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Hao X, Li Y, Liu L, Bai J, Liu J, Jiang C, Zheng L. Is duct-to-mucosa pancreaticojejunostomy necessary after pancreaticoduodenectomy: A meta-analysis of randomized controlled trials. Heliyon 2024; 10:e33156. [PMID: 39040391 PMCID: PMC11260976 DOI: 10.1016/j.heliyon.2024.e33156] [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: 02/19/2023] [Revised: 06/11/2024] [Accepted: 06/14/2024] [Indexed: 07/24/2024] Open
Abstract
The incidence of postoperative pancreatic fistula is influenced by the effectiveness of the pancreaticojejunostomy, and the most suitable pancreaticojejunostomy for pancreaticoduodenectomy remains uncertain. Since grade A postoperative pancreatic fistula is no longer considered a true fistula, the purpose of this meta-analysis was to compare the effectiveness of duct-to-mucosa anastomosis and invagination anastomosis in reducing the incidence of grade B/C postoperative pancreatic fistula. The meta-analysis was conducted using software Review Manager 5.3, and the fixed-effect model was employed for pooled statistic calculations. The Cochrane Collaboration Risk of Bias Tool was utilized for quality assessment. Ten randomized controlled trials from Embase, Web of Science, MEDLINE, and the Cochrane Library (1990.01-2022.10) including 1471 patients, met the inclusion criteria. This meta-analysis has been registered on PROSPERO with the registration number CRD42023491673. The incidence of grade B/C fistula was significantly lower in the invagination group (7.7 %) compared to the duct-to-mucosa group (12.8 %, mostly Cattell manner)(RR = 1.65, 95%CI: 1.14-2.39, P = 0.008; heterogeneity: P = 0.008, I2 = 68 %),heterogeneity among the results was addressed through sensitivity analysis. In patients with a soft pancreas, the incidence of grade B/C fistula was significantly lower in those who underwent invagination anastomosis (10 %) compared to those who underwent duct-to-mucosa anastomosis (41.9 %)(RR = 4.19, 95%CI: 1.33-13.25, P = 0.01).No significant differences were observed in terms of the occurrence of grade B/C fistula in firm pancreas, postoperative mortality, other major postoperative complications, anastomosis time, and postoperative bile leak. Therefore, we concluded that invagination anastomosis is significantly superior to duct-to-mucosa anastomosis in reducing the incidence of grade B/C fistula, especially in patients with a soft pancreas.
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Affiliation(s)
- Xiaofei Hao
- Fourth Outpatient Department, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Yi Li
- Section for Day Surgery, Department of General Surgery, The Third People's Hospital of Chengdu & The Affiliated Hospital of Southwest Jiaotong University, Chengdu, Sichuan, China
| | - Lin Liu
- Fourth Outpatient Department, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Jian Bai
- Fourth Outpatient Department, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Jia Liu
- Fourth Outpatient Department, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Cuinan Jiang
- Section for HepatoPancreatoBiliary Surgery, Department of General Surgery, The Third People's Hospital of Chengdu & The Affiliated Hospital of Southwest Jiaotong University, Chengdu, Sichuan, China
| | - Lu Zheng
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Army Medical University, Chongqing, China
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2
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Lu W, Wang L, Lou J, Tang K. Sequential therapy for pancreatic cancer patients with synchronous oligo-hepatic metastatic lesions. TUMORI JOURNAL 2023; 109:307-313. [PMID: 35815545 DOI: 10.1177/03008916221110265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Treatments for patients suffering from pancreatic cancer with oligo-hepatic metastasis have always been a cause of certain controversy. Herein, we reported 15 pancreatic cancer patients with oligo-hepatic metastasis who accepted sequential therapy of chemotherapy, radiofrequency ablation (RFA), and radical resection of the primary tumor. METHODS A total of 87 pancreatic cancer patients with synchronous oligo-metastatic hepatic lesions who received treatments in the 2nd Affiliated Hospital of Zhejiang University between January 2017 and July 2020 were enrolled. The chemotherapy regimens included modified folfirinox (54/87) and gemcitabine plus nab-paclitaxel (33/87). Test of blood tumor markers and contrast-enhanced computed tomography (CT) or magnetic resonance (MR) scan was performed at diagnosis and after eight weeks of chemotherapy. RESULTS Thirty-five patients received just chemotherapy because of poor reaction to the first round of chemotherapy(Overall survival (OS), 6.47±1.80 months); 15 patients reassessed as stable disease (SD)/partial response (PR) continued chemotherapy (OS, 10.35±3.15); nine patients reassessed as progressive disease (PD) after RFA and continued chemotherapy (OS, 10.90±2.60). The primary tumors in 13 patients were unresectable after chemotherapy and RFA (OS, 12.92±2.47), while 15 patients completed the sequential therapy of chemotherapy, radio-frequency ablation, and radical resection (OS, 16.76±6.55). CONCLUSIONS Sequential chemotherapy and RFA is a good treatment strategy to select the best candidates for surgical treatment among patients with pancreatic cancer with oligo-hepatic metastasis.
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Affiliation(s)
- Wenjie Lu
- Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lantian Wang
- Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianyao Lou
- Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kezhong Tang
- Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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3
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Giuliani T, Di Gioia A, Andrianello S, Marchegiani G, Bassi C. Pancreatoduodenectomy associated with colonic resections: indications, pitfalls, and outcomes. Updates Surg 2021; 73:379-390. [PMID: 33582983 DOI: 10.1007/s13304-021-00996-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
Pancreatoduodenectomy (PD) associated with colonic resections (CR) (PD-CR) might be a viable option in case of locally advanced periampullary tumors or right colon cancer. The aim of this review was to reappraise the indications and outcomes of PD-CR focusing on the occurrence of postoperative pancreatic fistula (POPF) and colonic anastomotic leak (CAL). A systematic literature search was performed in Medline and Cochrane Central Register of Controlled Trials (CENTRAL) for studies published between 2000 and 2020 concerning PD-CR for periampullary or colonic neoplasms. Twenty-seven studies were selected. Morbidity after PD-CR ranged from 12 to 65% and surgery-related mortality was approximately 10%. When reported, the rates of POPF and AL were as high as 40% and 33%, respectively. The oncological results were strictly linked to the nature of the primary tumor and did not significantly differ from those achieved with standard resections. Surgical radicality and nodal status resulted the main determinants of outcome for pancreatic and colonic cancer, respectively. Solid evidence about the surgical outcomes of PD-CR is lacking, mainly due to the small proportion of patients undergoing such combined resection. Given the elevated surgical risk, a multidisciplinary evaluation is recommended for patient's selection. The increasing use of neoadjuvant therapies is expected to further change the indications and outcomes of PD-CR in the next future.
