients with duodenal gastrinomas underwent PD resections (group 1, partial PD [n = 11], total PD [n = 2]), whereas 9 patients had no-PD resections (group 2) as initial operative procedure. Perioperative morbidity and mortality, including postoperative diabetes, differed not significantly between groups (P > 0.5). All patients of group 1 and 5 of 9 (55%) patients of group 2 had a negative secretin test at hospital discharge. However, after a median follow-up of 136 (3-276) months, 12 (92%) patients of group 1 were still normogastrinemic compared to only 3 of 9 (33%) patients of group 2 (P = 0.023). Three (33%) patients of group 2 had to undergo up to 3 reoperations for recurrent or metastatic disease compared to none of group 1.

CONCLUSIONS

Duodenal gastrinoma in MEN1 should be considered a surgically curable disease. PD seems to be the adequate approach to this disease, providing a high cure rate and acceptable morbidity compared to non-PD resections.

Ductal adenocarcinoma of the pancreatic head: A focus on current diagnostic and surgical concepts

Complete surgical resection still remains the only possibility of curing pancreatic cancer, however, only 10% of patients undergo curative surgery. Pancreatic resection currently remains the only method of curing patients, and has a 5-year overall survival rate between 7%-34% compared to a median survival of 3-11 mo for unresected cancer. Pancreatic surgery is a technically demanding procedure requiring highly standardized surgical techniques. Nevertheless, even in experienced hands, perioperative morbidity rates (delayed gastric emptying, pancreatic fistula etc.) are as high as 50%. Different strategies to reduce postoperative morbidity, such as different techniques of gastroenteric reconstruction (pancreatico-jejunostomy vs pancreatico-gastrostomy), intraoperative placement of a pancreatic main duct stent or temporary sealing of the main pancreatic duct with fibrin glue have not led to a significant improvement in clinical outcome. The perioperative application of somatostatin or its analogues may decrease the incidence of pancreatic fistulas in cases with soft pancreatic tissue and a small main pancreatic duct (< 3 mm). The positive effects of external pancreatic main duct drainage and antecolic gastrointestinal reconstruction have been observed to decrease the rate of pancreatic fistulas and delayed gastric emptying, respectively. Currently, the concept of extended radical lymphadenectomy has been found to be associated with higher perioperative morbidity, but without any positive impact on overall survival. However, there is growing evidence that portal vein resections can be performed with acceptable low perioperative morbidity and mortality but does not achieve a cure.

[Contribution of the Study Center of the German Surgical Society to evidence based surgery]

Since the Study Center of the German Surgical Society (SDGC) was established in 2003 it has been supporting surgeons to implement their ideas for multicenter randomized studies. Assistance is provided for development (sample size calculation, protocol, funding application) implementation (submission to ethics committee, data management, monitoring) and analysis (statistical analysis, publication) in close collaboration with biometricians and data managers. Currently more than 2,500 patients have been included in 11 trials. The most complex SDGC study (SYNCHRONOUS) so far with up to 80 participating centers has been activated in September 2011. Furthermore, there is an increasing relevance for systematic reviews and meta analyses with regard to the development of studies and aggregation of results. For this reason a systematic review working group was established within the SDGC. To date 13 publications have been completed and 8 more are underway.