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Trébol J, Carabias-Orgaz A, Esteban-Velasco MC, García-Plaza A, González-Muñoz JI, Sánchez-Casado AB, Parreño-Manchado FC, Eguía-Larrea M, Alcázar-Montero JA. Digestive and breast cancer patients managed during the first wave of COVID-19 pandemic: Short and middle term outcomes. World J Methodol 2024; 14:92612. [PMID: 38983654 PMCID: PMC11229877 DOI: 10.5662/wjm.v14.i2.92612] [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: 01/31/2024] [Revised: 04/29/2024] [Accepted: 05/23/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND The first wave of coronavirus disease 2019 (COVID-19) pandemic in Spain lasted from middle March to the end of June 2020. Spanish population was subjected to lockdown periods and scheduled surgeries were discontinued or reduced during variable periods. In our centre, we managed patients previously and newly diagnosed with cancer. We established a strategy based on limiting perioperative social contacts, preoperative screening (symptoms and reverse transcription-polymerase chain reaction) and creating separated in-hospital COVID-19-free pathways for non-infected patients. We also adopted some practice modifications (surgery in different facilities, changes in staff and guidelines, using continuously changing personal protective equipment…), that supposed new inconveniences. AIM To analyse cancer patients with a decision for surgery managed during the first wave, focalizing on outcomes and pandemic-related modifications. METHODS We prospectively included adults with a confirmed diagnosis of colorectal, oesophago-gastric, liver-pancreatic or breast cancer with a decision for surgery, regardless of whether they ultimately underwent surgery. We analysed short-term outcomes [30-d postoperative morbimortality and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection] and outcomes after 3 years (adjuvant therapies, oncological events, death, SARS-CoV-2 infection and vaccination). We also investigated modifications to usual practice. RESULTS From 96 included patients, seven didn't receive treatment that period and four never (3 due to COVID-19). Operated patients: 28 colon and 21 rectal cancers; laparoscopy 53.6%/90.0%, mortality 3.57%/0%, major complications 7.04%/25.00%, anastomotic leaks 0%/5.00%, 3-years disease-free survival (DFS) 82.14%/52.4% and overall survival (OS) 78.57%/76.2%. Six liver metastases and six pancreatic cancers: no mortality, one major complication, three grade A/B liver failures, one bile leak; 3-year DFS 0%/33.3% and OS 50.0%/33.3% (liver metastases/pancreatic carcinoma). 5 gastric and 2 oesophageal tumours: mortality 0%/50%, major complications 0%/100%, anastomotic leaks 0%/100%, 3-year DFS and OS 66.67% (gastric carcinoma) and 0% (oesophagus). Twenty breast cancer without deaths/major complications; 3-year OS 100% and DFS 85%. Nobody contracted SARS-CoV-2 postoperatively. COVID-19 pandemic-related changes: 78.2% treated in alternative buildings, 43.8% waited more than 4 weeks, two additional colostomies and fewer laparoscopies. CONCLUSION Some patients lost curative-intent surgery due to COVID-19 pandemic. Despite practice modifications and 43.8% delays higher than 4 weeks, surgery was resumed with minimal changes without impacting outcomes. Clean pathways are essential to continue surgery safely.