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Affiliation(s)
- Tommaso Giuliani
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, P.le A. Scuro 10, 37134, Verona, Italy.
| | - Anthony Di Gioia
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, P.le A. Scuro 10, 37134, Verona, Italy
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, P.le A. Scuro 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, P.le A. Scuro 10, 37134, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, P.le A. Scuro 10, 37134, Verona, Italy
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Filippini DM, Grassi E, Palloni A, Carloni R, Casadei R, Ricci C, Serra C, Ercolani G, Brandi G, Di Marco M. Searching for novel multimodal treatments in oligometastatic pancreatic cancer. BMC Cancer 2020; 20:271. [PMID: 32228504 PMCID: PMC7106565 DOI: 10.1186/s12885-020-06718-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 03/05/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Metastatic pancreatic cancer has a median overall survival of less than 12 months, even if treated with chemotherapy. Selected patients with oligometastatic disease could benefit from multimodal treatments connecting chemotherapy and surgical treatment or radiofrequency ablation (RFA) of metastases. CASE PRESENTATION We present a patient with oligometastatic pancreatic cancer recurrence who was successfully treated with a multimodal therapeutic approach. A 57-year-old male initially presenting with resectable pancreatic cancer underwent pancreatoduodenectomy. The histopathological diagnosis revealed ductal pancreatic adenocarcinoma with positive surgical resection margins and negative lymph nodes. He completed six cycles of adjuvant therapy with gemcitabine (1000 mg/mq 1,8,15q 28), followed by external radiotherapy (54 Gy in 25 fractions) associated with gemcitabine 50 mg/mq twice weekly. Three years later, the patient developed multiple liver metastases, and he started FOLFIRINOX (oxaliplatin 85 mg/mq, irinotecan 180 mg/mq, leucovorin 400 mg/mq and fluorouracil 400 mg/mq given as a bolus followed by 2400 mg/mq as a 46 h continuous infusion,1q 14) as a first-line treatment. The CT scan showed a partial response after 6 cycles. After multidisciplinary discussion, the patient underwent a laparotomic metastasectomy of the three hepatic lesions. After additional postsurgical chemotherapy with 4 cycles of the FOLFIRINOX schedule, the patient remained free of recurrence for 12 months. A CT scan showed a new single liver metastasis, which was treated with radiofrequency ablation (RFA). A second radiofrequency ablation was performed when the patient developed another single liver lesion 12 months after the first RFA; currently, the patient is free from recurrence with an overall survival of 6 years from the diagnosis. CONCLUSIONS Our case has benefited from successful multimodal treatment, including surgical and local ablative techniques and systemic chemotherapy. A multimodal approach may be warranted in selected patients with oligometastatic pancreatic cancer and could improve overall survival. Further research is needed to investigate this approach.
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Affiliation(s)
- D M Filippini
- Department of Experimental, Diagnostic and Specialty Medicine University of Bologna, Sant'Orsola-Malpighi Hospital, Massarenti Street 11, 40100, Bologna, Italy
| | - E Grassi
- Department of Experimental, Diagnostic and Specialty Medicine University of Bologna, Sant'Orsola-Malpighi Hospital, Massarenti Street 11, 40100, Bologna, Italy.
| | - A Palloni
- Department of Experimental, Diagnostic and Specialty Medicine University of Bologna, Sant'Orsola-Malpighi Hospital, Massarenti Street 11, 40100, Bologna, Italy
| | - R Carloni
- Department of Experimental, Diagnostic and Specialty Medicine University of Bologna, Sant'Orsola-Malpighi Hospital, Massarenti Street 11, 40100, Bologna, Italy
| | - R Casadei
- Department of Medical and Surgical Sciences, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - C Ricci
- Department of Medical and Surgical Sciences, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - C Serra
- Department of Organ Failure and Transplantation, Ultrasound Unit, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - G Ercolani
- Department of Medical and Surgical Sciences, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy.,General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - G Brandi
- Department of Experimental, Diagnostic and Specialty Medicine University of Bologna, Sant'Orsola-Malpighi Hospital, Massarenti Street 11, 40100, Bologna, Italy
| | - M Di Marco
- Department of Experimental, Diagnostic and Specialty Medicine University of Bologna, Sant'Orsola-Malpighi Hospital, Massarenti Street 11, 40100, Bologna, Italy
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5
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Welch JC, Gleeson EM, Karachristos A, Pitt HA. Hepatopancreatoduodenectomy in North America: are the outcomes acceptable? HPB (Oxford) 2020; 22:360-367. [PMID: 31519357 DOI: 10.1016/j.hpb.2019.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatopancreatoduodenectomies (HPD) are historically associated with high morbidity and mortality. Currently, no data with hepatopancreatobiliary-specific complications have been available for HPD in North America. The aim of this retrospective analysis was to compare the outcomes of HPD to those of major hepatectomy (MH) and pancreatoduodenectomy (PD) in North America. METHODS The 2014-16 American College of Surgeons-National Surgical Quality Improvement Program database was queried for MH, PD, and HPD. Partial hepatectomies, wedge liver biopsies, distal pancreatectomies, pancreatic enucleations and total pancreatectomies were excluded. Propensity score matching was utilized to match 23 HPDs to 92 MHs and 138 PDs by 28 demographic, comorbidity, laboratory, operative and pathologic variables. Outcomes were compared among these three groups. RESULTS The overall morbidity and mortality for HPD were 87% and 26%, respectively, and were significantly higher (p < 0.01) compared to both MH (51%, 7.6%) and PD (52%, 1.4%). Post-hepatectomy liver failure (PHLF) was more common (p < 0.01) in HPD patients, but pancreatic fistula rates were similar. CONCLUSION The morbidity and mortality after HPD are significantly higher than after MH or PD alone and may explain why HPD is performed so infrequently in North America. Centralization of HPD to a very few centers may be a strategy to improve outcomes.
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Affiliation(s)
- Jonathan C Welch
- Lewis Katz School of Medicine at Temple University, 3500 N. Broad St., Philadelphia, PA, 19140, USA
| | - Elizabeth M Gleeson
- Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1259, New York, NY, 10029, USA
| | - Andreas Karachristos
- Department of Surgery, University of South Florida, 2 Tampa General Circle 7th Floor, Tampa, FL, 33606, USA
| | - Henry A Pitt
- Lewis Katz School of Medicine at Temple University, 3509 N. Broad St., Boyer Pavilion, E938, Philadelphia, PA 1914, USA.
