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Nakayama T, Ito K, Nakamura M, Inagaki F, Katagiri D, Yamamoto N, Mihara F, Takemura N, Kokudo N. Pancreaticoduodenectomy after bilirubin adsorption for distal cholangiocarcinoma with severe obstructive jaundice refractory to repeat preoperative endoscopic biliary drainage: a case report. Clin J Gastroenterol 2024; 17:711-716. [PMID: 38589719 DOI: 10.1007/s12328-024-01966-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
The necessity of biliary drainage before pancreaticoduodenectomy remains controversial in cases involving malignant obstructive jaundice; however, the benefits of biliary drainage have been reported in cases with severe hyperbilirubinemia. Herein, we present the case of a 61-year-old man suffering from jaundice due to distal cholangiocarcinoma. In this case, obstructive jaundice was refractory to repeat endoscopic drainage and bilirubin adsorption. Hyperbilirubinemia persisted despite successful implementation of biliary endoscopic sphincterotomy and two rounds of plastic stent placements. Stent occlusion and migration were unlikely and oral cholagogues proved ineffective. Owing to the patient's surgical candidacy and his aversion to nasobiliary drainage due to discomfort, bilirubin adsorption was introduced as an alternative therapeutic intervention. Following repeated adsorption sessions, a gradual decline in serum total bilirubin levels was observed and pancreaticoduodenectomy was scheduled. The patient successfully underwent pancreaticoduodenectomy with portal vein resection and reconstruction and D2 lymph node dissection. After the surgery, the serum bilirubin levels gradually decreased and the patient remained alive, with no recurrence at 26 months postoperatively. Therefore, this case highlights the feasibility and safety of performing pancreaticoduodenectomy in patients with severe, refractory jaundice who have not responded to repeated endoscopic interventions and have partially responded to bilirubin adsorption.
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Affiliation(s)
- Toshihiro Nakayama
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Mai Nakamura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Fuyuki Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Daisuke Katagiri
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan.
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
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Wu H, Zeng X, Liang Y, Li B, Chen L. Study of preserving the PTCD tube after laparoscopic pancreaticoduodenectomy. Medicine (Baltimore) 2023; 102:e32813. [PMID: 36749278 PMCID: PMC9901976 DOI: 10.1097/md.0000000000032813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Severe jaundice patients undergoing laparoscopic pancreaticoduodenectomy (LPD) tend to choose percutaneous transhepatic cholangial drainage (PTCD) for preoperative biliary drainage. However, there are few studies on whether to preserve PTCD drainage tubes after surgery. This study tentatively discusses that jaundice patients preserving the PTCD tube have similar postoperative recovery to that in ordinary patients undergoing LPD. We retrospectively reviewed 46 patients who underwent LPD between June 2019 and April 2022 at our department. They were divided into a drainage group with 16 patients and a normal group with 30 patients according to whether PTCD was performed. Patient demographics, perioperative data, and postoperative outcomes were observed and counted. The preoperative total bilirubin in the drainage group was significantly higher than that in the normal group. There was no significant difference in age, body mass index, American Society of Anesthesiologists grade, hemoglobin, albumin, operation time, postoperative hospital stay, or total complication rate between the 2 groups. The PTCD tube was preserved in all 16 patients after the operation, and only 1 patient (6.3%) developed PTCD-related postoperative complications, which were dislocations. It is safe and effective to choose PTCD to reduce jaundice before surgery and preserve PTCD tubes after surgery for moderate and severe jaundice patients who plan to undergo standardized and streamlined LPD. These patients achieve similar postoperative recovery of LPD as no-drainage patients.
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Affiliation(s)
- Haojun Wu
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xia Zeng
- Department of Ultrasound, Shangjin Nanfu Hosptial, Chengdu, Sichuan, China
| | - Ying Liang
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bei Li
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Liping Chen
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- * Correspondence: Liping Chen, Department of Biliary Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan 610041, PR China (e-mail: )
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Traub B, Link KH, Kornmann M. Curing pancreatic cancer. Semin Cancer Biol 2021; 76:232-246. [PMID: 34062264 DOI: 10.1016/j.semcancer.2021.05.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/14/2022]
Abstract
The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.
