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Verdeyen N, Gryspeerdt F, Abreu de Carvalho L, Dries P, Berrevoet F. A Comparison of Preoperative Predictive Scoring Systems for Postoperative Pancreatic Fistula after Pancreaticoduodenectomy Based on a Single-Center Analysis. J Clin Med 2024; 13:3286. [PMID: 38892998 PMCID: PMC11172640 DOI: 10.3390/jcm13113286] [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: 05/11/2024] [Revised: 05/26/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is associated with major postoperative morbidity and mortality. Several scoring systems have been described to stratify patients into risk groups according to the risk of POPF. The aim of this study was to compare scoring systems in patients who underwent a PD. Methods: A total of 196 patients undergoing PD from July 2019 to June 2022 were identified from a prospectively maintained database of the University Hospital Ghent. After performing a literature search, four validated, solely preoperative risk scores and the intraoperative Fistula Risk Score (FRS) were included in our analysis. Furthermore, we eliminated the variable blood loss (BL) from the FRS and created an additional score. Univariate and multivariate analyses were performed for all risk factors, followed by a ROC analysis for the six scoring systems. Results: All scores showed strong prognostic stratification for developing POPF (p < 0.001). FRS showed the best predictive accuracy in general (AUC 0.862). FRS without BL presented the best prognostic value of the scores that included solely preoperative variables (AUC 0.783). Soft pancreatic texture, male gender, and diameter of the Wirsung duct were independent prognostic factors on multivariate analysis. Conclusions: Although all predictive scoring systems stratify patients accurately by risk of POPF, preoperative risk stratification could improve clinical decision-making and implement preventive strategies for high-risk patients. Therefore, the preoperative use of the FRS without BL is a potential alternative.
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Affiliation(s)
- Naomi Verdeyen
- Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium;
| | - Filip Gryspeerdt
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, 9000 Ghent, Belgium; (F.G.); (L.A.d.C.); (P.D.)
| | - Luìs Abreu de Carvalho
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, 9000 Ghent, Belgium; (F.G.); (L.A.d.C.); (P.D.)
| | - Pieter Dries
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, 9000 Ghent, Belgium; (F.G.); (L.A.d.C.); (P.D.)
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, 9000 Ghent, Belgium; (F.G.); (L.A.d.C.); (P.D.)
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Russell TB, Labib PL, Denson J, Streeter A, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Croagh D, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh BA, Serrablo A, Aroori S. Postoperative complications after pancreatoduodenectomy for malignancy: results from the Recurrence After Whipple's (RAW) study. BJS Open 2023; 7:zrad106. [PMID: 38036696 PMCID: PMC10689345 DOI: 10.1093/bjsopen/zrad106] [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: 02/14/2023] [Revised: 08/04/2023] [Accepted: 08/27/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is associated with significant postoperative morbidity. Surgeons should have a sound understanding of the potential complications for consenting and benchmarking purposes. Furthermore, preoperative identification of high-risk patients can guide patient selection and potentially allow for targeted prehabilitation and/or individualized treatment regimens. Using a large multicentre cohort, this study aimed to calculate the incidence of all PD complications and identify risk factors. METHOD Data were extracted from the Recurrence After Whipple's (RAW) study, a retrospective cohort study of PD outcomes (29 centres from 8 countries, 2012-2015). The incidence and severity of all complications was recorded and potential risk factors for morbidity, major morbidity (Clavien-Dindo grade > IIIa), postoperative pancreatic fistula (POPF), post-pancreatectomy haemorrhage (PPH) and 90-day mortality were investigated. RESULTS Among the 1348 included patients, overall morbidity, major morbidity, POPF, PPH and perioperative death affected 53 per cent (n = 720), 17 per cent (n = 228), 8 per cent (n = 108), 6 per cent (n = 84) and 4 per cent (n = 53), respectively. Following multivariable tests, a high BMI (P = 0.007), an ASA grade > II (P < 0.0001) and a classic Whipple approach (P = 0.005) were all associated with increased overall morbidity. In addition, ASA grade > II patients were at increased risk of major morbidity (P < 0.0001), and a raised BMI correlated with a greater risk of POPF (P = 0.001). CONCLUSION In this multicentre study of PD outcomes, an ASA grade > II was a risk factor for major morbidity and a high BMI was a risk factor for POPF. Patients who are preoperatively identified to be high risk may benefit from targeted prehabilitation or individualized treatment regimens.
