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Olecki EJ, Perez Holguin RA, Mayhew MM, Wong WG, Vining CC, Peng JS, Shen C, Dixon MEB. Disparities in Surgical Treatment of Resectable Pancreatic Adenocarcinoma at Minority Serving Hospitals. J Surg Res 2024; 294:160-168. [PMID: 37897875 DOI: 10.1016/j.jss.2023.09.066] [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] [Received: 05/18/2023] [Revised: 09/02/2023] [Accepted: 09/24/2023] [Indexed: 10/30/2023]
Abstract
INTRODUCTION Minority serving hospitals (MSH) are those serving a disproportionally high number of minority patients. Previous research has demonstrated that treatment at MSH is associated with worse outcomes. We hypothesize that patients treated at MSH are less likely to undergo surgical resection of pancreatic adenocarcinoma compared to patients treated at non-MSH. METHODS Patients with resectable pancreatic cancer were identified using the National Cancer Database. Institutions treating Black and Hispanic patients in the top decile were categorized as an MSH. Factors associated with the primary outcome of definitive surgical resection were evaluated using multivariable logistic regression. Univariate and multivariable survival analysis was performed. RESULTS Of the 75,513 patients included in this study, 7.2% were treated at MSH. Patients treated at MSH were younger, more likely to be uninsured, and higher stage compared to those treated at non-MSH (P < 0.001). Patients treated at MSH underwent surgical resection at lower rates (MSH 40% versus non-MSH 44.5%, P < 0.001). On multivariable logistic regression, treatment at MSH was associated with decreased likelihood of undergoing definitive surgery (odds ratio 0.91, P = 0.006). Of those who underwent surgical resection, multivariable survival analysis revealed that treatment at an MSH was associated with increased morality (hazard ratio 1.12, P < 0.001). CONCLUSIONS Patients with resectable pancreatic adenocarcinoma treated at MSH are less likely to undergo surgical resection compared to those treated at non-MSH. Targeted interventions are needed to address the unique barriers facing MSH facilities in providing care to patients with pancreatic adenocarcinoma.
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Affiliation(s)
- Elizabeth J Olecki
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania.
| | - Rolfy A Perez Holguin
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Mackenzie M Mayhew
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - William G Wong
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Charles C Vining
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; Program for Liver, Pancreas & Foregut Tumors, Division of Surgical Oncology, Penn State Milton S Hershey Medical Center, Hershey, Pennsylvania
| | - June S Peng
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; Program for Liver, Pancreas & Foregut Tumors, Division of Surgical Oncology, Penn State Milton S Hershey Medical Center, Hershey, Pennsylvania
| | - Chan Shen
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Matthew E B Dixon
- Department of Surgery, Rush University Medical College, Chicago, Illinois; Section of Hepatopancreatobiliary Surgery, Division of Surgical Oncology, Rush University Medical Center, Chicago, Illinois
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Grosh KM, Folkert KN, Chou J, Shebrain SA, Munene GM. A Cohort Study of an Enhanced Recovery Pathway for Pancreatic Surgery at a Community Hospital. Am Surg 2023; 89:2350-2356. [PMID: 35491837 DOI: 10.1177/00031348221093806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to improve pancreatic surgery outcomes, though feasibility in a community hospital remain unclear. We hypothesized that an ERAS protocol would reduce hospital length of stay (LOS) without increased morbidity. METHODS An ERAS pathway was initiated for patients undergoing pancreatic surgery at a community cancer center and compared to a historical cohort. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates, comprehensive complication index (CCI®), textbook outcomes (TO), and mortality. RESULTS A total of 144 patients were included, with 63 patients in the ERAS group and 81 in the control group. The mean LOS decreased significantly in the ERAS group (6.85 [± 4.8]) vs 9.96 [±6.8] days, P = .001), without an increase in 30-day admission rates or CCI. CONCLUSIONS Implementation of an ERAS protocol in a community setting reduced LOS without a corresponding increase in readmission rates or morbidity.