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6
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Morris PD, Coker D, Crawford M, Yeo D, Sandroussi C. Liver resection as a component of en-bloc multivisceral resection for upper abdominal tumors is associated with increased morbidity. J Surg Oncol 2020; 121:511-517. [PMID: 31907944 DOI: 10.1002/jso.25824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/21/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND METHODS Complex en-bloc multivisceral and oncovascular resections for upper abdominal tumors remain rare, but there is increasing interest in their role. We analyze complications and survival for these operations. We performed a retrospective cohort study of patients who underwent en-bloc upper abdominal resections for tumors involving multiple organs. Primary outcomes were complications as per the Clavien-Dindo Classification and Comprehensive Complication Index (CCI). Secondary outcome was overall survival (OS). RESULTS We identified 60 consecutive patients who underwent resection from 2011 to 2018. Histopathology was heterogeneous, the most common being renal cell carcinoma. Eighteen patients had major complications. Mean (interquartile range) CCI was 29.6 (9.6-43.9). Liver resection was significantly associated with an increased CCI and increased the odds of a major complication (odds ratio: 4.67, 95% confidence interval [CI]: 1.31-16.59; P = .017). Charlson Comorbidity Score was significantly associated with the presence of at least one major complication. Mean OS was 47.1 months (95% CI: 37.6-56.6). CONCLUSION In appropriately selected patients, and when undertaken in centers with appropriate subspecialist surgical teams and intensive care services, en-bloc multivisceral resection of upper abdominal tumors is safe, but liver resection is associated with an increase in major complications.
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Affiliation(s)
- Paul David Morris
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, Australia
| | - David Coker
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Michael Crawford
- The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, Australia.,Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David Yeo
- The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, Australia.,Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Charbel Sandroussi
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, Australia.,University of Sydney, Sydney, Australia.,Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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7
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Camino Willhuber G, Elizondo C, Slullitel P. Analysis of Postoperative Complications in Spinal Surgery, Hospital Length of Stay, and Unplanned Readmission: Application of Dindo-Clavien Classification to Spine Surgery. Global Spine J 2019; 9:279-286. [PMID: 31192095 PMCID: PMC6542169 DOI: 10.1177/2192568218792053] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective study. Level of evidence III. OBJECTIVE Postoperative complications in spine surgery are associated with increased morbidity, hospital length of stay, and health care costs. Registry of complications in orthopedics and the spine surgery is heterogeneous. METHODS Between July 2016 and June 2017, 274 spinal surgeries were performed, the presence of postoperative complications was analyzed at 90 days (according to the classification of Dindo-Clavien, grades I-V), hospital length of stay, surgical complexity (low, medium, and high), unplanned readmission, and risk factors were evaluated. RESULTS A total of 79 patients suffered a complication (28.8%), of them 21 (26.7%) were grade I, 24 (30.3%) were grade II, 4 (5.7%) were grade IIIA, and 29 (37.3%) were grade IIIB. There were no IV and V grade cases. The most frequent complication was excessive pain followed by deep wound infection and anemia. Surgical complexity and surgical time were significantly associated with the risk of developing a complication. The average number of hospital length of stay in patients without and with complications were 2.7 and 10.6, respectively, and the unplanned readmission rate was 11%. CONCLUSIONS Registry of postoperative complications allows the correct standardization and risk factors required to establish measures to decrease them, the application of Dindo-Clavien classification was useful for the purpose of our study.
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Affiliation(s)
- Gaston Camino Willhuber
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,Gaston Camino Willhuber, Orthopaedic and Traumatology Department, Institute of Orthopedics “Carlos E. Ottolenghi,” Hospital Italiano de Buenos Aires, Potosí 4215 (C1199ACK), Buenos Aires, Argentina.
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8
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Kandel P, Wallace MB, Stauffer J, Bolan C, Raimondo M, Woodward TA, Gomez V, Ritter AW, Asbun H, Mody K. Survival of Patients with Oligometastatic Pancreatic Ductal Adenocarcinoma Treated with Combined Modality Treatment Including Surgical Resection: A Pilot Study. J Pancreat Cancer 2018; 4:88-94. [PMID: 30631861 PMCID: PMC6319614 DOI: 10.1089/pancan.2018.0011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose: To evaluate the overall survival of patients with oligometastatic pancreatic ductal adenocarcinoma (PDAC; metastatic tumor <4 cm, ≤2 metastatic tumors total) receiving neoadjuvant therapy, metastasectomy and/or ablation, and primary tumor resection. Methods: We performed a case–control study from January 2005 to December 2015. Patients who underwent curative-intent surgery combined modality therapy (M1 surgery group; 6 [14%], tumor [T]3, node [N]1, and oligo-metastases [M]1) were matched 1 to 3 based on TN stage with two control groups (M0 surgery and M1 no surgery). The M0 surgery group (18 [43%], T3, N1, and M0) included patients without metastases who underwent resection. The M1 no surgery group (18 [43%], T3, N1, and M1) included patients with metastatic PDAC who received palliative chemotherapy without surgical resection. Results: Median overall survival in the M1 surgery, M0 surgery, and M1 no surgery groups was 2.7 years (95% confidence interval [CI], 0.71–3.69), 2.02 years (95% CI, 0.98–3.05), and 0.98 years (95% CI, 0.55–1.25), respectively. Eastern Cooperative Oncology Group (ECOG) status was associated with survival (p = 0.01) after univariate analysis. After adjusting for ECOG status, multivariate analysis showed M1 surgery patients had improved survival compared with M1 no surgery patients and similar survival to M0 surgery patients. Conclusion: Multimodal therapy benefitted our M1 surgery patients. A larger, prospective study of this multidisciplinary management strategy is currently under way.
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Affiliation(s)
- Pujan Kandel
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - John Stauffer
- Department of Surgery, Mayo Clinic, Jacksonville, Florida
| | - Candice Bolan
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Massimo Raimondo
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Timothy A Woodward
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Victoria Gomez
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Ashton W Ritter
- Department of Hematology and Oncology, Mayo Clinic, Jacksonville, Florida
| | - Horacio Asbun
- Department of Surgery, Mayo Clinic, Jacksonville, Florida
| | - Kabir Mody
- Department of Hematology and Oncology, Mayo Clinic, Jacksonville, Florida
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9
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Sato N, Hasegawa Y, Saito A, Motoi F, Ariake K, Katayose Y, Nakagawa K, Kawaguchi K, Fukudo S, Unno M, Sato F. Association between chronological depressive changes and physical symptoms in postoperative pancreatic cancer patients. Biopsychosoc Med 2018; 12:13. [PMID: 30288172 PMCID: PMC6162953 DOI: 10.1186/s13030-018-0132-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 09/11/2018] [Indexed: 02/07/2023] Open
Abstract
Background Pancreatic cancer (PC) has poorer prognosis and higher surgical invasiveness than many other cancers, with associated psychiatric symptoms including depression and anxiety. Perioperative depression has not been investigated in PC patients regarding surgical stress and relevant interventions. Methods We evaluated chronological depressive changes and subjective physical symptoms in surgically treated PC patients preoperatively and at 3 and 6 months postoperatively. Enrolled patients undergoing pancreatic tumor surgery completed questionnaires based on the Self-Rating Depression Scale (SDS) and Functional Assessment of Cancer Therapy for Patients with Hepatobiliary Cancer (FACT-Hep) preoperatively, and at 3 and 6 months postoperatively. Responses were analyzed with JMP® Pro using one-way and two-way ANOVA, Spearman’s rank correlation coefficient, and multiple regression analysis. Results Malignancy was diagnosed in 73 of 101 patients postoperatively; SDS score was significantly higher in these patients than in those with benign tumors at all timepoints: malignant/benign, 41.8/37.9 preoperatively (p = 0.004); 43.5/37.8 3 months postoperatively (p = 0.006); and 42.9/37.7 6 months postoperatively (p = 0.020). SDS scores were significantly higher in patients < 65 years old with malignancy at 3 months than at 6 months postoperatively (44.6/42.5, p = 0.046) and in patients with malignancy who underwent pancreaticoduodenectomy at 3 months postoperatively than preoperatively (43.4/41.1; p = 0.028). SDS scores moderately correlated with 8 physical symptom-related FACT-Hep items 3 months postoperatively (p < 0.05), showing low-to-moderate correlation with 16 physical symptom-related FACT-Hep items at 6 months postoperatively (p < 0.05). Multiple regression analysis of FACT-Hep symptoms significantly correlated with SDS scores revealed the following significant variables: “lack of energy” (p < 0.000) and “pain” (p = 0.018) preoperatively (R2 = 0.43); “able to perform usual activities” (p = 0.031) and “lack of energy” (p < 0.000) at 3 months postoperatively (R2 = 0.51); and “stomach swelling or cramps” (p = 0.034) and “bowel control” (p = 0.049) at 6 months postoperatively (R2 = 0.52). Conclusions PC patients experience persistently high levels of depression preoperatively through 6 months postoperatively, with associated subjective symptoms including pain and gastrointestinal symptoms. Trial registration UMIN Clinical Trials Registry 000009592, Registered 20 December 2012.