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Affiliation(s)
- Thomas B Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Peter L Labib
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jemimah Denson
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Adam Streeter
- Department of Medical Statistics, University of Muenster, Muenster, Germany
- Department of Medical Statistics, University of Plymouth, Plymouth, UK
| | - Fabio Ausania
- Department of HPB Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Elizabeth Pando
- Department of HPB Surgery, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Keith J Roberts
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ambareen Kausar
- Department of HPB Surgery, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Vasileios K Mavroeidis
- Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Department of HPB Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Gabriele Marangoni
- Department of HPB Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | | | - Adam E Frampton
- Department of HPB Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Pavlos Lykoudis
- Department of HPB Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Manuel Maglione
- Department of HPB Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nassir Alhaboob
- Department of HPB Surgery, Ibn Sina Specialized Hospital, Khartoum, Sudan
| | - Hassaan Bari
- Department of HPB Surgery, Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | - Andrew M Smith
- Department of HPB Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Duncan Spalding
- Department of HPB Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Parthi Srinivasan
- Department of HPB Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Brian R Davidson
- Department of HPB Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Ricky H Bhogal
- Department of HPB Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Daniel Croagh
- Department of HPB Surgery, Monash Medical Centre, Melbourne, Australia
| | - Ismael Dominguez
- Department of HPB Surgery, Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Department of HPB Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dhanny Gomez
- Department of HPB Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Department of HPB Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Pierfrancesco Lapolla
- Department of HPB Surgery, Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Andrea Mingoli
- Department of HPB Surgery, Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Department of HPB Surgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Department of HPB Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- Department of HPB Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bilal A Al-Sarrieh
- Department of HPB Surgery, Swansea Bay University Health Board, Swansea, UK
| | - Alejandro Serrablo
- Department of HPB Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Alhulaili ZM, Linnemann RJ, Dascau L, Pleijhuis RG, Klaase JM. A Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis analysis to evaluate the quality of reporting of postoperative pancreatic fistula prediction models after pancreatoduodenectomy: A systematic review. Surgery 2023; 174:684-691. [PMID: 37296054 DOI: 10.1016/j.surg.2023.04.058] [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: 10/02/2022] [Revised: 03/06/2023] [Accepted: 04/27/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is a frequent and potentially lethal complication after pancreatoduodenectomy. Several models have been developed to predict postoperative pancreatic fistula risk. This study was performed to evaluate the quality of reporting of postoperative pancreatic fistula prediction models after pancreatoduodenectomy using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) checklist that provides guidelines on reporting prediction models to enhance transparency and to help in the decision-making regarding the implementation of the appropriate risk models into clinical practice. METHODS Studies that described prediction models to predict postoperative pancreatic fistula after pancreatoduodenectomy were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The TRIPOD checklist was used to evaluate the adherence rate. The area under the curve and other performance measures were extracted if reported. A quadrant matrix chart is created to plot the area under the curve against TRIPOD adherence rate to find models with a combination of above-average TRIPOD adherence and area under the curve. RESULTS In total, 52 predictive models were included (23 development, 15 external validation, 4 incremental value, and 10 development and external validation). No risk model achieved 100% adherence to the TRIPOD. The mean adherence rate was 65%. Most authors failed to report on missing data and actions to blind assessment of predictors. Thirteen models had an above-average performance for TRIPOD checklist adherence and area under the curve. CONCLUSION Although the average TRIPOD adherence rate for postoperative pancreatic fistula models after pancreatoduodenectomy was 65%, higher compared to other published models, it does not meet TRIPOD standards for transparency. This study identified 13 models that performed above average in TRIPOD adherence and area under the curve, which could be the appropriate models to be used in clinical practice.
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Affiliation(s)
- Zahraa M Alhulaili
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Ralph J Linnemann
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Larisa Dascau
- Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Rick G Pleijhuis
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Joost M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, the Netherlands.
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Mustansir F, Jajja MR, Lovasik BP, Sharma J, Lin E, Sweeney JF, Sarmiento JM. Does CPT Modifier 22 Appropriately Reflect a Difficult Pancreaticoduodenectomy? Retrospective Analysis of Operative Outcomes and Cost. J Am Coll Surg 2023; 236:993-1000. [PMID: 36735633 DOI: 10.1097/xcs.0000000000000609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND CPT coding allows addition of a 2-digit modifier code to denote particularly difficult procedures necessitating additional reimbursement, called the modifier 22. The use of modifier 22 in relation to pancreatic surgery and outcomes, specifically pancreaticoduodenectomy (PD), has not been explored. STUDY DESIGN All PDs performed from 2010 to 2019 at a quaternary healthcare system were analyzed for differences in preoperative characteristics, outcomes, and cost based on the use of modifier 22. Adjusted logistic regression analysis was used to identify factors predictive of modifier 22 use. RESULTS A total of 1,284 patients underwent PD between 2010 and 2019; 1,173 with complete data were included, of which 320 (27.3%) were coded with modifier 22. Patients coded with modifier 22 demonstrated a significantly longer duration of surgery (365.9 ± 168.4 vs 227 ± 97.1; p < 0.001). They also incurred significantly higher cost of index admission ($37,446 ± 34,187 vs $28,279 ± 27,980; p = 0.002). An adjusted multivariable analysis (specifically adjusted for surgeon variation) revealed duration of surgery (p < 0.001), neoadjuvant chemotherapy (p = 0.039), class II obesity (p = 0.019), and chronic pancreatitis (p = 0.005) to be predictive of modifier 22 use. CONCLUSIONS Despite the subjective nature of this CPT modifier, modifier 22 is an appropriate marker of intraoperative difficulty. Preoperative and intraoperative characteristics that lead to its addition may be used to further delineate difficult PDs.
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Affiliation(s)
- Fatima Mustansir
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - Mohammad Raheel Jajja
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - Brendan P Lovasik
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - Jyotirmay Sharma
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - Edward Lin
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - John F Sweeney
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
| | - Juan M Sarmiento
- From the Department of Surgery (Mustansir, Jajja, Lovasik, Sharma, Lin, Sweeney, Sarmiento), Emory University, Atlanta, GA
- Winship Cancer Institute (Sarmiento), Emory University, Atlanta, GA
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Russell TB, Labib PLZ, Aroori S. Five-year follow-up after pancreatoduodenectomy performed for malignancy: A single-centre study. Ann Hepatobiliary Pancreat Surg 2023; 27:76-86. [PMID: 36168824 PMCID: PMC9947371 DOI: 10.14701/ahbps.22-039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/13/2022] [Accepted: 07/21/2022] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims The aim of this study was to describe short- and long-term outcomes of patients who underwent pancreatoduodenectomy (PD) at a typical United Kingdom hepatopancreatobiliary unit. Methods A retrospective analysis of all PD patients with histologically-confirmed pancreatic ductal adenocarcinoma (PDAC), ampullary adenocarcinoma (AA), or distal cholangiocarcinoma (CC) from September 1st, 2006 to May 31st, 2015 was carried out. The following information was obtained: demographics, comorbidities, preoperative investigations, neoadjuvant treatment, operative details, postoperative management, complications, adjuvant treatment, five-year recurrence, and five-year survival. Effects of selected preoperative variables on short- and long-term outcomes were investigated. Results Of 271 included patients, 57.9% had PDAC, 25.8% had AA, and 16.2% had CC. In total, 67.9% experienced morbidity and 17.3% developed a Clavien-Dindo grade ≥ III complication. The 90-day mortality was 3.3%. Clinically-relevant postoperative pancreatic fistula, bile leak, gastrojejunal leak, postpancreatectomy haemorrhage and delayed gastric emptying affected 8.1%, 4.1%, 0.0%, 9.2%, and 19.9% of patients, respectively. American Society of Anesthesiologists grade III-VI correlated with overall morbidity (p = 0.002) and major morbidity (p = 0.009), but not 90-day mortality or five-year survival. The same pattern was observed in patients with a preoperative serum bilirubin > 29 μmol/L and/or a neutrophil/lymphocyte ratio > 3.1. Five-year cancer recurrence and five-year survival were 68.3% and 22.5%, respectively. PDAC patients had higher five-year recurrence but lower five-year survival rates (both p = 0.001). Conclusions In our series, the majority of patients experienced a complication. However, few patients experienced major morbidity. Surgical risk factors did not affect five-year survival.