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Affiliation(s)
- Kent M Grosh
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Kyra N Folkert
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Jesse Chou
- Department of Plastic and Maxillofacial Surgery, University of Virginia, Charlottesville, VA, USA
| | - Saad A Shebrain
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Gitonga M Munene
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
- Western Michigan Cancer Center, Kalamazoo, MI, USA
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3
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Han JS, Dunham CM, Renner CE, Neubauer SA, McCarron FN, Chirichella TJ. Establishing an open and robotic pancreatic surgery program in a level 1 trauma center community teaching hospital and comparing its outcomes to high-volume academic center outcomes: a retrospective review. BMC Surg 2022; 22:414. [PMID: 36474230 PMCID: PMC9724418 DOI: 10.1186/s12893-022-01867-7] [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: 07/12/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The debate of whether to centralize hepato-pancreato-biliary surgery has been ongoing. The principal objective was to compare outcomes of a community pancreatic surgical program with those of high-volume academic centers. METHODS The current pancreatic surgical study occurred in an environment where (1) a certified abdominal transplant surgeon performed all surgeries; (2) complementary quality enhancement programs had been developed; (3) the hospital's trauma center had been verified; and (4) the hospital's surgical training had been accredited. Pancreatic surgical outcomes at high-volume academic centers were obtained through PubMed literature searches. Articles were selected if they described diverse surgical procedures. Two-tailed Fisher exact and mid-P tests were used to perform 2 × 2 contingency analyses. RESULTS The study patients consisted of 64 consecutive pancreatic surgical patients. The study patients had a similar pancreaticoduodenectomy proportion (59.4%) when compared to literature patients (66.8%; P = 0.227). The study patients also had a similar distal pancreatectomy proportion (25.0%) when compared to literature patients (31.9%; P = 0.276). The study patients had a significantly higher American Society of Anesthesiologists physical status ≥ 3 proportion (100%) than literature patients (28.1%; P < 0.001). The 90-day study mortality proportion (0%) was similar to the literature proportion (2.3%; P = 0.397). The study postoperative pancreatic fistula proportion was lower (3.2%), when compared to the literature proportion (18.4%; P < 0.001; risk ratio = 5.8). The study patients had a lower reoperation proportion (3.1%) than the literature proportion (8.7%; mid-P = 0.051; risk ratio = 2.8). The study patients had a lower surgical site infection proportion (3.1%) than those in the literature (21.1%; P < 0.001; risk ratio = 6.8). The study patients had equivalent delayed gastric emptying (15.6%) when compared to literature patients (10.6%; P = 0.216). The study patients had decreased Clavien-Dindo grades III-IV complications (10.9%) compared to the literature patients (21.8%; mid-P = 0.018). Lastly, the study patients had a similar readmission proportion (20.3%) compared to literature patients (18.4%; P = 0.732). CONCLUSION Despite pancreatic surgical patients having greater preoperative medical comorbidities, the current community study outcomes were comparable to or better than high-volume academic center results.
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Affiliation(s)
- Jane S. Han
- grid.451516.2Department of Surgery, Bon Secours Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44504 USA
| | - C. Michael Dunham
- grid.451516.2Department of Surgery, Bon Secours Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44504 USA
| | - Charles E. Renner
- grid.451516.2Department of Surgery, Bon Secours Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44504 USA
| | - Steven A. Neubauer
- grid.451516.2Department of Surgery, Bon Secours Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44504 USA
| | - F. Nikki McCarron
- grid.443867.a0000 0000 9149 4843Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH 44106 USA
| | - Thomas J. Chirichella
- grid.451516.2Department of Surgery, Bon Secours Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44504 USA
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Nakano Y, Hirata Y, Shimogawara T, Yamada T, Mihara K, Nishiyama R, Nishiya S, Taniguchi H, Egawa T. Frailty is a useful predictive marker of postoperative complications after pancreaticoduodenectomy. World J Surg Oncol 2020; 18:194. [PMID: 32746840 PMCID: PMC7401197 DOI: 10.1186/s12957-020-01969-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/24/2020] [Indexed: 02/06/2023] Open
Abstract
Background Frailty results in a high risk for disability, hospitalization, and mortality. This study aimed to investigate perioperative details of frail patients who underwent pancreatectomy and whether frailty can be a predictive factor of postoperative complications, especially of clinically relevant postoperative pancreatic fistula (CR-POPF). Methods This retrospective study included patients who underwent pancreatectomy in our hospital between August 2016 and March 2019. The patients were divided into frail and pre-/non-frail groups. The diagnostic criteria were based on the Japanese version of the Cardiovascular Health Study. Results Of 93 patients, 11 (11.8%) and 82 (88.2%) were frail and pre-/non-frail patients, with median ages of 82 and 72 years, respectively (p = 0.041). Postoperative complications (Clavien-Dindo ≧ IIIa) were found in 8 and 32 patients (p = 0.034), CR-POPF in 3 and 13 patients (p = 0.346), and postoperative hospital stays were 21 and 17 days (p = 0.041), respectively. On multivariate analysis, frailty was an independent predictive factor (odds ratio [OR] 5.604, 95.0% confidence interval [CI] 1.002-30.734; p = 0.047) of postoperative complications (Clavien-Dindo ≧ IIIa) after pancreaticoduodenectomy. On multivariate analysis, a soft pancreas (OR 5.696, 95.0% CI 1.142-28.149; p = 0.034) was an independent and significant predictive factor of CR-POPF after pancreaticoduodenectomy. Conclusions Frailty may be a useful predictive factor of postoperative complications in patients undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Yutaka Nakano
- Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, Kanagawa, 230-0012, Japan.
