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Nießen A, Klaiber U, Lewosinska M, Nickel F, Billmann F, Hinz U, Büchler MW, Hackert T. Portal vein resection in pancreatic neuroendocrine neoplasms. Surgery 2024; 175:1154-1161. [PMID: 38262817 DOI: 10.1016/j.surg.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 12/07/2023] [Accepted: 12/16/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Surgery offers the only cure for borderline resectable or locally advanced pancreatic neuroendocrine neoplasms. Data on incidence, perioperative and long-term outcomes of portal vein resection for pancreatic neuroendocrine neoplasms are scarce. This study aimed to analyze the outcome and prognostic factors of portal vein resection in surgery for pancreatic neuroendocrine neoplasms. METHODS Consecutive patients were analyzed. Portal vein resection was classified according to the International Study Group of Pancreatic Surgery. Clinicopathologic features and overall and disease-free survival were assessed and compared with standard resection in a matched-pair analysis. RESULTS A total of 54 of 666 (8%) resected pancreatic neuroendocrine neoplasms patients underwent portal vein resection, including 7 (13%) tangential resections with venorrhaphy (type 1), 2 (4%) patch reconstructions (type 2), 35 (65%) end-to-end anastomoses (type 3), and 10 (19%) graft interpositions (type 4); 52% of those underwent pancreatoduodenectomy, 22% distal pancreatectomy, and 26% total pancreatectomy. Postoperative portal vein thrombosis occurred in 19%. Postoperative pancreatic fistula grades B and C (9% vs 16%; P = .357), complications Clavien-Dindo grade ≥IIIb (28% vs 13%; P = .071), and 90-day mortality rate (2% each) were not significantly different compared with 108 matched patients. The 5-year overall survival was 45% (standard resection: 68%; P = .432), and the 5-year disease-free survival was 25% (standard resection: 34%; P = .716). Radical resection was associated with 5-year overall survival of 51% and 5-year disease-specific survival of 75%. CONCLUSION This is the largest single-center analysis evaluating perioperative and long-term outcomes of portal vein resection for pancreatic neuroendocrine neoplasms. The postoperative complication rate after portal vein resection is comparable with standard resection. The 90-day mortality is low. Radical resection leads to excellent 5-year oncological survival.
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Affiliation(s)
- Anna Nießen
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany; Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. https://twitter.com/anna_niessen
| | - Ulla Klaiber
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Austria
| | - Magdalena Lewosinska
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany; Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franck Billmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany; Botton-Champalimaud Pancreatic Cancer Centre, Champalimaud Foundation, Lisbon, Portugal.
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany; Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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2
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Groen JV, Michiels N, Besselink MG, Bosscha K, Busch OR, van Dam R, van Eijck CHJ, Koerkamp BG, van der Harst E, de Hingh IH, Karsten TM, Lips DJ, de Meijer VE, Molenaar IQ, Nieuwenhuijs VB, Roos D, van Santvoort HC, Wijsman JH, Wit F, Zonderhuis BM, de Vos-Geelen J, Wasser MN, Bonsing BA, Stommel MWJ, Mieog JSD. Practice variation in venous resection during pancreatoduodenectomy for pancreatic cancer: A nationwide cohort study. Surgery 2023; 174:924-933. [PMID: 37451894 DOI: 10.1016/j.surg.2023.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/19/2023] [Accepted: 06/18/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Practice variation exists in venous resection during pancreatoduodenectomy, but little is known about the potential causes and consequences as large studies are lacking. This study explores the potential causes and consequences of practice variation in venous resection during pancreatoduodenectomy for pancreatic cancer in the Netherlands. METHODS This nationwide retrospective cohort study included patients undergoing pancreatoduodenectomy for pancreatic cancer in 18 centers from 2013 through 2017. RESULTS Among 1,311 patients undergoing pancreatoduodenectomy, 351 (27%) had a venous resection, and the overall median annual center volume of venous resection was 4. No association was found between the center volume of pancreatoduodenectomy and the rate of venous resections, nor between patient and tumor characteristics and the rate of venous resections per center. Female sex, lower body mass index, neoadjuvant therapy, venous involvement, and stenosis on imaging were predictive for venous resection. Adjusted for these factors, 3 centers performed significantly more, and 3 centers performed significantly fewer venous resections than expected. In patients with venous resection, significantly less major morbidity (22% vs 38%) and longer overall survival (median 16 vs 12 months) were observed in centers with an above-median annual volume of venous resections (>4). CONCLUSION Patient and tumor characteristics did not explain significant practice variation between centers in the Netherlands in venous resection during pancreatoduodenectomy for pancreatic cancer. The clinical outcomes of venous resection might be related to the volume of the procedure.