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Affiliation(s)
- Jacobo Trébol
- Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca 37007, Salamanca, Spain
- Cirugía, Universidad de Salamanca, Salamanca 37007, Salamanca, Spain
| | - Ana Carabias-Orgaz
- Oftalmología, Complejo Asistencial Universitario de Salamanca, Salamanca 37007, Salamanca, Spain
| | - María Carmen Esteban-Velasco
- Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca 37007, Salamanca, Spain
- Cirugía, Universidad de Salamanca, Salamanca 37007, Salamanca, Spain
| | - Asunción García-Plaza
- Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca 37007, Salamanca, Spain
| | - Juan Ignacio González-Muñoz
- Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca 37007, Salamanca, Spain
- Cirugía, Universidad de Salamanca, Salamanca 37007, Salamanca, Spain
| | - Ana Belén Sánchez-Casado
- Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca 37007, Salamanca, Spain
| | - Felipe Carlos Parreño-Manchado
- Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca 37007, Salamanca, Spain
- Cirugía, Universidad de Salamanca, Salamanca 37007, Salamanca, Spain
| | - Marta Eguía-Larrea
- Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca 37007, Salamanca, Spain
- Cirugía, Universidad de Salamanca, Salamanca 37007, Salamanca, Spain
| | - José Antonio Alcázar-Montero
- Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca 37007, Salamanca, Spain
- Cirugía, Universidad de Salamanca, Salamanca 37007, Salamanca, Spain
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Wang Y, Wen N, Xiong X, Li B, Lu J. Biliary drainage in malignant biliary obstruction: an umbrella review of randomized controlled trials. Front Oncol 2023; 13:1235490. [PMID: 37731638 PMCID: PMC10508238 DOI: 10.3389/fonc.2023.1235490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/21/2023] [Indexed: 09/22/2023] Open
Abstract
Background There are still many controversies about biliary drainage in MBO, and we aimed to summarize and evaluate the evidence associated with biliary drainage. Methods We conducted an umbrella review of SRoMAs based on RCTs. Through July 28, 2022, Embase, PubMed, WOS, and Cochrane Database were searched. Two reviewers independently screened the studies, extracted the data, and appraised the methodological quality of the included studies. GRADE was used to evaluate the quality of the evidence. Results 36 SRoMAs were identified. After excluding 24 overlapping studies, 12 SRoMAs, including 76 RCTs, and 124 clinical outcomes for biliary drainage in MBO were included. Of the 124 pieces of evidence evaluated, 13 were rated "High" quality, 38 were rated "Moderate", and the rest were rated "Low" or "Very low". For patients with MBO, 125I seeds+stent can reduce the risk of stent occlusion, RFA+stent can improve the prognosis; compared with PC, SEMS can increase the risk of tumor ingrowth and reduce the occurrence of sludge formation, and the incidence of tumor ingrowth in C-SEMS/PC-SEMS was significantly lower than that in U-SEMS. There was no difference in the success rate of drainage between EUS-BD and ERCP-BD, but the use of EUS-BD can reduce the incidence of stent dysfunction. For patients with obstructive jaundice, PBD does not affect postoperative mortality compared to direct surgery. The use of MS in patients with periampullary cancer during PBD can reduce the risk of re-intervention and stent occlusion compared to PC. In addition, we included four RCTs that showed that when performing EUS-BD on MBO, hepaticogastrostomy has higher technical success rates than choledochoduodenostomy. Patients who received Bilateral-ENBD had a lower additional drainage rate than those who received Unilateral-ENBD. Conclusions Our study summarizes a large amount of evidence related to biliary drainage, which helps to reduce the uncertainty in the selection of biliary drainage strategies for MBO patients under different circumstances.
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Affiliation(s)
- Yaoqun Wang
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ningyuan Wen
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xianze Xiong
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bei Li
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiong Lu
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Watanabe J, Miki A, Sasanuma H, Kotani K, Sata N. Metal vs plastic stents for preoperative biliary drainage in patients with periampullary cancer: An updated systematic review and meta-analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:6-20. [PMID: 35466557 DOI: 10.1002/jhbp.1162] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/10/2022] [Accepted: 03/27/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND/PURPOSE Metal stents (MS) are recommended for preoperative biliary drainage (PBD) in patients with periampullary cancer, but whether MS are superior in terms of re-intervention and direct cost is debatable. This study aimed to compare the effects of MS and PS on the outcomes of patients with periampullary cancer. METHODS For this random-effects meta-analysis, electronic databases were screened for randomized controlled trials (RCTs) published until January 2022. Subgroup analyses were performed basis on the center type and presence of NAC. RESULTS In this meta-analysis, seven RCTs (440 participants) were included. MS reduced re-interventions (risk ratio [RR] = 0.42, 95% confidence interval [CI] = 0.25-0.72) and direct costs (mean difference = -474 USD, 95% CI = -656 to -292). PBD-related complications (RR = 0.74, 95% CI = 0.32-1.71) and postoperative complications (RR = 0.73, 95% CI = 0.45-1.17) did not differ between MS and PS. Compared PS, MS reduced postoperative complications in high-volume centers (RR = 0.64, 95% CI = 0.49-0.84) and PBD-related complications in patients receiving NAC (RR = 0.29, 95% CI = 0.08-1.08). CONCLUSIONS Metal stents likely reduces re-interventions and direct costs. Further studies are needed to confirm the effects of MS on the outcomes.