| | - Yuki Hirata
- Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, Kanagawa, 230-0012, Japan
| | - Tatsuya Shimogawara
- Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, Kanagawa, 230-0012, Japan
| | - Toru Yamada
- Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, Kanagawa, 230-0012, Japan
| | - Koki Mihara
- Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, Kanagawa, 230-0012, Japan
| | - Ryo Nishiyama
- Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, Kanagawa, 230-0012, Japan
| | - Shin Nishiya
- Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, Kanagawa, 230-0012, Japan
| | - Hideki Taniguchi
- Department of Patients Support Center, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, Kanagawa, 230-0012, Japan
| | - Tomohisa Egawa
- Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, Kanagawa, 230-0012, Japan
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5
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Schlick CJ, Yang AD. Is there value in cancer center accreditation? Am J Surg 2020; 220:27-28. [PMID: 32416939 DOI: 10.1016/j.amjsurg.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/01/2020] [Accepted: 05/02/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Cary Jo Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Sahlström E, Nilsson J, Tingstedt B, Bergenfeldt M, Andersson R, Andersson B. Surgical exploration without resection in pancreatic and periampullary tumors: Report from a national database. Scand J Surg 2020; 110:344-350. [PMID: 32299289 PMCID: PMC8551431 DOI: 10.1177/1457496920913669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background and objective: Pancreatic and periampullary cancers are sometimes found to have a too advanced disease during surgery to allow resection. The aim was to describe characteristics, treatment, outcome, and time trends for patients that were planned for pancreatic surgery but found unresectable during surgery. Methods: Data from the Swedish National Pancreatic and Periampullary Cancer Registry were used. All patients registered between January 2010 and August 2018 were included. The patient cohort was divided in two halves based on year of diagnosis. Results: In total, 12,377 patients were included in the registry and finally 4568 patients were scheduled for surgery. During surgical exploration, 3879 (84.9%) patients underwent pancreatic resection, 658 (14.4%) patients were found unresectable, and 31 (0.7%) had no pancreatic resection due to other reasons (e.g. benign lesion, comorbidity). More patients underwent surgical exploration and resection during the second time period, but exploration without resection was unchanged (15.7% vs 13.7%; p = 0.062). Survival rates were lower among the unresectable patients with pancreatic and periampullary tumors compared to the resectable patients, including 30-day mortality (n = 17 (3.5%) vs n = 39 (1.6%), p = 0.004) and 90-day mortality (n = 72 (15.0%) vs n = 70 (2.8%), p < 0.001). Palliative surgery became less common during the second half of the time period (p < 0.001). Conclusions: Unresectability is associated with an unfavorable prognosis. The frequency did not decrease during the study period, but palliative surgical procedures became less common.
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Affiliation(s)
- Emil Sahlström
- Department of Clinical Sciences, Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Johan Nilsson
- Department of Clinical Sciences, Lund, Cardiothoracic Surgery Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Bobby Tingstedt
- Department of Clinical Sciences, Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Magnus Bergenfeldt
- Department of Clinical Sciences, Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Roland Andersson
- Department of Clinical Sciences, Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Surgery, Clinical Sciences, Lund, Lund University and Skåne University Hospital, Lund, SE-221 85, Sweden
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7
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Levi ST, Gough BL, Darcy CE, Petrelli NJ, Bennett JJ. Pancreatic resections: 30 and 90-day outcomes in octogenarians. Surg Oncol 2020; 37:101319. [PMID: 34103239 DOI: 10.1016/j.suronc.2020.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/03/2019] [Accepted: 01/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pancreatic tumors are frequently found in a geriatric population. Given that the median age of patients with pancreatic cancer is 70 years at diagnosis and the ubiquity of CT and MRI imaging has increased the detection of pancreas masses, pancreatic surgeons often find themselves operating on patients of advanced age. This study sought to evaluate the outcomes of pancreatic resection in an octogenarian population at a single institution with a dedicated surgical oncology team. STUDY DESIGN A retrospective chart review was performed for all patients undergoing pancreatic resection over a 13-year period at an academic community cancer center. Patient characteristics and operative outcomes were compared between patients aged 80 and older, and those younger than 80. Student t-tests, Fisher's exact test, and Kruskal-Wallis tests were used for univariate analyses. RESULTS Over the 13-year period, a total of 48 patients of 403 undergoing pancreatic resections were aged 80 or older. Of these 48 patients, 35 underwent pancreaticoduodenectomy (Whipple) and 13 underwent distal pancreatectomy. Patient characteristics including ASA classification were similar among the two age groups. The procedures themselves were equally complicated with similar operative times, transfusion requirements, estimated blood losses, and portal vein resections. The number and severity of complications such as delayed gastric emptying and pancreatic leak were not statistically different between the two groups. Additionally, the 30-day reoperation, readmission, and mortality rates were not statistically different. Outcomes at 90-days revealed an increased rate of readmission amongst octogenarians who underwent Whipple without an increase in rates of major complications. The total number of deaths in the octogenarian group was 3 (6.2%) vs. 6 (1.7%) in the non-octogenarian group (p = 0.080). The median length of stay was similar amongst the two age groups. CONCLUSIONS At a large-volume academic community cancer center with a dedicated surgical oncology team, highly selected octogenarians can undergo pancreatic resection safely with outcomes that do not differ significantly from their younger counterparts.