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Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Center, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands; Department of Epidemiology, Maastricht UMC+, The Netherlands
| | - Tom M Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (loc. Oost), Amsterdam, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, The Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein; Regional Academic Cancer Center Utrecht, The Netherlands
| | | | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein; Regional Academic Cancer Center Utrecht, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - Babs M Zonderhuis
- Cancer Center Amsterdam, The Netherlands; Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, The Netherlands
| | - Martin N Wasser
- Department of Radiology, Leiden University Medical Center, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, The Netherlands
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3
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Willems RAL, Michiels N, Lanting VR, Bouwense S, van den Broek BLJ, Graus M, Klok FA, Groot Koerkamp B, de Laat B, Roest M, Wilmink JW, van Es N, Mieog JSD, Ten Cate H, de Vos-Geelen J. Venous Thromboembolism and Primary Thromboprophylaxis in Perioperative Pancreatic Cancer Care. Cancers (Basel) 2023; 15:3546. [PMID: 37509209 PMCID: PMC10376958 DOI: 10.3390/cancers15143546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Recent studies have shown that patients with pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant chemo(radio)therapy followed by surgery have an improved outcome compared to patients treated with upfront surgery. Hence, patients with PDAC are more and more frequently treated with chemotherapy in the neoadjuvant setting. PDAC patients are at a high risk of developing venous thromboembolism (VTE), which is associated with decreased survival rates. As patients with PDAC were historically offered immediate surgical resection, data on VTE incidence and associated preoperative risk factors are scarce. Current guidelines recommend primary prophylactic anticoagulation in selected groups of patients with advanced PDAC. However, recommendations for patients with (borderline) resectable PDAC treated with chemotherapy in the neoadjuvant setting are lacking. Nevertheless, the prevention of complications is crucial to maintain the best possible condition for surgery. This narrative review summarizes current literature on VTE incidence, associated risk factors, risk assessment tools, and primary thromboprophylaxis in PDAC patients treated with neoadjuvant chemo(radio)therapy.
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Affiliation(s)
- R A L Willems
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - N Michiels
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - V R Lanting
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
- Tergooi Hospitals, Internal Medicine, 1201 DA Hilversum, The Netherlands
| | - S Bouwense
- Department of Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- NUTRIM, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - B L J van den Broek
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - M Graus
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - F A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - B de Laat
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - M Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - N van Es
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - H Ten Cate
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - J de Vos-Geelen
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
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4
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Michiels N, Doppenberg D, Groen JV, van Veldhuisen E, Bonsing BA, Busch OR, Crobach ASLP, van Delden OM, van Dieren S, Farina A, de Hingh IHJT, Hurks R, Nederend J, Shahbazi Feshtali S, Tank Y, Vahrmeijer AL, Wasser M, Besselink MG, Mieog JSD. Intraoperative Ultrasound During Surgical Exploration in Patients with Pancreatic Cancer and Vascular Involvement (ULTRAPANC): A Prospective Multicenter Study. Ann Surg Oncol 2023; 30:3455-3463. [PMID: 36774435 PMCID: PMC10175412 DOI: 10.1245/s10434-023-13112-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/02/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Determining the resectability of pancreatic cancer with vascular involvement on preoperative computed tomography imaging remains challenging, especially following preoperative chemotherapy and chemoradiotherapy. Intraoperative ultrasound (IOUS) may provide real-time additional information, but prospective multicenter series confirming its value are lacking. PATIENTS AND METHODS This prospective multicenter study included patients undergoing surgical exploration for pancreatic cancer with vascular involvement. All patients underwent IOUS at the start of explorative laparotomy. Primary outcomes were resectability status as defined by the National Comprehensive Cancer Network and the extent of vascular involvement. RESULTS Overall, 85 patients were included, of whom 74 (87%) were post preoperative chemotherapy, and mostly following FOLFIRINOX regimen (n = 57; 76%). On the basis of preoperative imaging, 34 (40%) patients were staged as resectable (RPC), 32 (38%) borderline resectable (BRPC), and 19 (22%) locally advanced pancreatic cancer (LAPC). IOUS changed the resectability status in 32/85 (38%) patients (p < 0.001), including 8/19 (42%) patients with LAPC who were downstaged (4 to BRPC, 4 to RPC), and 22/32 (69%) patients with BRPC who were downstaged to RPC. Among patients with presumed superior mesenteric artery (SMA) involvement, 20/28 (71%) had no SMA involvement on IOUS. In 15 of these 20 patients a pancreatic resection was performed, all with R0 SMA margin. CONCLUSION IOUS during surgical exploration for pancreatic cancer and vascular involvement downstaged the resectability status in over one-third of patients, which could facilitate progress during surgical exploration. This finding should be confirmed by larger studies, including detailed pathology assessment. Trial Registration www.trialregister.nl (NL7621).