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Affiliation(s)
- Thomas Brendon Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | | | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom,Corresponding author: Somaiah Aroori, MD, FRCS Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth PL6 8DH, United Kingdom Tel: +44-7837388342, E-mail: ORCID: https://orcid.org/0000-0002-5613-6463
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Russell TB, Labib PL, Bowles M, Aroori S. Serious complications of pancreatoduodenectomy correlate with lower rates of adjuvant chemotherapy: Would high-risk patients benefit from neoadjuvant therapy? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:142-149. [PMID: 36075841 DOI: 10.1016/j.ejso.2022.08.032] [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: 06/06/2022] [Revised: 08/10/2022] [Accepted: 08/26/2022] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Patients who suffer a serious complication of pancreatoduodenectomy (PD) may have their adjuvant chemotherapy (AC) delayed or omitted as a result. We aimed to investigate whether PD complications affected AC rates. MATERIALS AND METHODS A retrospective analysis of all PD patients with histologically-confirmed pancreatic ductal adenocarcinoma (2006-2015) was performed; 90-day mortality patients were excluded. Patients who commenced AC were compared to those who did not (morbidity rates and survival) and patients who developed selected postoperative complications were compared to those who did not (AC rates and survival). RESULTS 157 patients were included and 90-day mortality was 3.8%. Of the remaining patients, 102 (68.5%) received AC (AC data unavailable for two patients). Survival was longer in the AC group (p = 0.004). AC patients had less frequently experienced a postoperative chest infection (8.82% vs 34.0%, p = 0.0003) or a postoperative complication which was Clavien-Dindo (CD) grade ≥ II (29.4% vs 57.4%, p = 0.0019) or ≥ III (6.86% vs 21.3%, p = 0.023). Patients who experienced a postoperative chest infection (36.0% vs 75.0%, p = 0.0003) or a postoperative complication which was CD grade ≥ II (48.9% vs 73.1%, p = 0.0099) or ≥ III (29.4% vs 70.3%, p = 0.0018) less frequently commenced AC. CONCLUSION Patients who received AC had less frequently experienced a serious postoperative complication. Efforts should be made to preoperatively identify those who are high-risk for a serious complication as this cohort may benefit from neoadjuvant therapy.
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Affiliation(s)
- Thomas B Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| | - Peter L Labib
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| | - Matthew Bowles
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK.
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Alhulaili ZM, Pleijhuis RG, Nijkamp MW, Klaase JM. External Validation of a Risk Model for Severe Complications following Pancreatoduodenectomy Based on Three Preoperative Variables. Cancers (Basel) 2022; 14:cancers14225551. [PMID: 36428643 PMCID: PMC9688739 DOI: 10.3390/cancers14225551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is the only cure for periampullary and pancreatic cancer. It has morbidity rates of 40-60%, with severe complications in 30%. Prediction models to predict complications are crucial. A risk model for severe complications was developed by Schroder et al. based on BMI, ASA classification and Hounsfield Units of the pancreatic body on the preoperative CT scan. These variables were independent predictors for severe complications upon internal validation. Our aim was to externally validate this model using an independent cohort of patients. METHODS A retrospective analysis was performed on 318 patients who underwent PD at our institution from 2013 to 2021. The outcome of interest was severe complications Clavien-Dindo ≥ IIIa. Model calibration, discrimination and performance were assessed. RESULTS A total of 308 patients were included. Patients with incomplete data were excluded. A total of 89 (28.9%) patients had severe complications. The externally validated model achieved: C-index = 0.67 (95% CI: 0.60-0.73), regression coefficient = 0.37, intercept = 0.13, Brier score = 0.25. CONCLUSIONS The performance ability, discriminative power, and calibration of this model were acceptable. Our risk calculator can help surgeons identify high-risk patients for post-operative complications to improve shared decision-making and tailor perioperative management.
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Affiliation(s)
- Zahraa M. Alhulaili
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
| | - Rick G. Pleijhuis
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
| | - Maarten W. Nijkamp
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
| | - Joost M. Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
- Correspondence:
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Gorji L, Beal EW. Surgical Treatment of Distal Cholangiocarcinoma. Curr Oncol 2022; 29:6674-6687. [PMID: 36135093 PMCID: PMC9498206 DOI: 10.3390/curroncol29090524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 12/03/2022] Open
Abstract
Distal cholangiocarcinoma (dCCA) is a rare malignancy arising from the epithelial cells of the distal biliary tract and has a poor prognosis. dCCA is often clinically silent and patients commonly present with locally advanced and/or distant disease. For patients identified with early stage, resectable disease, surgical resection with negative margins remains the only curative treatment strategy available. However, despite appropriate treatment and diligent surveillance, risk of recurrence remains high with nearly 50% of patients experiencing recurrence at 5 years subsequent to surgical resection; therefore, it is prudent to continue to optimize neoadjuvant and adjuvant therapies in order to reduce the risk of recurrence and improve overall survival. In this review, we discuss the clinical presentation, workup and surgical treatment of dCCA.