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Affiliation(s)
- Shoshana T Levi
- Division of Surgical Oncology, Helen F Graham Cancer Center and Research Institute, Christiana Care Health System, USA.
| | - Benjamin L Gough
- Division of Surgical Oncology, Helen F Graham Cancer Center and Research Institute, Christiana Care Health System, USA
| | - Christine E Darcy
- Division of Surgical Oncology, Helen F Graham Cancer Center and Research Institute, Christiana Care Health System, USA
| | - Nicholas J Petrelli
- Division of Surgical Oncology, Helen F Graham Cancer Center and Research Institute, Christiana Care Health System, USA
| | - Joseph J Bennett
- Division of Surgical Oncology, Helen F Graham Cancer Center and Research Institute, Christiana Care Health System, USA
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Balzan SMP, Gava VG, Pedrotti S, Magalhães MA, Schwengber A, Dotto ML, Krebs CR. PREVALENCE OF HEPATIC ARTERIAL VARIATIONS WITH IMPLICATIONS IN PANCREATODUODENECTOMY. ACTA ACUST UNITED AC 2019; 32:e1455. [PMID: 31644675 PMCID: PMC6812148 DOI: 10.1590/0102-672020190001e1455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/12/2019] [Indexed: 12/16/2022]
Abstract
Background:
Pancreaticoduodenectomy is the usual surgical option for curative treatment
of periampullary cancer and carries a significant mortality. Arterial
anomalies of the celiac axis are not uncommon and might lead to iatrogenic
lesions or requiring arterial resection/reconstruction in a
pancreatoduodenectomy.
Aim:
Determine the prevalence of arterial variations having implications in
pancreatoduodenectomy.
Methods:
Celiac trunk and hepatic arterial system anatomy was retrospectively
evaluated in 200 abdominal enhanced computed tomography studies.
Results:
Normal anatomy of hepatic arterial system was found in 87% of cases. An
anomalous right hepatic artery was identified in 13% of cases. In 12 cases
there was a substitute right hepatic artery arising from superior mesenteric
artery and in two cases an accessory right hepatic artery with similar
origin. A hepatomesenteric trunk was identified in seven cases and in five
there was a right hepatic artery directly from the celiac trunk. All cases
of anomalous right hepatic artery had a route was behind the pancreatic head
and then, posteriorly and laterally, to the main portal vein before reaching
the liver.
Conclusions:
Hepatic artery variations, such as anomalous right hepatic artery crossing
posterior to the portal vein, are frequently seen (13%). These patients,
when undergoing pancreatoduodenectomy, may require a change in the surgical
approach to achieve an adequate resection. Preoperative imaging can clearly
identify such variations and help to achieve a safer pancreatic head
dissection with proper surgical planning.
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Affiliation(s)
- Silvio Marcio Pegoraro Balzan
- Department of Biology and Pharmacy, Medicine Course, University of Santa Cruz do Sul, Santa Cruz do Sul.,Institute of Oncology Saint Gallen, Hepatobiliary-pancreatic Surgery, Santa Cruz do Sul.,Hospital Moinhos de Vento, Oncology Center Lydia Wong Ling, Porto Alegre
| | | | - Sabrina Pedrotti
- Department of Biology and Pharmacy, Medicine Course, University of Santa Cruz do Sul, Santa Cruz do Sul
| | | | - Alex Schwengber
- Department of Biology and Pharmacy, Medicine Course, University of Santa Cruz do Sul, Santa Cruz do Sul.,Institute of Oncology Saint Gallen, Hepatobiliary-pancreatic Surgery, Santa Cruz do Sul
| | - Marcelo Luiz Dotto
- Department of Biology and Pharmacy, Medicine Course, University of Santa Cruz do Sul, Santa Cruz do Sul.,Institute of Oncology Saint Gallen, Hepatobiliary-pancreatic Surgery, Santa Cruz do Sul
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