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Affiliation(s)
- Nynke Michiels
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Deesje Doppenberg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jesse V. Groen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Eran van Veldhuisen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Otto M. van Delden
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Arantza Farina
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Rob Hurks
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Yeliz Tank
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - A. L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin Wasser
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - for the Dutch Pancreatic Cancer Group
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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5
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Hackert T, Klaiber U, Hinz U, Strunk S, Loos M, Strobel O, Berchtold C, Kulu Y, Mehrabi A, Müller-Stich BP, Schneider M, Büchler MW. Portal Vein Resection in Pancreatic Cancer Surgery: Risk of Thrombosis and Radicality Determine Survival. Ann Surg 2023; 277:e1291-e1298. [PMID: 35793384 DOI: 10.1097/sla.0000000000005444] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the outcomes of pancreatic cancer [pancreatic ductal adenocarcinoma (PDAC)] surgery with concomitant portal vein resection (PVR), focusing on the PVR type according to the International Study Group of Pancreatic Surgery (ISGPS). BACKGROUND Surgery offers the only chance for cure in PDAC. PVR is often performed for borderline or locally advanced tumors. METHODS Consecutive patients with PDAC operated between January 2006 and January 2018 were included. Clinicopathologic characteristics and outcomes were analyzed and tested for survival prediction. RESULTS Of 2265 PDAC resections, 1571 (69.4%) were standard resections and 694 (30.6%) were resections with PVR, including 149 (21.5%) tangential resections with venorrhaphy (ISGPS type 1), 21 (3.0%) resections with patch reconstruction (type 2), 491 (70.7%) end-to-end anastomoses (type 3), and 33 (4.8%) resections with graft interposition (type 4). The 90-day mortality rate was 2.6% after standard resection and 6.3% after resection with PVR ( P <0.0001). Postoperative portal vein thrombosis and pancreas-specific surgical complications most frequently occurred after PVR with graft interposition (21.2% and 48.5%, respectively). In multivariable analysis, age 70 years and above, ASA stages 3/4, increased preoperative serum carbohydrate antigen 19-9, neoadjuvant treatment, total pancreatectomy, PVR, higher UICC stage, and R+ resections were significant negative prognostic factors for overall survival. Radical R0 (>1 mm) resection resulted in 23.3 months of median survival. CONCLUSIONS This is the largest single-center, comparative cohort study of PVR in PDAC surgery, showing that postoperative morbidity correlates with the reconstruction type. When radical resection is achieved, thrombosis risk is outweighed by beneficial overall survival times of nearly 2 years.
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Affiliation(s)
- Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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6
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Consensus Statement on the Use of Near-Infrared Fluorescence Imaging during Pancreatic Cancer Surgery Based on a Delphi Study: Surgeons' Perspectives on Current Use and Future Recommendations. Cancers (Basel) 2023; 15:cancers15030652. [PMID: 36765609 PMCID: PMC9913161 DOI: 10.3390/cancers15030652] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
Indocyanine green (ICG) is one of the only clinically approved near-infrared (NIR) fluorophores used during fluorescence-guided surgery (FGS), but it lacks tumor specificity for pancreatic ductal adenocarcinoma (PDAC). Several tumor-targeted fluorescent probes have been evaluated in PDAC patients, yet no uniformity or consensus exists among the surgical community on the current and future needs of FGS during PDAC surgery. In this first-published consensus report on FGS for PDAC, expert opinions were gathered on current use and future recommendations from surgeons' perspectives. A Delphi survey was conducted among international FGS experts via Google Forms. Experts were asked to anonymously vote on 76 statements, with ≥70% agreement considered consensus and ≥80% participation/statement considered vote robustness. Consensus was reached for 61/76 statements. All statements were considered robust. All experts agreed that FGS is safe with few drawbacks during PDAC surgery, but that it should not yet be implemented routinely for tumor identification due to a lack of PDAC-specific NIR tracers and insufficient evidence proving FGS's benefit over standard methods. However, aside from tumor imaging, surgeons suggest they would benefit from visualizing vasculature and surrounding anatomy with ICG during PDAC surgery. Future research could also benefit from identifying neuroendocrine tumors. More research focusing on standardization and combining tumor identification and vital-structure imaging would greatly improve FGS's use during PDAC surgery.