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Affiliation(s)
- Naoko Sato
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan.,5Department of Oncology Nursing, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai, 980-8575 Japan
| | - Yoshimi Hasegawa
- 2Department of Nursing, Tohoku University School of Health Sciences, Sendai, Japan
| | - Asami Saito
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fuyuhiko Motoi
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kyohei Ariake
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Katayose
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Nakagawa
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Kawaguchi
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shin Fukudo
- 4Department of Behavioral Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fumiko Sato
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
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10
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Willhuber GC, Stagnaro J, Petracchi M, Donndorff A, Monzon DG, Bonorino JA, Zamboni DT, Bilbao F, Albergo J, Piuzzi NS, Bongiovanni S. Short-term complication rate following orthopedic surgery in a tertiary care center in Argentina. SICOT J 2018; 4:26. [PMID: 29956663 PMCID: PMC6024591 DOI: 10.1051/sicotj/2018027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/04/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Registration of adverse events following orthopedic surgery has a critical role in patient safety and has received increasing attention. The purpose of this study was to determine the prevalence and severity of postoperative complications in the department of orthopedic unit in a tertiary hospital. METHODS A retrospective review from the postoperative complication registry of a cohort of consecutive patients operated in the department of orthopedic surgery from May 2015 to June 2016 was performed. Short-term complications (3 months after surgery), age gender, types of surgery (elective, scheduled urgency, non-scheduled urgency, and emergency), operative time, surgical start time (morning, afternoon or evening), American Society of Anesthesiologists score and surgeon's experience were assessed. Complications were classified based on their severity according to Dindo-Clavien system: Grade I complications do not require alterations in the postoperative course or additional treatment; Grade II complications require pharmacological treatment; Grade III require surgical, endoscopic, or radiological interventions without (IIIa) or with (IIIb) general anesthesia; Grade IV are life-threatening with single (IVa) or multi-organ (IVb) dysfunction(s), and require ICU management; and Grade V result in death of the patient. Complications were further classified in minor (Dindo I, II, IIIa) and major (Dindo IIIb, IVa, IVb and V), according to clinical severity. RESULTS 1960 surgeries were performed. The overall 90-day complication rate was 12.7% (249/1960). Twenty-three complications (9.2 %) were type I, 159 (63.8%) type II, 9 (3.6%) type IIIa, 42 (16.8%) type IIIb, 7 (2.8%) type IVa and 9 (3.6%) were grade V according to Dindo-Clavien classification (DCC). The most frequent complication was anemia that required blood transfusion (27%) followed by wound infection (15.6%) and urinary tract infection (6%). DISCUSSION The overall complication rate after orthopedic surgery in our department was 12.7%. The implementation of the DCC following orthopedic surgery was an important tool to measure the standard of care.
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Affiliation(s)
| | | | - Matias Petracchi
- Hospital Italiano de San Justo "Agustin Rocca", Buenos Aires, Argentina
| | - Agustin Donndorff
- Hospital Italiano de San Justo "Agustin Rocca", Buenos Aires, Argentina
| | | | | | | | - Facundo Bilbao
- Hospital Italiano de San Justo "Agustin Rocca", Buenos Aires, Argentina
| | - Jose Albergo
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina - Hospital Italiano de San Justo "Agustin Rocca", Buenos Aires, Argentina
| | - Nicolas S Piuzzi
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina - Department of Orthopaedic Surgery & Biomedical Engineering, Cleveland Clinic, Cleveland, USA - Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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11
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Distal pancreatectomy associated with multivisceral resection: results from a single centre experience. Langenbecks Arch Surg 2016; 402:457-464. [DOI: 10.1007/s00423-016-1514-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 09/12/2016] [Indexed: 01/03/2023]
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12
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Björnsson B, Sparrelid E, Hasselgren K, Gasslander T, Isaksson B, Sandström P. Associating Liver Partition and Portal Vein Ligation for Primary Hepatobiliary Malignancies and Non-Colorectal Liver Metastases. Scand J Surg 2016; 105:158-62. [DOI: 10.1177/1457496915613650] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/01/2015] [Indexed: 12/30/2022]
Abstract
Background and Aims: Associating liver partition and portal vein ligation for staged hepatectomy may increase the possibility of radical resection in the case of liver malignancy. Concerns have been raised about the high morbidity and mortality associated with the procedure, particularly when applied for diagnoses other than colorectal liver metastases. The aim of this study was to analyze the initial experience with associating liver partition and portal vein ligation for staged hepatectomy in cases of non-colorectal liver metastases and primary hepatobiliary malignancies in Scandinavia. Materials and Methods: A retrospective analysis of all associating liver partition and portal vein ligation for staged hepatectomy procedures performed at two Swedish university hospitals for non-colorectal liver metastases and primary hepatobiliary malignancies was performed. The primary focus was on the safety of the procedure. Results and Conclusion: Ten patients were included: four had hepatocellular cancer, three had intrahepatic cholangiocarcinoma, one had a Klatskin tumor, one had ocular melanoma metastasis, and one had a metastasis from a Wilms’ tumor. All patients completed both operations, and the highest grade of complication (according to the Clavien-Dindo classification) was 3A, which was observed in one patient. No 90-day mortality was observed. Radical resection (R0) was achieved in nine patients, while the resection was R2 in one patient. The low morbidity and mortality observed in this cohort compared with those of earlier reports on associating liver partition and portal vein ligation for staged hepatectomy for diagnoses other than colorectal liver metastases may be related to the selection of patients with limited comorbidity. In addition, procedures other than associating liver partition and portal vein ligation for staged hepatectomy had been avoided in most of the patients. In conclusion, associating liver partition and portal vein ligation for staged hepatectomy can be applied to primary hepatobiliary malignancies and non-colorectal liver metastases with acceptable rates of morbidity and mortality.