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Affiliation(s)
- Benno Traub
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
| | - Karl-Heinz Link
- Clinic for General and Visceral Surgery, University of Ulm, Ulm, Germany; Surgical and Asklepios Tumor Center (ATC), Asklepios Paulinen Klinik Wiesbaden, Richard Strauss-Str. 4, Wiesbaden, Germany.
| | - Marko Kornmann
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
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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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Shen Z, Xu Z, Wang W, Xu W, Zhou Y, Lu X, Deng X, Weng Y, Shen B. A novel nomogram for predicting the risk of major complications after pancreaticoduodenectomy in patients with obstructive jaundice. Clin Chim Acta 2021; 517:162-170. [PMID: 33711328 DOI: 10.1016/j.cca.2021.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/07/2021] [Accepted: 02/21/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this study was to construct and internally validate a nomogram for predicting major complications in obstructive jaundice patients planned to undergo pancreaticoduodenectomy (PD). METHODS The clinical data of 835 obstructive jaundice patients who underwent PD in a high-volume center were collected and retrospectively analyzed during an 8-year period. Factors affecting the major complication rate were optimized by least absolute shrinkage and selection operator (LASSO) regression analysis and were incorporated in logistic regression analysis. The performance of this nomogram was evaluated by discrimination, calibration, internal validation and clinical utility. RESULTS Predictors included in the model were sex, American Society of Anesthesiologists (ASA) score, preoperative biliary drainage (PBD), neutrophil-to-lymphocyte ratio (NLR), hemoglobin, prealbumin, total bilirubin, transfusion, and pathology category. The model had good discrimination and calibration with a C-index of 0.700. Internal validation generated an acceptable C-index of 0.701. Decision curve analysis indicated this nomogram was clinically useful for predicting the possibility of major complications at a threshold between 1% and 59%. CONCLUSION This novel nomogram could be conveniently used and assist in decisions for PBD in clinical practice.
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Affiliation(s)
- Ziyun Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China; State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiwei Xu
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China; State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China; State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Xu
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China; State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yiran Zhou
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China; State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiongxiong Lu
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China; State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China; State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China; State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China; State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Itoyama R, Okabe H, Nakao Y, Yusa T, Nakagawa S, Imai K, Hayashi H, Yamashita YI, Baba H. The pivotal predictor of severe postoperative complications of pancreatoduodenectomy: complex links of bacterial contamination from preoperative biliary drainage. Surg Today 2020; 50:1594-1600. [DOI: 10.1007/s00595-020-02061-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/20/2020] [Indexed: 02/07/2023]
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Shen Z, Zhang J, Zhao S, Zhou Y, Wang W, Shen B. Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis. Pancreatology 2020; 20:529-536. [PMID: 32107192 DOI: 10.1016/j.pan.2020.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/16/2020] [Accepted: 02/01/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The influence of preoperative biliary drainage (PBD) for obstructive jaundiced patients before pancreaticoduodenectomy is debated in the past decades. The aim of this study is to assess the impact of preoperative biliary drainage on intraoperative and postoperative outcomes in patients with severely obstructive jaundice. METHODS Data were collected retrospectively from severely obstructive jaundiced patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy from January 2012 to December 2017. The univariate and multivariate analyses were performed to assess independent risk factors for overall postoperative complications. A propensity score-matched (PSM) analysis was performed to adjust baseline characteristics between PBD and direct surgery (DS) groups. After PSM, intraoperative data and postoperative complications were compared between the two groups. RESULTS A total of 200 patients were included. The rate of overall postoperative complication occurred in 119 (59.5%) patients, with prealbumin <150 mg/L (OR = 3.03; 95%CI = [1.63-5.62]; p < 0.001), ASA (American Society of Anesthesiology score) classification II-III (OR = 2.27; 95%CI = [1.21-4.27]; p = 0.011), and direct surgery (OR = 3.88; 95%CI = [1.67-8.99]; p = 0.002) identified as independent risk factors in multivariate analysis. After PSM, there was similar operative time and intraoperative transfusion between PBD and DS group. However, DS group had a higher incidence of overall postoperative complication (p = 0.005), grades B and C of post-pancreatectomy hemorrhage (PPH) (p = 0.032), and grades B and C of postoperative pancreatic fistula (POPF) (p = 0.045) compared to PBD group. CONCLUSIONS In this retrospective study, in order to reduce overall postoperative complications, PBD should be performed routinely for those patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Ziyun Shen
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jun Zhang
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shiwei Zhao
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yiran Zhou
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Baiyong Shen
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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8
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Kulkarni NM, Soloff EV, Tolat PP, Sangster GP, Fleming JB, Brook OR, Wang ZJ, Hecht EM, Zins M, Bhosale PR, Arif-Tiwari H, Mannelli L, Kambadakone AR, Tamm EP. White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology's disease-focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease. Abdom Radiol (NY) 2020; 45:716-728. [PMID: 31748823 DOI: 10.1007/s00261-019-02289-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal malignancy with a poor 5-year survival rate. Accurate staging of PDAC is an important initial step in the development of a stage-specific treatment plan. Different staging systems/consensus statements convened by different societies and academic practices are currently used. The most recent version of the American Joint Committee on Cancer (AJCC) tumor/node/metastases (TNM) staging system for PDAC has shifted its focus from guiding management to assessing prognosis. In order to preoperatively define the resectability of PDAC and to guide management, additional classification systems have been developed. The National Comprehensive Cancer Network (NCCN) guidelines, one of the most commonly used systems, provide recommendations on the management and the determination of resectability for PDAC. The NCCN divides PDAC into three categories of resectability based on tumor-vessel relationship: 'resectable,' 'borderline resectable,' and 'unresectable'. Among these, the borderline disease category is of special interest given its evolution over time and the resulting variations in the definition and the associated recommendations for management between different societies. It is important to be familiar with the evolving criteria, and treatment and follow-up recommendations for PDAC. In this article, the most current AJCC staging (8th edition), NCCN guidelines (version 2.2019-April 9, 2019), and challenges and controversies in borderline resectable PDAC are reviewed.