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7
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Groen JV, Michiels N, van Roessel S, Besselink MG, Bosscha K, Busch OR, van Dam R, van Eijck CHJ, Koerkamp BG, van der Harst E, de Hingh IH, Karsten TM, Lips DJ, de Meijer VE, Molenaar IQ, Nieuwenhuijs VB, Roos D, van Santvoort HC, Wijsman JH, Wit F, Zonderhuis BM, de Vos-Geelen J, Wasser MN, Bonsing BA, Stommel MWJ, Mieog JSD. Venous wedge and segment resection during pancreatoduodenectomy for pancreatic cancer: impact on short- and long-term outcomes in a nationwide cohort analysis. Br J Surg 2021; 109:96-104. [PMID: 34791069 PMCID: PMC10364765 DOI: 10.1093/bjs/znab345] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 09/03/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Venous resection of the superior mesenteric or portal vein is increasingly performed in pancreatic cancer surgery, whereas results of studies on short- and long-term outcomes are contradictory. The aim of this study was to evaluate the impact of the type of venous resection in pancreatoduodenectomy for pancreatic cancer on postoperative morbidity and overall survival. METHODS This nationwide retrospective cohort study included all patients who underwent pancreatoduodenectomy for pancreatic cancer in 18 centres (2013-2017). RESULTS A total of 1311 patients were included, of whom 17 per cent underwent wedge resection and 10 per cent segmental resection. Patients with segmental resection had higher rates of major morbidity (39 versus 20 versus 23 per cent, respectively; P < 0.001) and portal or superior mesenteric vein thrombosis (18 versus 5 versus 1 per cent, respectively; P < 0.001) and worse overall survival (median 12 versus 16 versus 20 months, respectively; P < 0.001), compared to patients with wedge resection and those without venous resection. Multivariable analysis showed patients with segmental resection, but not those who had wedge resection, had higher rates of major morbidity (odds ratio = 1.93, 95 per cent c.i. 1.20 to 3.11) and worse overall survival (hazard ratio = 1.40, 95 per cent c.i. 1.10 to 1.78), compared to patients without venous resection. Among patients who received neoadjuvant therapy, there was no difference in overall survival among patients with segmental and wedge resection and those without venous resection (median 32 versus 25 versus 33 months, respectively; P = 0.470), although there was a difference in major morbidity rates (52 versus 19 versus 21 per cent, respectively; P = 0.012). CONCLUSION In pancreatic surgery, the short- and long-term outcomes are worse in patients with venous segmental resection, compared to patients with wedge resection and those without venous resection.
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Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Stijn van Roessel
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Epidemiology, GROW—School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Tom M Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (loc. Oost), Amsterdam, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, UMC Utrecht Cancer Centre, St Antonius Hospital Nieuwegein; Regional Academic Cancer Centre Utrecht, Utrecht, the Netherlands
| | | | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Centre, St Antonius Hospital Nieuwegein; Regional Academic Cancer Centre Utrecht, Utrecht, the Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - Babs M Zonderhuis
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW—School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Martin N Wasser
- Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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8
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Groen JV, van Manen L, van Roessel S, van Dam JL, Bonsing BA, Doukas M, van Eijck CHJ, Farina Sarasqueta A, Putter H, Vahrmeijer AL, Verheij J, Besselink MG, Groot Koerkamp B, Mieog JSD. Resection of the Portal-Superior Mesenteric Vein in Pancreatic Cancer: Pathological Assessment and Recurrence Patterns. Pancreas 2021; 50:1218-1229. [PMID: 34714287 DOI: 10.1097/mpa.0000000000001897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The portal vein (PV)-superior mesenteric vein (SMV) margin is the most affected margin in pancreatic cancer. This study investigates the association between venous resection, tumor invasion in the resected PV-SMV, recurrence patterns, and overall survival (OS). METHODS This multicenter cohort study included patients who underwent pancreatoduodenectomy for pancreatic cancer (2010-2017). In addition, a systematic literature search was performed. RESULTS In total, 531 patients were included, of which 149 (28%) underwent venous resection of whom 53% had tumor invasion in the resected PV-SMV. Patients with venous resection had a significant higher rate of R1 margins (69% vs 37%) and had more often multiple R1 margins (43% vs 16%). Patient with venous resection had a significant shorter time to locoregional recurrence and a shorter OS (15 vs 19 months). At multivariable analyses, venous resection and tumor invasion in the resected PV-SMV were not predictive for time to recurrence and OS. The literature overview showed that pathological assessment of the resected PV-SMV is not adequately standardized. CONCLUSIONS Only half of patients with venous resection had pathology confirmed tumor invasion in the resected PV-SMV, and both are not independently associated with time to recurrence and OS. The pathological assessment of the resected PV-SMV needs to be standardized.
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Affiliation(s)
- Jesse V Groen
- From the Department of Surgery, Leiden University Medical Center, Leiden
| | - Labrinus van Manen
- From the Department of Surgery, Leiden University Medical Center, Leiden
| | - Stijn van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam
| | | | - Bert A Bonsing
- From the Department of Surgery, Leiden University Medical Center, Leiden
| | - Michael Doukas
- Pathology, Erasmus MC University Medical Center, Rotterdam
| | | | | | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam
| | | | - J Sven D Mieog
- From the Department of Surgery, Leiden University Medical Center, Leiden
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