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Affiliation(s)
- B. Björnsson
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - E. Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - K. Hasselgren
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - T. Gasslander
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - B. Isaksson
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - P. Sandström
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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13
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Liver steatosis assessed by preoperative MRI: An independent risk factor for severe complications after major hepatic resection. Surgery 2016; 159:1050-7. [DOI: 10.1016/j.surg.2015.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 09/20/2015] [Accepted: 10/06/2015] [Indexed: 02/06/2023]
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Hasselgren K, Sandström P, Gasslander T, Björnsson B. Multivisceral Resection in Patients with Advanced Abdominal Tumors. Scand J Surg 2016; 105:147-52. [PMID: 26929293 DOI: 10.1177/1457496915622128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/05/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIM Multivisceral resection for advanced tumors can result in prolonged survival but may also increase the risk of postoperative morbidity and mortality. The primary aim of this study was to investigate whether extensive resections increase the severity of postoperative complications. MATERIALS AND METHODS A retrospective study was conducted between 2009 and 2014 at the Linköping University Hospital surgical department. All patients with a confirmed or presumed malignant disease who underwent a non-standardized surgical procedure requiring a multivisceral resection were included. The primary endpoint was 90-day complications according to the Clavien-Dindo score. RESULTS Forty-eight patients were included, with an age range of 17-77 years. A median of three organs was resected. The most common diagnoses were neuroendocrine tumor (n = 8), gastric cancer (n = 7), and gastrointestinal stromal tumor (n = 6). One patient died during surgery. Complications ⩾ grade 3b according to Clavien-Dindo score occurred in 10 patients. R0 resection was achieved in 32 patients. No correlation was observed between the number of anastomoses, perioperative blood loss, operative time, and complications. Only postoperative blood transfusion was correlated with severe complications (p = 0.046); however, a tendency toward more complications with an increasing number of resected organs was observed (p = 0.06). CONCLUSION Multivisceral resection can result in R0, potentially curing patients with advanced tumors. Here, no correlation between extensive resections and complications was observed. Only postoperative blood transfusion was correlated with severe complications.
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Affiliation(s)
- K Hasselgren
- Department of Surgery, Linköping University, Linköping, Sweden Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - P Sandström
- Department of Surgery, Linköping University, Linköping, Sweden Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - T Gasslander
- Department of Surgery, Linköping University, Linköping, Sweden Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - B Björnsson
- Department of Surgery, Linköping University, Linköping, Sweden Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Lu F, Poruk KE, Weiss MJ. Surgery for oligometastasis of pancreatic cancer. Chin J Cancer Res 2015; 27:358-67. [PMID: 26361405 DOI: 10.3978/j.issn.1000-9604.2015.05.02] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 04/08/2015] [Indexed: 12/17/2022] Open
Abstract
The incidence of pancreatic adenocarcinoma (PDAC) has steadily increased over the past several decades. The majority of PDAC patients will present with distant metastases, limiting surgical management in this population. Hepatectomy and pulmonary metastasectomy (PM) has been well established for colorectal cancer patients with isolated, resectable hepatic or pulmonary metastatic disease. Recent advancements in effective systemic therapy for PDAC have led to the selection of certain patients where metastectomy may be potentially indicated. However, the indication for resection of oligometastases in PDAC is not well defined. This review will discuss the current literature on the surgical management of metastatic disease for PDAC with a specific focus on surgical resection for isolated hepatic and pulmonary metastases.
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Affiliation(s)
- Fengchun Lu
- 1 Department of General Surgery, Union Hospital, Fujian Medical University, Fuzhou 350001, China ; 2 Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Katherine E Poruk
- 1 Department of General Surgery, Union Hospital, Fujian Medical University, Fuzhou 350001, China ; 2 Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Matthew J Weiss
- 1 Department of General Surgery, Union Hospital, Fujian Medical University, Fuzhou 350001, China ; 2 Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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16
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Sánchez Cabús S, Fernández-Cruz L. [Surgery for pancreatic cancer: Evidence-based surgical strategies]. Cir Esp 2015; 93:423-35. [PMID: 25957457 DOI: 10.1016/j.ciresp.2015.03.009] [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: 10/30/2014] [Accepted: 03/27/2015] [Indexed: 11/29/2022]
Abstract
Pancreatic cancer surgery represents a challenge for surgeons due to its technical complexity, the potential complications that may appear, and ultimately because of its poor survival. The aim of this article is to summarize the scientific evidence regarding the surgical treatment of pancreatic cancer in order to help surgeons in the decision making process in the management of these patients .Here we will review such fundamental issues as the need for a biopsy before surgery, the type of pancreatic anastomosis leading to better results, and the need for placement of drains after pancreatic surgery will be discussed.
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Harris DY, McAngus JK, Kuo YF, Lindsey RW. Correlations between a dedicated orthopaedic complications grading system and early adverse outcomes in joint arthroplasty. Clin Orthop Relat Res 2015; 473:1524-31. [PMID: 25413712 PMCID: PMC4353523 DOI: 10.1007/s11999-014-4058-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 11/10/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reliable classification of postoperative complications is important for quality improvement efforts. In 2014, The Knee Society proposed a grading system for complications after TKA, but to our knowledge, a relationship between complication grades and surgical outcomes has not yet been established. QUESTIONS/PURPOSES We attempted to determine (1) whether an association exists between complication grade and early adverse outcomes after TKA and THA, and (2) what proportion of the variability in complications could be associated with the classification grade (a metric of potential predictive value of the grading schema). METHODS A total of 210 primary THAs and TKAs in 201 patients performed at one center from January 1, 2011 to December 31, 2011 were reviewed; of those, 188 patients (94%; 197 procedures) had complete 90-day postoperative data and were evaluated retrospectively for postoperative complications. We defined and graded complications according to the classification system proposed by Iorio et al. and The Knee Society. Early adverse outcomes assessed included length of hospital stay and unplanned readmissions or reoperations. A total of 254 complications were documented in 135 patients (137 procedures); 53 patients (60 procedures) had no complications. Bivariate analyses were conducted to identify associations between complication grade and early adverse outcomes and patient variables; analyses considered patient variables including age, sex, status as a state prisoner (yes or no), American Society of Anesthesiologists score, BMI, and procedure (TKA or THA). Multiple regression and logistic regression analyses were conducted to determine the association between complication grade and early adverse outcomes (length of stay [LOS] and unplanned readmission or reoperations) adjusted for confounding patient variables. Alpha was set at 0.05 for two-sided tests. RESULTS Maximum complication grade (range, from 0-4) was associated with a longer LOS (for each point increase of maximum grade, LOS increased 0.105 ± 0.024 days, p < 0.001) and more readmissions or reoperations (odds ratio [OR], 3.79; 95% CI, 1.91-7.54; p < 0.001). Total grade (range, 0-22) also was associated with increased LOS (for each point increase of total grade, LOS increased 0.032 ± 0.006 days, p < 0.001) and increased readmissions or reoperations (OR, 1.34; 95% CI, 1.18-1.53; p < 0.001). Total grade could account for 38% of the variation in LOS and readmissions or reoperations (C-statistic = 0.94; 95% CI, 0.90-0.98); whereas maximum complication grade could account for 35% of the variation in LOS and readmissions or reoperations (C-statistic = 0.35; 95% CI, 0.88-0.96). Thus, we found total grade to be a slightly better predictor of LOS and readmissions or reoperations than maximum grade. CONCLUSIONS We found that the proposed grading system is applicable to TKA and THA in terms of documentation of complication severity and as an indicator of increased LOS and increased unplanned readmissions or reoperation rates. That total complication grade was a better predictor of LOS than maximum grade suggests that multiple complications of a lesser grade can be just as important as a single higher grade complication in terms of effect on outcomes.