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Affiliation(s)
- Leva Gorji
- Department of Surgery, Kettering Health Dayton, Dayton, OH 45405, USA
| | - Eliza W. Beal
- Departments of Oncology and Surgery, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 48201, USA
- Correspondence:
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Wiltberger G, den Dulk M, Bednarsch J, Czigany Z, Lang SA, Andert A, Lamberzt A, Heij LR, de Vos-Geelen J, Stommel MWJ, van Dam RM, Dejong C, Ulmer F, Neumann UP. Perioperative and long-term outcome of en-bloc arterial resection in pancreatic surgery. HPB (Oxford) 2022; 24:1119-1128. [PMID: 35078714 DOI: 10.1016/j.hpb.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/03/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic tumors are frequently diagnosed in a locally advanced stage with poor prognosis if untreated. This study assesses the safety and oncological outcomes of pancreatic surgery with arterial en-bloc resection. METHODS We retrospectively reviewed a prospectively maintained database of patients who underwent a pancreatic resection with arterial resection between 2011 and 2020. Univariable analyses were used to assess prognostic factors for survival. RESULTS Forty consecutive patients (22 female; 18 male) undergoing arterial resections were included. Surgical procedures consisted of 19 pancreatoduodenectomies (PD, 48%), 16 distal splenopancreatectomy (DSP, 40%), and 5 total pancreatectomies (TP, 12%). Arterial resection included hepatic arteries (HA, N = 23), coeliac trunk (TC, N = 15) and superior mesenteric artery (SMA, N = 2). Neoadjuvant therapy was applied in 22 patients (58%). Major complications after surgery were observed in 15% of cases. 90-day mortality was 5%. Median disease-free survival and median overall survival were for the R0/CRM- group 22.8 months and 27.9 months, 9.5 and 19.8 months for the R0/CRM+ group, and 10.1 and 13.1 months for the R1 group, respectively. CONCLUSION In highly selected patients, arterial en-bloc resection can be performed with acceptable mortality and morbidity rates and beneficial oncological outcome.
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Affiliation(s)
- Georg Wiltberger
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Aachen, Germany.
| | - Marcel den Dulk
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
| | - Jan Bednarsch
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - Zoltan Czigany
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - Sven A Lang
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - Anne Andert
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - Andreas Lamberzt
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - Lara R Heij
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, the Netherlands; Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
| | - Cornelis Dejong
- Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
| | - Florian Ulmer
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - Ulf P Neumann
- Department of General, Visceral, and Transplantation Surgery, University Hospital of RWTH Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
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10
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Park J, Han SS, Park SJ, Kang MJ, Park HM, Yu J, Kim SW. Effect of perioperative fluid volume restriction on the incidence of complications following pancreaticoduodenectomy. ANZ J Surg 2022; 92:1797-1802. [PMID: 35531886 DOI: 10.1111/ans.17751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/14/2022] [Accepted: 04/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Perioperative fluid restriction has been suggested to reduce morbidity and length of stay. The purpose of this study was to compare the morbidity following pancreaticoduodenectomy (PD) between fluid restriction group and conventional management group. METHODS Seventy-two patients were enrolled for perioperative fluid restriction of PD. During the operation, main fluid was infused at a rate of less than 8 mL/kg/hr. Until POD#3, 10% dextrose and Hartmann's solution were administered at rates of 40 mL/h and {(1.5*body weight) - 42} mL/h, respectively. The historical control group consisted of 139 patients. We compared the rates of major complication (Clavien-Dindo grade III to V) and clinically relevant postoperative pancreatic fistula (CR-POPF), length of hospital stays (LOS), amount of urine output, and the rate of acute kidney injury (AKI). RESULTS The rates of major complication (19.0% versus 18.7%; p > 0.999), CR-POPF (15.5% versus 15.1%; p > 0.999), and LOS (19 days [range: 10-52] versus 19 days [range: 11-75]; p = 0.514) were comparable in the study and the control group, respectively. Amount of urine output during the operation and from POD#1 to POD#3 was more than minimal amount (0.5 mL/kg/hr) in the both groups. Incidence rate of AKI in the study group was not higher than the control group (Stage I: 1.7% versus 2.9%, p > 0.999; stage II: 0% versus 1.4%, p > 0.999). CONCLUSION There was no decrease in incidence of morbidity including POPF following PD with perioperative fluid restriction. Fluid restriction was feasible because it did not reduce urine output and did not increase incidence of AKI.
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Affiliation(s)
- Jangho Park
- Department of General Surgery, Osan Hankook Hospital, Osan, Republic of Korea.,Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Sung-Sik Han
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Sang-Jae Park
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Mee Joo Kang
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Hyeong Min Park
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Jihye Yu
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Sun-Whe Kim
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
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11
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Agrawal S, Khanal B, Das U, Sah SP, Gupta RK. Pancreaticoduodenectomy: Impact of Volume on Outcomes at a Tertiary Care Center-Our Experience in Single Institute of Nepal. J Gastrointest Cancer 2021; 53:692-699. [PMID: 34480743 DOI: 10.1007/s12029-021-00705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy is a complex high-risk surgical procedure usually done for malignant disease carrying significant postoperative morbidity and mortality. An audit and analysis of rate of postoperative morbidity and mortality and the impact of case volume can provide information about the lacunas in patient care and methods to improve it for safe and early discharge of patients. This study was conducted to find out demographic profile, the rate of perioperative morbidities, mortality, and impact of case volume on patients undergoing pancreaticoduodenectomy for malignant disease which may serve as a guide to uplift the patient care in our center. METHODS Retrospective analysis of prospectively collected data of patients undergoing pancreaticoduodenectomy from 2015 to 2019 was performed. A total of 62 patients were included in the study. Patient's clinic-demographic details and intraoperative and postoperative events were recorded. The rate of various postoperative morbidities and mortality and year-wise trend of these factors were analyzed. RESULTS Most of the patients were in the sixth decade of life (38.7%) with male preponderance (61.3%). Pancreatic cancer was most commonly seen followed by cholangiocarcinoma (46.8%). SSI (32.3%), intraabdominal collection (25.8%), anastomotic leak (14.5%), pancreatic fistula (22.6%), and postpancreatectomy hemorrhage (8.1%) were the major postoperative events. Mortality was found in 12.9% patients. CONCLUSION There has been a decrease in rate of all these postoperative adverse events and improvement in the intraoperative blood loss and surgical duration with advancing years and increasing number of cases.