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Affiliation(s)
- Jun Watanabe
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
- Division of Community and Family Medicine, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
| | - Atsushi Miki
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
| | - Hideki Sasanuma
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
| | - Naohiro Sata
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
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McKay SC. Outcomes of patients undergoing elective liver and pancreas cancer surgery during the SARS-CoV-2 pandemic: an international, multicentre, prospective cohort study. HPB (Oxford) 2022; 24:1668-1678. [PMID: 35562256 PMCID: PMC8925198 DOI: 10.1016/j.hpb.2022.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/02/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The effect of SARS-CoV-2 infection upon HPB cancer surgery perioperative outcomes is unclear. Establishing risk is key to individualising treatment pathways. We aimed to identify the mortality rate and complications risk for HPB cancer elective surgery during the pandemic. METHODS International, prospective, multicentre study of consecutive adult patients undergoing elective HPB cancer operations during the initial SARS-CoV-2 pandemic. Primary outcome was 30-day perioperative mortality. Secondary outcomes included major and surgery-specific 30-day complications. Multilevel cox proportional hazards and logistic regression models estimated association of SARS-CoV-2 and postoperative outcomes. RESULTS Among 2038 patients (259 hospitals, 49 countries; liver n = 1080; pancreas n = 958) some 6.2%, n = 127, contracted perioperative SARS-CoV-2. Perioperative mortality (9.4%, 12/127 vs 2.6%, 49/1911) and major complications (29.1%, 37/127 vs 13.2%, 253/1911) were higher with SARS-CoV-2 infection, persisting when age, sex and comorbidity were accounted for (HR survival 4.15, 95% CI 1.64 to 10.49; OR major complications 3.41, 95% CI 1.72 to 6.75). SARS-CoV-2 was associated with late postoperative bleeding (11.0% vs 4.2%) and grade B/C postoperative pancreatic fistula (17.9% vs 8.6%). CONCLUSION SARS-CoV-2 infection was associated with significantly higher perioperative morbidity and mortality. Patients without SARS-CoV-2 had acceptable morbidity and mortality rates, highlighting the need to protect patients to enable safe ongoing surgery.
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Key Words
- strobe, strengthening the reporting of observational studies in epidemiology
- hcc, hepatocellular carcinoma
- cca, cholangiocarcinoma
- crlm, colorectal liver metastasis
- ards, acute respiratory distress syndrome
- isgls, international study group of liver surgery
- isgps, international study group on pancreatic surgery
- qrt-pcr, quantitative reverse transcription polymerase chain reaction
- ct, computed tomography
- redcap, research electronic capture database
- asa, american association of anesthesiologists
- tace, transarterial chemoembolization
- rfa, radiofrequency ablation
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Affiliation(s)
- Siobhan C. McKay
- Liver Unit, Queen Elizabeth Hospital Birmingham, UK,Department of Academic Surgery, University of Birmingham, UK,Correspondence: Siobhan C McKay, Liver Unit, Queen Elizabeth Hospital Birmingham, UK
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Hansen CP, Storkholm JH, Sillesen MH, Krohn PS, Burgdorf SK, Hillingsø JG. Pancreatic surgery during the COVID-19 pandemic 2020-2021: an observational cohort study from a third level referral center. BMC Surg 2022; 22:200. [PMID: 35597984 PMCID: PMC9124050 DOI: 10.1186/s12893-022-01651-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background During the COVID pandemic there has been limited access to elective surgery including oncologic surgery in several countries world-wide. The aim of this study was to investigate if there was any lockdown effect on pancreatic surgery with special focus on malignant pancreatic and periampullary tumours. Methods Patients who underwent pancreatic surgery during the two Danish lockdown periods from 11. March 2020 and the following 12 months were compared with patients who were operated the preceding 3 years. Data on patients’ characteristics, waiting time, operations, and clinical outcomes were evaluated. Results During lockdown and the previous three years the annual number of resections were 242, 232, 253, and 254, respectively (p = 0.851). Although the numbers were not significantly different, there were fluctuations in operations and waiting time during the lockdown. During the second outbreak of COVID October 2020 to March 2021 the overall median waiting time increased to 33 days (quartiles 26;39) compared to 23 (17;33) days during the first outbreak from March to May 2020 (p = 0.019). The same difference was seen for patients with malignant tumours, 30 (23;36) vs. 22 (18;30) months (p = 0.001). However, the fluctuations and waiting time during lockdown was like the preceding three years. Neither 30- nor 90-days mortality, length of stay, number of extended operations, and complications and tumour stage were significantly different from previous years. Conclusions There were significant fluctuations in waiting time for operations during the lockdown, but these variations were not different from the preceding three years, wherefore other explanations than an impact from COVID are conceivable.