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Affiliation(s)
- Naveen M Kulkarni
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI, 53226, USA.
| | - Erik V Soloff
- Department of Radiology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Parag P Tolat
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Guillermo P Sangster
- Department of Radiology, LSU Health - Shreveport Ochsner-LSU Health - Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Jason B Fleming
- Gastrointestinal Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Shapiro 4, Boston, MA, 02215-5400, USA
| | - Zhen Jane Wang
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Elizabeth M Hecht
- Department of Radiology, Columbia University Medical Center, 622 W 168th St, PH1-317, New York, NY, 10032, USA
| | - Marc Zins
- Department of Radiology, Groupe Hospitalier Paris Saint-Joseph, 185 Rue Raymond Losserand, 75014, Paris, France
| | - Priya R Bhosale
- Abdominal Imaging Department, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1473, Houston, TX, 77030-400, USA
| | - Hina Arif-Tiwari
- Department of Radiology, University of Arizona College of Medicine, 1501 N. Campbell Ave., P.O. Box 245067, Tucson, AZ, 85724, USA
| | | | - Avinash R Kambadakone
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
| | - Eric P Tamm
- Abdominal Imaging Department, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1473, Houston, TX, 77030-400, USA
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Hank T, Strobel O. Conversion Surgery for Advanced Pancreatic Cancer. J Clin Med 2019; 8:jcm8111945. [PMID: 31718103 PMCID: PMC6912686 DOI: 10.3390/jcm8111945] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/03/2019] [Accepted: 11/06/2019] [Indexed: 12/24/2022] Open
Abstract
While primarily unresectable locally advanced pancreatic cancer (LAPC) used to be an indication for palliative therapy, a strategy of neoadjuvant therapy (NAT) and conversion surgery is being increasingly used after more effective chemotherapy regimens have become available for pancreatic ductal adenocarcinoma. While high-level evidence from prospective studies is still sparse, several large retrospective studies have recently reported their experience with NAT and conversion surgery for LAPC. This review aims to provide a current overview about different NAT regimens, conversion rates, survival outcomes and determinants of post-resection outcomes, as well as surgical strategies in the context of conversion surgery after NAT. FOLFIRINOX is the predominant regimen used and associated with the highest reported conversion rates. Conversion rates considerably vary between less than 5% and more than half of the study population with heterogeneous long-term outcomes, owing to a lack of intention-to-treat analyses in most studies and a high heterogeneity in resectability criteria, treatment strategies, and reporting among studies. Since radiological criteria of local resectability are no longer applicable after NAT, patients without progressive disease should undergo surgical exploration. Surgery after NAT has to be aimed at local radicality around the peripancreatic vessels and should be performed in expert centers. Future studies in this rapidly evolving field need to be prospective, analyze intention-to-treat populations, report stringent and objective inclusion criteria and criteria for resection. Innovative regimens for NAT in combination with a radical surgical approach hold high promise for patients with LAPC in the future.