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Affiliation(s)
- Sunit Agrawal
- General Surgery and MIS Unit, BPKIHS, Dharan, Nepal.
| | | | - Ujjwal Das
- General Surgery and MIS Unit, BPKIHS, Dharan, Nepal
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12
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Procalcitonin and C-Reactive Protein as an Early Predictor of Infection in Elective Gastrointestinal Cancer Surgery-a Prospective Observational Study. J Gastrointest Cancer 2021; 53:605-613. [PMID: 34328613 DOI: 10.1007/s12029-021-00661-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Postoperative infections are a common entity following elective gastrointestinal surgery among which intra-abdominal infection is notorious and life threatening. Early detection could reduce postoperative morbidity and permit safe and early discharge. This study was aimed to establish the usefulness of procalcitonin (PCT) and C-reactive protein (CRP) on postoperative day 3 as reliable markers for early detection of intra-abdominal infection and other postoperative infections following elective gastrointestinal cancer surgery. METHODS A total of 125 patients following elective gastrointestinal cancer surgery were prospectively observed until discharge from January 2018 to December 2019. The incidence of intra-abdominal infections and other postoperative infections was recorded. Serum PCT and CRP were estimated on postoperative day 3 for all the patients. ROC analysis of PCT and CRP was performed to establish their predictability in detecting these infections. Risk factors for postoperative infections were also studied. RESULTS The incidence of intra-abdominal infection (IAI) was 24%. The difference in PCT between the infected and non-infected patients was statistically significant (p = 0.001) but not in CRP (p = 0.223). On ROC analysis of CRP and PCT in detecting IAI, the areas under the curve were 0.494 and 0.615 respectively. CONCLUSION Raised serum PCT values on postoperative day 3 indicate the presence of infections and should prompt the surgeon to consider other investigations to confirm the presence of IAI and other postoperative infections and plan early intervention thus expediting the postoperative recovery. CLINICAL TRIAL REGISTRATION NUMBER CTRI/2018/12/016695.
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13
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Guilbaud T, Garnier J, Girard E, Ewald J, Risse O, Moutardier V, Chirica M, Birnbaum DJ, Turrini O. Postoperative day 1 combination of serum C-reactive protein and drain amylase values predicts risks of clinically relevant pancreatic fistula. The "90-1000" score. Surgery 2021; 170:1508-1516. [PMID: 34092376 DOI: 10.1016/j.surg.2021.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/20/2021] [Accepted: 04/26/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Several scoring systems predict risks of clinically relevant postoperative pancreatic fistula after pancreatectomy, but none have emerged as the gold standard. This study aimed to evaluate the accuracy of postoperative day 1 drain amylase and serum C-reactive protein levels in predicting clinically relevant postoperative pancreatic fistula compared with intraoperative pancreatic characteristics. METHODS Patients who underwent pancreatectomy between 2017 and 2019 were included prospectively. Cutoff values were determined using receiver operating characteristic curves, and a score combining postoperative day 1 drain amylase and serum C-reactive protein was tested in a multivariate logistic regression model to evaluate clinically relevant postoperative pancreatic fistula risk. RESULTS A total of 274 pancreatic resections (182 pancreaticoduodenectomies and 92 distal pancreatectomies) were included. The pancreatic gland texture was "soft" in 47.8% (n = 131), and 55.8% (n = 153) had a small size main pancreatic duct (≤3 mm). Clinically relevant postoperative pancreatic fistula occurred in 58 patients (21.2%). Drain amylase ≥1,000 UI/L and serum C-reactive protein ≥90 mg/L were identified as the optimal cutoffs to predict clinically relevant postoperative pancreatic fistula. On multivariate analysis these cutoffs were independent predictors of clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies (drain amylase: P < .001, serum C-reactive protein: P = .006) and distal pancreatectomies (drain amylase: P = .009, serum C-reactive protein: P = .001). The postoperative day 1 "90-1000" model, a 2-value score relying on these cutoffs, significantly (P < .001) outperformed intraoperative pancreatic parenchymal characteristics in predicting clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies and distal pancreatectomies. A postoperative day 1 "90-1000" score = 0 had a negative predictive value of 97% and 94%, respectively, after pancreaticoduodenectomy and distal pancreatectomies. CONCLUSION A combined score relying on postoperative day 1 values of drain amylase and serum C-reactive protein levels was accurate in predicting risks of clinically relevant postoperative pancreatic fistula after pancreatectomy.
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Affiliation(s)
- Théophile Guilbaud
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Marseille, France.
| | - Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France
| | - Edouard Girard
- Department of Digestive Surgery and Liver Transplantation, Hôpital Michalon, Grenoble University, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France
| | - Olivier Risse
- Department of Digestive Surgery and Liver Transplantation, Hôpital Michalon, Grenoble University, France
| | - Vincent Moutardier
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Mircea Chirica
- Department of Digestive Surgery and Liver Transplantation, Hôpital Michalon, Grenoble University, France
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Olivier Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France
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14
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Furbetta N, Gianardi D, Guadagni S, Di Franco G, Palmeri M, Bianchini M, Pisani K, Di Candio G, Morelli L. Somatostatin administration following pancreatoduodenectomy: a case-matched comparison according to surgical technique, body mass index, American Society of Anesthesiologists' score and Fistula Risk Score. Surg Today 2020; 51:1044-1053. [PMID: 33270148 PMCID: PMC8141487 DOI: 10.1007/s00595-020-02189-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE This study evaluated the controversial role of somatostatin after pancreatoduodenectomy (PD), stratifying patients for the main risk factors using the most recent postoperative pancreatic fistula (POPF) classification and including only patients who had undergone PD with the same technique of pancreatojejunostomy. METHODS Between November 2010 and February 2020, 218 PD procedures were carried out via personal modified pancreatojejunostomy (mPJ-PD). Somatostatin was routinely administered between 2010 and 2016, while from 2017, 97 mPJ-PD procedures without somatostatin (WS) were performed. The WS group was retrospectively compared with a control (C) group obtained with one-to-one case-control matching according to the body mass index, American Society of Anesthesiologists' score, and Fistula Risk Score (FRS). RESULTS A total of 144 patients (72 WS group versus 72 C group) were compared. In the WS group. 6 patients (8.3%) developed clinically relevant POPF, compared with 8 patients (11.1%) in the C group (p = 0.656). In addition, on analyzing the subgroup of high-risk patients according to the FRS, we did not note any significant differences in POPF occurrence. Furthermore, no marked differences in the morbidity or mortality were found. Digestive bleeding and diabetes onset rates were higher in the WS group than in the control group, but not significantly so. CONCLUSIONS The results of the present study confirm no benefit with the routine administration of somatostatin after PD to prevent POPF, even in high-risk patients. However, a possible role in the prevention of postoperative digestive bleeding and diabetes was observed.