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Affiliation(s)
- Dorothy Y. Harris
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0165 USA
| | - Jillian K. McAngus
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0165 USA
| | - Yong-Fang Kuo
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0165 USA
| | - Ronald W. Lindsey
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0165 USA
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18
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Abstract
OBJECTIVES Li Fraumeni syndrome is an autosomal dominant cancer syndrome due to a germline mutation in the p53 tumor suppressor gene. It results in multiple primary neoplasms in children and adults. A common question when faced with a Li Fraumeni patient who develops multiple primary cancers and/or recurrences is what is the proper treatment? Data suggests that ionizing radiation exposure increases the incidence of second malignancies in the Li Fraumeni population. Therefore, how much surgery can a cancer patient tolerate and still derive benefit from it? METHODS We describe a representative case of a 54-year-old female with Li Fraumeni syndrome with an enlarging adrenocortical hepatic metastasis, a new primary ampullary cancer, and an extensive surgical history. RESULTS We performed a simultaneous pancreaticoduodenectomy and repeat partial hepatectomy. CONCLUSIONS We propose that surgery is underutilized in metastatic solid organ familial cancers in general, and argue that an aggressive surgical approach should be considered in a multidisciplinary manner for patients with Li Fraumeni syndrome and recurrent tumors. However, because of the rarity of this familial cancer there is a paucity of evidence to support this approach, therefore a review of the literature is presented.
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Abstract
As the number of liver resections in the United States has increased, operations are more commonly performed on older patients with multiple comorbidities. The advent of effective chemotherapy and techniques such as portal vein embolization, have compounded the number of increasingly complex resections taking up to 75% of healthy livers. Four potentially devastating complications of liver resection include postoperative hemorrhage, venous thromboembolism, bile leak, and post-hepatectomy liver failure. The risk factors and management of these complications are herein explored, stressing the importance of identifying preoperative factors that can decrease the risk for these potentially fatal complications.
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Affiliation(s)
- Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Emory University Hospital, 550 Peachtree Street Northeast, 9th Floor MOT, Atlanta, GA 30308, USA.
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20
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Hartwig W, Vollmer CM, Fingerhut A, Yeo CJ, Neoptolemos JP, Adham M, Andrén-Sandberg A, Asbun HJ, Bassi C, Bockhorn M, Charnley R, Conlon KC, Dervenis C, Fernandez-Cruz L, Friess H, Gouma DJ, Imrie CW, Lillemoe KD, Milićević MN, Montorsi M, Shrikhande SV, Vashist YK, Izbicki JR, Büchler MW. Extended pancreatectomy in pancreatic ductal adenocarcinoma: definition and consensus of the International Study Group for Pancreatic Surgery (ISGPS). Surgery 2014; 156:1-14. [PMID: 24856668 DOI: 10.1016/j.surg.2014.02.009] [Citation(s) in RCA: 196] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 02/14/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Complete macroscopic tumor resection is one of the most relevant predictors of long-term survival in pancreatic ductal adenocarcinoma. Because locally advanced pancreatic tumors can involve adjacent organs, "extended" pancreatectomy that includes the resection of additional organs may be needed to achieve this goal. Our aim was to develop a common consistent terminology to be used in centers reporting results of pancreatic resections for cancer. METHODS An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature on extended pancreatectomies and worked together to establish a consensus on the definition and the role of extended pancreatectomy in pancreatic cancer. RESULTS Macroscopic (R1) and microscopic (R0) complete tumor resection can be achieved in patients with locally advanced disease by extended pancreatectomy. Operative time, blood loss, need for blood transfusions, duration of stay in the intensive care unit, and hospital morbidity, and possibly also perioperative mortality are increased with extended resections. Long-term survival is similar compared with standard resections but appears to be better compared with bypass surgery or nonsurgical palliative chemotherapy or chemoradiotherapy. It was not possible to identify any clear prognostic criteria based on the specific additional organ resected. CONCLUSION Despite increased perioperative morbidity, extended pancreatectomy is warranted in locally advanced disease to achieve long-term survival in pancreatic ductal adenocarcinoma if macroscopic clearance can be achieved. Definitions of extended pancreatectomies for locally advanced disease (and not distant metastatic disease) are established that are crucial for comparison of results of future trials across different practices and countries, in particular for those using neoadjuvant therapy.
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Affiliation(s)
- Werner Hartwig
- Department of Surgery, Klinikum Großhadern, University of Munich, Munich, Germany
| | - Charles M Vollmer
- Department of Gastrointestinal Surgery, Penn Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Abe Fingerhut
- Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France
| | - Charles J Yeo
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - John P Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK
| | - Mustapha Adham
- Department of HPB Surgery, Hopital Edouard Herriot, Lyon, France
| | - Ake Andrén-Sandberg
- Department of Surgery, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Horacio J Asbun
- Department of General Surgery, Mayo Clinic, Jacksonville, FL
| | - Claudio Bassi
- Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy
| | - Max Bockhorn
- Department of General-, Visceral- and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Richard Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Kevin C Conlon
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | | | - Laureano Fernandez-Cruz
- Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Clem W Imrie
- Academic Unit of Surgery, University of Glasgow, Glasgow, UK
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Miroslav N Milićević
- First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Marco Montorsi
- Department of General Surgery, Instituto Clinico Humanitas IRCCS, University of Milan, Milan, Italy
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Yogesh K Vashist
- Department of General-, Visceral- and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General-, Visceral- and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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Addeo P, Oussoultzoglou E, Fuchshuber P, Rosso E, Nobili C, Langella S, Jaeck D, Bachellier P. Safety and outcome of combined liver and pancreatic resections. Br J Surg 2014; 101:693-700. [DOI: 10.1002/bjs.9443] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2014] [Indexed: 12/22/2022]
Abstract
Abstract
Background
In Western countries, combined liver and pancreatic resections (CLPR) are performed rarely because of the perceived high morbidity and mortality rates. This study evaluated the safety and outcomes of CLPR at a tertiary European centre for hepatopancreatobiliary surgery.