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Affiliation(s)
- Carsten Palnæs Hansen
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark.
| | - Jan Henrik Storkholm
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Martin Hylleholt Sillesen
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Paul Suno Krohn
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Stefan Kobbelgaard Burgdorf
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Jens Georg Hillingsø
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
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Nehme F, Lee JH. Preoperative biliary drainage for pancreatic cancer. Dig Endosc 2022; 34:428-438. [PMID: 34275165 DOI: 10.1111/den.14081] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/15/2021] [Indexed: 12/15/2022]
Abstract
Pancreatic adenocarcinoma is currently one of the leading causes of cancer-related morbidity and mortality with dismal long term survival after diagnosis. Nearly 85% of pancreatic cancer patients present with advanced disease precluding curative surgical resection. In those who are candidates for surgery, preoperative biliary drainage (PBD) has been developed since the 1960s in order to improve surgical outcomes. While obstructive jaundice in resectable pancreatic cancer has been traditionally treated before surgical resection in all patients, data over the past decade demonstrated increased perioperative complications and morbidity with systematic PBD compared to direct surgery. With new evidence of potential adverse events, the role of routine PBD is being reassessed. Current indications for PBD include cholangitis, delayed surgery, and relief of jaundice in patients planned to receive neoadjuvant therapy (NAT). NAT is being increasingly utilized in borderline resectable as well as resectable pancreatic cancer and a higher proportion of patients with likely require PBD in the future. The evidence for endoscopic retrograde cholangiopancreatography as first line for PBD is robust with supporting data from endoscopic ultrasound assisted biliary drainage. Self-expanding metal stent was shown to be cost-effective in recent studies without increase in morbidity compared to plastic stents in this setting. In this review, we will summarize the current evidence for PBD in patients with pancreatic cancer.
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Affiliation(s)
- Fredy Nehme
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, USA
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Gemenetzis G, McKay S, Pathak S, Moir J, Laing R, Jamieson NB, Young AL, Chatzizacharias NA, Giovinazzo F, Roberts KJ. Surgical Management of Non-Metastatic Pancreatic Cancer in the United Kingdom: Results of a Nationwide Survey on Current Practice. Front Oncol 2021; 11:791946. [PMID: 35004314 PMCID: PMC8733562 DOI: 10.3389/fonc.2021.791946] [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: 10/11/2021] [Accepted: 12/01/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundIt is presently unclear what clinical pathways are followed for patients with non-metastatic PDAC in specialised centres for pancreatic surgery across the United Kingdom (UK).MethodsBetween August 2019 and August 2020 an electronic survey was conducted aiming at a national cohort of pancreatic surgeons in the UK. Participants replied to a list of standardised questions and clinical vignettes, and data were collected and analysed focusing on management preferences, resectability criteria, and contraindications to surgery.ResultsWithin the study period, 65 pancreatic surgeons from 27 specialist centres in the UK (96%) completed the survey. Multidisciplinary team meetings are utilised universally for the management of patients with PDAC, however, different staging systems for resectability classification are being applied. In borderline resectable PDAC, most surgeons were keen to proceed with surgical exploration post NAT, but differences were noted in preferred chemotherapy regimens. Surgeons from standard volume institutions performed fewer vein resections annually and were more likely to deem patients with locally advanced PDAC as unresectable. Intra-institutional variability in patient management was also present and ranging between 20-80%.ConclusionsSignificant variability in the surgical management of non-metastatic PDAC was identified both on inter- and intra-institutional level.