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Affiliation(s)
- Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Kevin Pisani
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
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15
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Eng NL, Mustin DE, Lovasik BP, Turgeon MK, Gamboa AC, Shah MM, Cardona K, Sarmiento JM, Russell MC, Maithel SK, Switchenko JM, Kooby DA. Relationship between Cancer Diagnosis and Complications Following Pancreatoduodenectomy for Duodenal Adenoma. Ann Surg Oncol 2020; 28:1097-1105. [PMID: 32691338 DOI: 10.1245/s10434-020-08767-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) for duodenal adenoma (DA) resection may be associated with excessive surgical risk for patients with potentially benign lesions, given the absence of pancreatic duct obstruction. We examined factors associated with final malignant pathology and evaluated the postoperative course of patients with DA versus pancreatic ductal adenocarcinoma (PDAC). METHODS We retrospectively analyzed patients with DA who underwent PD from 2008 to 2018 and assessed the accuracy rate of preoperative biopsy and factors associated with final malignant pathology. Complications for DA patients were compared with those of matched PDAC patients. RESULTS Forty-five consecutive patients who underwent PD for DA were identified, and the preoperative biopsy false negative rate was 29. Factors associated with final malignant pathology included age over 70 years, preoperative biliary obstruction, and common bile duct diameter > 8 mm (p < 0.05). Compared with patients with PDAC (n = 302), DA patients experienced more major complications (31% vs. 15%, p < 0.01), more grade C postoperative pancreatic fistulas (9% vs. 1%, p < 0.01), and greater mortality (7% vs. 2%, p < 0.05). Propensity score matched patients with DA had more major complications following PD (32% vs. 12%, p < 0.05). CONCLUSIONS Preoperative biopsy of duodenal adenomas is associated with a high false-negative rate for malignancy, and PD for DA is associated with higher complication rates than PD for PDAC. These results aid discussion among patients and surgeons who are considering observation versus PD for DA, especially in younger patients without biliary obstruction, who are less likely to harbor malignancy.
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Affiliation(s)
- Nina L Eng
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Danielle E Mustin
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Brendan P Lovasik
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael K Turgeon
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Adriana C Gamboa
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mihir M Shah
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Kenneth Cardona
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Maria C Russell
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
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16
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Wang X, Cai Y, Jiang J, Peng B. Laparoscopic Pancreaticoduodenectomy: Outcomes and Experience of 550 Patients in a Single Institution. Ann Surg Oncol 2020; 27:4562-4573. [DOI: 10.1245/s10434-020-08533-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Indexed: 12/12/2022]
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17
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Van Beijsterveld CAFM, Bongers BC, Den Dulk M, Van Kuijk SMJ, Dejong CHC, Van Meeteren NLU. Exploring the relation between preoperative physical functioning and the impact of major complications in patients following pancreatic resection. HPB (Oxford) 2020; 22:716-727. [PMID: 31740275 DOI: 10.1016/j.hpb.2019.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 09/14/2019] [Accepted: 09/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to evaluate the association between preoperative level of physical functioning and time to recovery of physical functioning, postoperative complications, and the impact of postoperative major complications in patients undergoing elective pancreatic resection. Additionally, prediction models to identify high-risk patients for developing a major complication were externally validated. METHODS Perioperative data of patients who underwent pancreatic resection were analysed. Primary outcomes were time to recovery of physical functioning and postoperative major complications. Impact of a major complication was explored by evaluating its effect on time to recovery of physical functioning. Risk-prediction models were retrieved following a systematic review. RESULTS Multivariable analysis (n = 63) showed that ASA grade III (OR 3.498) and preoperative platelet count (OR 1.005) were associated with major complications, whereas aerobic capacity (OR 0.347) was associated with time to recovery of physical functioning. Age, preoperative aerobic capacity, functional mobility, and perceived level of functional capacity were associated with the impact of a major complication. The AUC of two risk prediction models were 0.556 and 0.701. CONCLUSION Preoperative parameters of physical function were associated with postoperative outcomes and may be useful in outcome prediction, although future approaches should not only register the incidence of major complications but also take the impact of a complication on a patient's physical functioning into account.
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Affiliation(s)
- Christel A F M Van Beijsterveld
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands; Department of Physical Therapy, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, the Netherlands.