Methods
A review of two prospectively maintained databases for pancreatic and liver resections was undertaken to identify patients undergoing CLPR between January 1994 and January 2012. Clinicopathological and surgical outcomes were analysed. Univariable and multivariable analyses for postoperative morbidity were performed.
Results
Fifty consecutive patients with a median age of 58 (range 20–81) years underwent CLPR. Indications for surgery were neuroendocrine carcinoma (16 patients), biliary cancer (15), colonic cancer (5), duodenal cancer (1) and others (13). The type of pancreatic resection included pancreaticoduodenectomy (30), distal pancreatectomy (17), spleen-preserving distal pancreatectomy (2) and total pancreatectomy (1). Twenty-three patients had associated major hepatectomies, 27 underwent minor liver resections and 11 had associated vascular resections. Mortality and morbidity rates were 4 and 46 per cent respectively. Univariable and multivariable analysis showed no differences in postoperative morbidity in relation to extent of liver resection or type of pancreatic resection. Use of preoperative chemotherapy was the only independent risk factor associated with postoperative morbidity (P = 0·021).
Conclusion
CLPR can be performed with fairly low morbidity and mortality rates. Postoperative outcomes were not affected by the extent of liver resection or the type of pancreatic resection. Patients receiving chemotherapy should be evaluated carefully before surgery is considered.
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Affiliation(s)
- P Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - E Oussoultzoglou
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - P Fuchshuber
- Department of Surgery, The Permanente Medical Group, Kaiser Permanente Medical Center, Walnut Creek, California, USA
| | - E Rosso
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - C Nobili
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - S Langella
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - D Jaeck
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - P Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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Combined liver and multivisceral resections. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2014; 2014:976546. [PMID: 24659854 PMCID: PMC3934675 DOI: 10.1155/2014/976546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 01/01/2014] [Indexed: 02/07/2023]
Abstract
Background. Combined liver and multivisceral resections are infrequent procedures, which demand extensive experience and considerable surgical skills. Methods. An electronic search of literature related to this topic published before June 2013 was performed. Results. There is limited scientific evidence of the feasibility and clinical outcomes of these complex procedures. The majority of these cases are simultaneous resections of colorectal tumors with liver metastases. Combined liver and multivisceral resections can be performed with acceptable postoperative morbidity and mortality rates only in carefully selected patients. Conclusion. Lack of experience in these aggressive surgeries justifies a careful selection of patients, considering their comorbidities.
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Ebata T, Yokoyama Y, Igami T, Sugawara G, Mizuno T, Nagino M. Review of hepatopancreatoduodenectomy for biliary cancer: an extended radical approach of Japanese origin. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:550-5. [PMID: 24464987 DOI: 10.1002/jhbp.80] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cholangiocarcinomas exhibit various modes of local extension, and some tumors can only be completely resected by hepatopancreatoduodenectomy (HPD), which is defined as the resection of the whole extrahepatic biliary system with the adjacent liver and pancreatoduodenum. Since Takasaki et al. introduced HPD for locally advanced gallbladder cancer in 1980, Japanese hepatobiliary surgeons have aggressively challenged this extended procedure for advanced biliary tumors. Early experiences with HPD were frequently associated with liver failure and sequential mortality, leading to an underestimation of the survival benefit of HPD. However, with improvements in surgical techniques and perioperative patient care, including portal vein embolization, over the last two decades, the mortality rate after HPD has gradually decreased. Recent studies have demonstrated a favorable survival in cholangiocarcinoma, provided that R0 resection is achieved. In contrast, HPD for gallbladder cancer remains controversial because of the extremely poor survival, although the study populations have been limited. HPD can be performed with low mortality and offers a better probability of long-term survival in patients with cholangiocarcinoma. We should consider HPD to be a standard approach for laterally advanced cholangiocarcinomas that are otherwise unresectable.
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Affiliation(s)
- Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Iorio R, Della Valle CJ, Healy WL, Berend KR, Cushner FD, Dalury DF, Lonner JH. Stratification of standardized TKA complications and adverse events: a brief communication. Clin Orthop Relat Res 2014; 472:194-205. [PMID: 23568680 PMCID: PMC3889450 DOI: 10.1007/s11999-013-2980-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Total Knee Arthroplasty (TKA) Complications Workgroup of the Knee Society developed a standardized list and definitions of complications associated with TKA. Twenty-two complications and adverse events believed important for reporting outcomes of TKA were identified. The Editorial Board of Clinical Orthopaedics and Related Research (®), the Executive Board of the Knee Society, and the members of the Knee Society TKA Complications Workgroup came to the conclusion that reporting of a list of TKA adverse events and complications would be more valuable if they were stratified using a validated classification system. QUESTIONS/PURPOSES The purpose of this article was to stratify the previously published standardized list of TKA adverse events and complications. METHODS A modified version of the Sink adaptation of the Clavien-Dindo Surgical Complication Classification was applied to the list of standardized TKA complications and adverse events. RESULTS The proposed stratified classifications of TKA complications were reviewed and endorsed by the Knee Society. CONCLUSIONS Stratification of TKA complications will allow more in-depth and detailed outcome reporting for surgeons, hospitals, third-party payers, government agencies, joint replacement registries, and orthopaedic researchers. This improvement in reporting of TKA complications will also improve the quality of orthopaedic literature.