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Affiliation(s)
- Georgios Gemenetzis
- Department of Hepatobiliary (HPB) and Transplant Surgery, Royal Infirmary Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Keith J. Roberts, ; Georgios Gemenetzis,
| | - Siobhan McKay
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Samir Pathak
- Department of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - John Moir
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, The Freeman Hospital, Newcastle, United Kingdom
| | - Richard Laing
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Nigel B. Jamieson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Alastair L. Young
- Department of Pancreatic Surgery, St James’s University Hospital, Leeds, United Kingdom
| | | | - Francesco Giovinazzo
- Department of General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Keith J. Roberts
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
- *Correspondence: Keith J. Roberts, ; Georgios Gemenetzis,
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Marchegiani G, Perri G, Bianchi B, Esposito A, Landoni L, Casetti L, Tuveri M, Malleo G, Paiella S, Fontana M, Pea A, De Pastena M, Salvia R, Bassi C. Pancreatic surgery during COVID-19 pandemic: major activity disruption of a third-level referral center during 2020. Updates Surg 2021; 74:953-961. [PMID: 34689316 PMCID: PMC8541802 DOI: 10.1007/s13304-021-01197-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/18/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The COVID-19 pandemic has severely limited the access to cancer surgery, but it is not known to what extent referral centers for pancreatic diseases were affected by its outbreak. The aim of this study is to describe the effect of COVID-19 pandemic on a third-level referral center for pancreatic surgery in Italy. METHODS The 2020 activity of The Pancreas Institute of the University of Verona was reviewed, comparing different phases of the COVID-19 pandemic outbreaks using the pre-COVID era as a control. Endpoints were the overall caseload of pancreatic resections, surgical waiting list, administration of preoperative therapy, major morbidity and mortality, residents' training; number of inpatients beds, outpatient visits/procedures/diagnostics. RESULTS In 2020, there was an overall significant reduction of pancreatic resections performed (394 vs. 506 in 2019), particularly during the first (March-May) and second (October-December) COVID-19 outbreaks, with an all-time-low of 16 resections/months in April (compared to 43 average resection/month in 2019). The rates of major morbidity (Clavien-Dindo ≥ 3) and mortality were similar to 2019 (16 vs 12%, p = 0.11 and 3 vs 2%, p = 0.29, respectively). During the first and second outbreaks resident's training, inpatient beds, outpatient visits, diagnostics, and procedures were severely impaired, while the waiting list for up-front cancer resections and the use of preoperative chemotherapy concomitantly raised. CONCLUSION The COVID-19 pandemic has severely disrupted the activity of a third-level referral center for pancreatic surgery, affecting the access to cancer surgical procedures and raising concerns regarding the solidity of the current centralization model.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy.
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Beatrice Bianchi
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Luca Landoni
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Luca Casetti
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Massimiliano Tuveri
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Martina Fontana
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Antonio Pea
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Matteo De Pastena
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
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Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13071669. [PMID: 33916294 PMCID: PMC8037133 DOI: 10.3390/cancers13071669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life. Abstract Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.
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Pande R, Hodson J, Marudanayagam R, Chatzizacharias N, Dasari B, Muiesan P, Sutcliffe RP, Mirza DF, Isaac J, Roberts KJ. Survival Advantage of Upfront Surgery for Pancreatic Head Cancer Without Preoperative Biliary Drainage. Front Oncol 2020; 10:526514. [PMID: 33251128 PMCID: PMC7673268 DOI: 10.3389/fonc.2020.526514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 10/13/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction Level 1 evidence from randomized trials demonstrates less complication when jaundiced patients with resectable pancreatic cancer proceed directly to surgery, rather than undergo preoperative biliary drainage (PBD) first. Although "fast track" surgery significantly increases the resectability rate, it is unknown whether this translates into a survival benefit. This study evaluated the effect of upfront surgery on long-term survival using an intention-to-treat (ITT) analysis. Methods Patients were identified from a prospectively maintained database, stratified according to whether or not they underwent PBD. Results Among 157 patients, 84 (54%) underwent PBD. Of these, 73% underwent surgery, compared to 100% of those without PBD (p<0.001). Reasons for not undergoing surgery were progression of cancer (N=11), progressive frailty (N=5), or PBD-related complication (N=7). In those who underwent surgery, PBD was associated with a longer time from diagnosis to surgery (median: 59 vs. 14 days, p<0.001), and a higher rate of unresectable cancer at surgery (26% vs. 3%, p<0.001). On an ITT basis, patients treated with PBD had significantly shorter survival, at a median of 15 vs. 19 months (HR: 1.59, 95% CI: 1.07-2.37, p=0.023). However, for the subset of patients who underwent resection, survival was similar in the two groups (HR: 1.07, 95% CI: 0.66-1.73, p=0.773). Conclusions A reduced time to surgery with avoidance of PBD offers survival benefit. This is only appreciated on ITT analysis, which includes patients who are initially considered candidates for surgery, but ultimately do not undergo surgery. Considering this 'hidden' cohort of patients is important when considering optimal pathways for the treatment of resectable pancreatic cancer.
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Affiliation(s)
- Rupaly Pande
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ravi Marudanayagam
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - N Chatzizacharias
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Bobby Dasari
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Paolo Muiesan
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Robert P Sutcliffe
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Darius F Mirza
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - John Isaac
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Keith J Roberts
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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