| | - Bart C Bongers
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands; SOMT University of Physiotherapy, PO Box 585, 3800 AN, Amersfoort, the Netherlands; Department of Nutrition and Movement Sciences, Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Marcel Den Dulk
- Department of Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, the Netherlands; Department of Surgery, University Hospital RWTH-Aachen, 52074, Aachen, Germany
| | - Sander M J Van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, the Netherlands
| | - Cornelius H C Dejong
- Department of Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, the Netherlands; Department of Surgery, University Hospital RWTH-Aachen, 52074, Aachen, Germany; Department of Surgery, Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Nico L U Van Meeteren
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands; Top Sector Life Sciences and Health (Health∼Holland), P.O. Box 93035, 2509 AA, The Hague, the Netherlands
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18
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Wang D, Liu X, Wu H, Liu K, Zhou X, Liu J, Guo W, Zhang Z. Clinical evaluation of modified invaginated pancreaticojejunostomy for pancreaticoduodenectomy. World J Surg Oncol 2020; 18:75. [PMID: 32295594 PMCID: PMC7161299 DOI: 10.1186/s12957-020-01851-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 04/06/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) remains the major curative operation for malignant neoplasm of pancreas or cancerous tumors near the pancreas. Despite advancements in recent years, the postoperative recurrence rate of these neoplasms and tumors remains high. Moreover, overall morbidity remains high due to clinically relevant postoperative pancreatic fistula (POPF). METHODS To compare the clinical outcomes of modified invaginated anastomosis and mucosa-to-mucosa anastomosis, this retrospective study included 343 patients who underwent PD from January 2008 to January 2019 at Beijing Friendship Hospital, Capital Medical University. The patients' general conditions and disease status were preoperatively evaluated. The surgical procedure was recorded, and operative management was appropriately performed. RESULTS Compared with mucosa-to-mucosa anastomosis, modified invaginated anastomosis resulted in a higher intraoperative blood transfusion rate (P < 0.001) and lower hospitalization expenses (P = 0.049). However, no significant differences were found in operation time (P = 0.790), intraoperative bleeding (P = 0.428), postoperative recovery exhaust time (P = 0.442), time to normal flow of food (P = 0.163), and hospitalization time (P = 0.567). Operation time was a risk factor for POPF (odds ratio 1.010; 95% confidence interval 1.003-1.016; P = 0.003). The incidence of pancreatic fistula (grades B and C) was lower in the patients who underwent modified invaginated anastomosis (14.1%) than in those who underwent mucosa-to-mucosa anastomosis (15.3%). The operation time was greater in the POPF group than in the non POPF group among the patients who received modified invaginated anastomosis (P = 0.003) and mucosa-to-mucosa anastomosis (P = 0.002). CONCLUSION Modified invaginated pancreaticojejunostomy for PD resulted in a decreased incidence of POPF; it may serve as a new approach for PD while managing patients who have undergone PD.
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Affiliation(s)
- Dong Wang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Xiao Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Hongwei Wu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Kun Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Xiaona Zhou
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Jun Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Wei Guo
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China.
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China.
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19
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A van Beijsterveld C, Bongers BC, den Dulk M, Dejong CH, van Meeteren NL. Personalized community-based prehabilitation for a high-risk surgical patient opting for pylorus-preserving pancreaticoduodenectomy: a case report. Physiother Theory Pract 2020; 37:1497-1509. [PMID: 32013652 DOI: 10.1080/09593985.2019.1709233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: Prehabilitation aims for an optimal physical functioning level before, during, and after hospitalization for major surgery. The purpose of this case report was to illustrate the care pathway of a high-risk patient who opted for pylorus-preserving pancreaticoduodenectomy, including preparation for this procedure by participating in a community-based exercise prehabilitation program. The report describes patient examination, evaluation in decision-making for surgery, the prehabilitation program, and outcomes within the context of the Hypothesis-Oriented Algorithm for Clinicians II.Case Description: The patient was a 75-year-old woman with a history of several comorbidities and a polypoid mass in the descending segment of the duodenum. Based on the preoperative assessment, the level of physical functioning was expected to be insufficient to cope adequately with the stress of hospitalization and surgery.Intervention: A 4-week prehabilitation program, including aerobic, resistance, and functional task training in a community-based physical therapy practice.Outcomes: Prehabilitation had a beneficial impact on improving functional mobility preoperatively (timed up-and-go test score improved from 19.4 to 10.0 s, five times sit-to-stand test score improved from 30.1 to 10.1 s, and two-minute walk test distance improved from 55.0 to 107.0 m). Surgery and postoperative recovery proceeded without complications. She achieved independent physical functioning on postoperative day 6 and was discharged home on postoperative day 12.Conclusion: Preoperative risk-assessment can support clinical decision-making in a high-risk patient opting for major abdominal surgery. Furthermore, a remarkable improvement in physical functioning can be achieved by community-based prehabilitation in a high-risk surgical patient.
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Affiliation(s)
- Christel A van Beijsterveld
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Physical Therapy, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bart C Bongers
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,SOMT University of Physical therapy, Amersfoort, The Netherlands.,Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty, Maastricht University, Maastricht, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Surgery, University Hospital RWTH-Aachen, Aachen, Germany
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Surgery, University Hospital RWTH-Aachen, Aachen, Germany.,Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Nico L van Meeteren
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Top Sector Life Sciences and Health (Health∼Holland), The Hague, The Netherlands
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20
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You Y, Han IW, Choi DW, Heo JS, Ryu Y, Park DJ, Choi SH, Han S. Nomogram for predicting postoperative pancreatic fistula. HPB (Oxford) 2019; 21:1436-1445. [PMID: 30982739 DOI: 10.1016/j.hpb.2019.03.351] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/26/2019] [Accepted: 03/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous studies analyzed risk factors for postoperative pancreatic fistula (POPF) and developed risk prediction tool using scoring system. However, no study has built a nomogram based on individual risk factors. This study aimed to evaluate individual risks of POPF and propose a nomogram for predicting POPF. METHODS From 2007 to 2016, medical records of 1771 patients undergoing pancreaticoduodenctomy were reviewed retrospectively. Variables with p < 0.05 in multivariate logistic regression analysis were included in the nomogram. Internal performance validation was executed using a repeated cross validation method. RESULTS Of 1771 patients, 222 (12.5%) experienced POPF. In multivariable analysis, sex (p = 0.004), body mass index (BMI) (p < 0.001), ASA score (p = 0.039), preoperative albumin (p = 0.035), pancreatic duct diameter (p = 0.002), and location of tumor (p < 0.001) were identified as independent predictors for POPF. Based on these six variables, a POPF nomogram was developed. The area under the curve (AUC) estimated from the receiver operating characteristic (ROC) graph was 0.709 in the train set and 0.652 in the test set. CONCLUSIONS A POPF nomogram was developed. This nomogram may be useful for selecting patients who need more intensified therapy and establishing customized treatment strategy.