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Affiliation(s)
- Richard Iorio
- New York University Langone Medical Center/Hospital for Joint Diseases, 1 Indian Hill Road, New York, NY, 10804, USA,
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Sink EL, Leunig M, Zaltz I, Gilbert JC, Clohisy J. Reliability of a complication classification system for orthopaedic surgery. Clin Orthop Relat Res 2012; 470:2220-6. [PMID: 22528378 PMCID: PMC3392390 DOI: 10.1007/s11999-012-2343-2] [Citation(s) in RCA: 220] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 03/26/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Quality of health care and safety have been emphasized by various professional and governmental groups. However, no standardized method exists for grading and reporting complications in orthopaedic surgery. Conclusions regarding outcomes are incomplete without a standardized, objective complication grading scheme applied concurrently. The general surgery literature has the Clavien-Dindo classification that meets the above criteria. QUESTIONS/PURPOSES We asked whether a previously reported classification would show high intraobserver and interobserver reliabilities when modified for orthopaedic surgery specifically looking at hip preservation surgery. We therefore determined the interreader and intrareader reliabilities of the adapted classification scheme as applied to hip preservation surgery. METHODS We adapted the validated Clavien-Dindo complication classification system and tested its reliability for orthopaedic surgery, specifically hip preservation surgery. There are five grades based on the treatment required to manage the complication and the potential for long-term morbidity. Forty-four complication scenarios were created from a prospective multicenter database of hip preservation procedures and from the literature. Ten readers who perform hip surgery at eight centers in three countries graded the scenarios at two different times. Fleiss' and Cohen's κ statistics were performed for interobserver and intraobserver reliabilities, respectively. RESULTS The overall Fleiss' κ value for interobserver reliability was 0.887 (95% CI, 0.855-0.891). The weighted κ was 0.925 (95% CI, 0.894-0.956) for Grade I, 0.838 (95% CI, 0.807-0.869) for Grade II, 0.87 (95% CI, 0.835-0.866) for Grade III, and 0.898 (95% CI, 0.866-0.929) for Grade IV. The Cohen's κ value for intraobserver reliability was 0.891 (95% CI, 0.857-0.925). CONCLUSIONS The adapted classification system shows high interobserver and intraobserver reliabilities for grading of complications when applied to orthopaedic surgery looking at complications of hip preservation surgery. This grading scheme may facilitate standardization of complication reporting and make outcome studies more comparable.
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Affiliation(s)
- Ernest L. Sink
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | | | - Ira Zaltz
- Oakland Orthopaedic Surgeons, Royal Oak, MI USA
| | | | - John Clohisy
- Washington University in St Louis, St Louis, MO USA
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Cata JP, Gottumukkala V. Blood Loss and Massive Transfusion in Patients Undergoing Major Oncological Surgery: What Do We Know? ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/918938] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with solid malignancies who were not candidates for tumor resections in the past are now presenting for extensive oncological resections. Cancer patients are at risk for thromboembolic complications due to an underlying hypercoagulable state; however, some patients may have an increased risk for bleeding due to the effects of chemotherapy, the administration of anticoagulant drugs, tumor-related fibrinolysis, tumor location, tumor vascularity, and extent of disease. A common potential complication of all complex oncological surgeries is massive intra- and postoperative hemorrhage and the subsequent risk for massive blood transfusion. This can be anticipated or unexpected. Several surgical and anesthesia interventions including preoperative tumor embolization, major vessel occlusion, hemodynamic manipulation, and perioperative antifibrinolytic therapy have been used to prevent or control blood loss with varying success. The exact incidence of massive blood transfusion in oncological surgery is largely unknown and/or underreported. The current literature mostly consists of purely descriptive observational studies. Thus, recommendation regarding specific perioperative intervention cannot be made at this point, and more research is warranted.
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Affiliation(s)
- Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA
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Bramis K, Petrou A, Papalambros A, Manzelli A, Mantonakis E, Brennan N, Felekouras E. Serous cystadenocarcinoma of the pancreas: report of a case and management reflections. World J Surg Oncol 2012; 10:51. [PMID: 22400805 PMCID: PMC3317835 DOI: 10.1186/1477-7819-10-51] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Accepted: 03/08/2012] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Serous adenomas represent 1-2% of pancreatic neoplasms and typically are asymptomatic not requiring any treatment and simple observation is the option of choice. Although, they carry a realistic risk of malignancy despite the general view that they never become malignant. We report a case, which, according to our best knowledge is the 27th case reported in the literature. METHODS We reviewed the literature by performing a search in Pub Med and Medline. RESULTS A 86-year old patient known to have a serous cystadenoma of the pancreas treated conservatively through a close clinical and radiological follow up which was unattended for 4 years ending up to our emergency department suffering an acute abdomen. Exploratory laparotomy revealed a perforated prepyloric ulcer which was treated accordingly. Patient died some weeks later due to severe medical co morbidities. CONCLUSION Serous cystic neoplasms of the pancreas carry a realistic risk of malignancy despite the general view that they never become malignant. In our opinion the treatment strategy of serous cystic neoplasms of the pancreas should be aggressive even in cases of remote metastases since prognosis of the disease is satisfactory.
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Affiliation(s)
- K Bramis
- LAIKON Hospital, First Department of Surgery, University of Athens Medical School, Greece
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Pancreatic resections for advanced M1-pancreatic carcinoma: the value of synchronous metastasectomy. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2010; 2010:579672. [PMID: 21197481 PMCID: PMC3010622 DOI: 10.1155/2010/579672] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Accepted: 10/31/2010] [Indexed: 12/16/2022]
Abstract
Background. For M1 pancreatic adenocarcinomas pancreatic resection is usually not indicated. However, in highly selected patients synchronous metastasectomy may be appropriate together with pancreatic resection when operative morbidity is low.
Materials and Methods. From January 1, 2004 to December, 2007 a total of 20 patients with pancreatic malignancies were retrospectively evaluated who underwent pancreatic surgery with synchronous resection of hepatic, adjacent organ, or peritoneal metastases for proven UICC stage IV periampullary cancer of the pancreas. Perioperative as well as clinicopathological parameters were evaluated.
Results. There were 20 patients (9 men, 11 women; mean age 58 years) identified. The primary tumor was located in the pancreatic head (n = 9, 45%), in pancreatic tail (n = 9, 45%), and in the papilla Vateri (n = 2, 10%). Metastases were located in the liver (n = 14, 70%), peritoneum (n = 5, 25%), and omentum majus (n = 2, 10%). Lymphnode metastases were present in 16 patients (80%). All patients received resection of their tumors together with metastasectomy. Pylorus preserving duodenopancreatectomy was performed in 8 patients, distal pancreatectomy in 8, duodenopancreatectomy in 2, and total pancreatectomy in 2. Morbidity was 45% and there was no perioperative mortality. Median postoperative survival was 10.7 months (2.6–37.7 months) which was not significantly different from a matched-pair group of patients who underwent pancreatic resection for UICC adenocarcinoma of the pancreas (median survival 15.6 months; P = .1). Conclusion. Pancreatic resection for M1 periampullary cancer of the pancreas can be performed safely in well-selected patients. However, indication for surgery has to be made on an individual basis.
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Hemming AW, Magliocca JF, Fujita S, Kayler LK, Hochwald S, Zendejas I, Kim RD. Combined Resection of the Liver and Pancreas for Malignancy. J Am Coll Surg 2010; 210:808-14, 814-6. [DOI: 10.1016/j.jamcollsurg.2009.12.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2009] [Accepted: 12/08/2009] [Indexed: 12/23/2022]
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Abstract
BACKGROUND AND AIMS The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients', nurses', and doctors' perception. MATERIAL AND METHODS Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication. RESULTS We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test). CONCLUSIONS This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as "minor or major" should be removed from the surgical literature.
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