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Chen B, Trudeau MT, Maggino L, Ecker BL, Keele LJ, DeMatteo RP, Drebin JA, Fraker DL, Lee MK, Roses RE, Vollmer CM. Defining the Safety Profile for Performing Pancreatoduodenectomy in the Setting of Hyperbilirubinemia. Ann Surg Oncol 2019; 27:1595-1605. [PMID: 31691110 DOI: 10.1245/s10434-019-08044-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hyperbilirubinemia is commonly observed in patients requiring pancreatoduodenectomy (PD). Thus far, literature regarding the danger of operating in the setting of hyperbilirubinemia is equivocal. What remains undefined is at what specific level of bilirubin there is an adverse safety profile for undergoing PD. The aim of this study is to identify the optimal safety profile of patients with hyperbilirubinemia undergoing PD. PATIENTS AND METHODS The present work analyzed 803 PDs from 2004 to 2018. A generalized additive model was used to determine cutoff values of total serum bilirubin (TB) that were associated with increases in adverse outcomes, including 90-day mortality. Subgroup comparisons and biliary stent-specific analyses were performed for patients with TB below and above the cutoff. RESULTS TB of 13 mg/dL was associated with an increase in 90-day mortality (P = 0.043) and was the dominant risk factor on multivariate logistic regression [odds ratio (OR) 8.193, P = 0.001]. Increased TB levels were also associated with reoperations, number of complications per patient, and length of stay. Patients with TB greater than or equal to 13 mg/dL (TB ≥ 13) who received successful biliary decompression through stenting had less combined death and serious morbidity (P = 0.048). CONCLUSIONS Preoperative TB ≥ 13 mg/dL was associated with increased 90-day mortality after PD. Reducing a TB ≥ 13 is generally recommended before proceeding to surgery.
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Affiliation(s)
- Bofeng Chen
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maxwell T Trudeau
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Surgery, University of Verona, The Pancreas Institute, Verona, Italy
| | - Brett L Ecker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Luke J Keele
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ronald P DeMatteo
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jeffrey A Drebin
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Major K Lee
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Pamecha V, Sadashiv Patil N, Kumar S, Rajendran V, Gupta S, Vasantrao Sasturkar S, Kumar Sinha P, Arora A, Agarwal N, Baghmar S. Upfront pancreaticoduodenectomy in severely jaundiced patients: is it safe? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:524-533. [DOI: 10.1002/jhbp.671] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Viniyendra Pamecha
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Nilesh Sadashiv Patil
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Senthil Kumar
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Vivek Rajendran
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Sahil Gupta
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Shridhar Vasantrao Sasturkar
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Piyush Kumar Sinha
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Asit Arora
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Nikhil Agarwal
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Saphalta Baghmar
- Department of Medical Oncology Institute of Liver and Biliary Sciences New Delhi India
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Bolm L, Petrova E, Woehrmann L, Werner J, Uhl W, Nuessler N, Ghadimi M, Bausch D, Lapshyn H, Gaedcke J, Belyaev O, D'Haese JG, Klier T, Keck T, Wellner UF. The impact of preoperative biliary stenting in pancreatic cancer: A case-matched study from the German nationwide pancreatic surgery registry (DGAV StuDoQ|Pancreas). Pancreatology 2019; 19:985-993. [PMID: 31563328 DOI: 10.1016/j.pan.2019.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 08/29/2019] [Accepted: 09/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVE The impact of preoperative biliary stenting (PBS) before pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is controversial. METHODS Patients undergoing PD with or without PBS for PDAC were identified from the German DGAV-StuDoQlPancreas registry. The impact of PBS on perioperative complications was analyzed. RESULTS 1133 patients undergoing PD for PDAC were identified from the registry. After matching, 480 PBS patients vs. 480 patients without PBS were analyzed. Postoperative complications Clavien-Dindo classification (CDC) grade IIIa-IVb were higher in PBS patients (PBS 27% vs. no PBS 22%, p = 0.027). 320 PBS patients (66%) had no history of jaundice. In these patients, PBS was associated with higher morbidity. In contrast, PBS was not associated with higher complication rates in patients with history of jaundice. Serum bilirubin levels of 15 mg/dl and higher lead to more CDC IIIa-IVb (24% vs. 28%, p = 0.053) and higher mortality (3% vs. 7%, p < 0.001). PBS in patients with serum bilirubin levels of >15 mg/dl increased CDC IIa-IVb complications (21% vs. 50%, p = 0.001), mortality was equivalent. CONCLUSION Most PBS procedures were performed in patients with no history of jaundice and increased morbidity. Serum bilirubin levels >15 mg/dl lead to higher morbidity and mortality. PBS correlated with higher complication rates in these patients.
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Affiliation(s)
- Louisa Bolm
- Department of Surgery, University Medical Center Luebeck, Germany
| | | | - Lukas Woehrmann
- Department of Surgery, University Medical Center Luebeck, Germany
| | - Jens Werner
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians University Munich, Germany
| | - Waldemar Uhl
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Natascha Nuessler
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, Municipal Hospital Munich, Germany
| | - Michael Ghadimi
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Germany
| | - Dirk Bausch
- Department of Surgery, University Medical Center Luebeck, Germany
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Luebeck, Germany
| | - Jochen Gaedcke
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Germany
| | - Orlin Belyaev
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Jan G D'Haese
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians University Munich, Germany
| | - Thomas Klier
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, Municipal Hospital Munich, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Luebeck, Germany; DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany.
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Luebeck, Germany; DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany
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