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Affiliation(s)
- Yunghun You
- Department of Surgery, Konkuk University Choongju Hospital, Konkuk University School of Medicine, 6, Gwangmyeong 1-gil, Chungju-si, Chungcheongbuk-do, 27376, South Korea
| | - In W Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - Dong W Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jin S Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Youngju Ryu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Dae J Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Seong H Choi
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158, Paryong-ro, Masanhoewon-gu, Changwon-si, Gyeongsangnam-do, 51353, South Korea
| | - Sunjong Han
- Department of Surgery, Seoul National University College of Medicine, Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
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21
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Huo Z, Shi Z, Zhai S, Li J, Qian H, Tang X, Weng Y, Shi Y, Wang L, Wang Y, Deng X, Shen B. Predicting Selection Preference of Robotic Pancreaticoduodenectomy (RPD) in a Chinese Single Center Population: Development and Assessment of a New Predictive Nomogram. Med Sci Monit 2019; 25:8034-8042. [PMID: 31654999 PMCID: PMC6827327 DOI: 10.12659/msm.917446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Robotic pancreaticoduodenectomy (RPD) is a novel type of minimally invasive surgery to treat tumors located at the head of the pancreas. This study aimed to construct a novel prediction model for predicting selection preference for RPD in a Chinese single medical center population. MATERIAL AND METHODS The clinical data from 451 pancreatic ductal adenocarcinoma patients were collected and analyzed from January 2013 to December 2016. Twenty-three items affecting clinical strategies were optimized by LASSO (least absolute shrinkage and selection operator) regression analysis and then were incorporated in multivariable logistic regression analysis. C-index was used for evaluating the discriminative ability. Decision curve was applied to determine clinical application of this model and the calibration of this nomogram was evaluated by calibration plot. The model was internally validated through bootstrapping validation. RESULTS Clinicopathological factors included in the model were age, history of diabetes mellitus, history of hypertension, history of heart, brain and kidney disease, history of abdominal surgery, symptoms (jaundice, accidental discovery and weight loss), anemia, elevated carcinoembryonic antigen (CEA), smoking, alcohol intake, American Society of Anesthesiologists (ASA) scores, vascular invasion, overweight, preoperative lymph node metastasis and tumor size >3.5 cm. A C-index of 0.831 indicated good discrimination and calibration of this model. Interval validation generated an acceptable C-index of 0.787. When surgical approach was determined at the threshold of preference possibility less than 63%, decision curve analysis indicated that this model had good clinical application value in this range. CONCLUSIONS This new nomogram could be conveniently used to predict the selection preference of robotic surgery for patients with pancreatic head cancer.
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Affiliation(s)
- Zhen Huo
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Zhihao Shi
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Shuyu Zhai
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Jingfeng Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Hao Qian
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Xiaomei Tang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Yuanchi Weng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Yusheng Shi
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Liwen Wang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Yue Wang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Xiaxing Deng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
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22
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Comparison of Perioperative Outcomes Between Laparoscopic and Open Approach for Pancreatoduodenectomy: The PADULAP Randomized Controlled Trial. Ann Surg 2019; 268:731-739. [PMID: 30138162 DOI: 10.1097/sla.0000000000002893] [Citation(s) in RCA: 223] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare perioperative outcomes of pancreatoduodenectomy (PD) performed through the laparoscopic route or by open surgery. SUMMARY BACKGROUND DATA Laparoscopic PD is being progressively performed in selected patients. METHODS An open-label single-center RCT was conducted between February 2013 and September 2017. The primary endpoint was the length of hospital stay (LOS). Secondary endpoints were operative time, transfusion requirements, specific pancreatic complications (pancreatic or biliary fistula, pancreatic hemorrhage, and delayed gastric emptying), Clavien-Dindo grade ≥ 3 complications, comprehensive complication index (CCI) score, poor quality outcome (PQO), and the quality of pathologic resection. Analyses were performed on an intention to treat basis. RESULTS Of 86 patients assessed for PD, 66 were randomized (34 laparoscopic approach, 32 open surgery). Conversion to an open procedure was needed in 8 (23.5%) patients. Laparoscopic versus open PD was associated with a significantly shorter LOS (median 13.5 vs. 17 d; P = 0.024) and longer median operative time (486 vs. 365 min; P = 0.0001). The laparoscopic approach was associated with significantly better outcomes regarding Clavien-Dindo grade ≥ 3 complications (5 vs. 11 patients; P = 0.04), CCI score (20.6 vs. 29.6; P = 0.038), and PQO (10 vs. 14 patients; P = 0.041). No significant differences in transfusion requirements, pancreas-specific complications, the number of lymph nodes retrieved, and resection margins between the two approaches were found. CONCLUSIONS Laparoscopic PD versus open surgery is associated with a shorter LOS and a more favorable postoperative course while maintaining oncological standards of a curative-intent surgical resection. TRIAL REGISTRY ISRCTN93168938.
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23
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Rodriguez-Lopez M, Tejero-Pintor FJ, Perez-Saborido B, Barrera-Rebollo A, Bailon-Cuadrado M, Pacheco-Sanchez D. Severe morbidity after pancreatectomy is accurately predicted by preoperative pancreatic resection score (PREPARE): A prospective validation analysis from a medium-volume center. Hepatobiliary Pancreat Dis Int 2018; 17:559-565. [PMID: 30316626 DOI: 10.1016/j.hbpd.2018.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 09/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Major morbidity in pancreatic surgery remains high. Different scores for predicting complications have been described. Preoperative pancreatic resection (PREPARE) score is based on objective preoperative variables and offers good predictive accuracy for Clavien ≥ III complications. This study aimed to validate this score and analyze other preoperative variables in a prospective study performed in a medium-volume center. METHODS A total of 50 pancreatic resections were included. Preoperative variables were registered and PREPARE was calculated. The main outcome was severe morbidity (Clavien ≥ III) up to 30 days after discharge. The secondary outcomes were length of stay (LOS) and readmission. Statistical validation was performed to compare severe morbidity rate among the scores categories. Association with other preoperative variables (not included in PREPARE) was also tested. RESULTS Of the 50 pancreatic resections, the severe morbidity was 34.0%, with median LOS of 11 days. Readmission rate was 25.5%. Severe morbidity rates according to PREPARE categories were 18.5% in low-risk group, 41.7% in intermediate-risk group, and 63.6% in high-risk group, respectively (P = 0.023). The accuracy was 72% (Hosmer-Lemeshow, P = 0.86). ROC curve was obtained both for PREPARE score expressed as incremental values and categorized as the three risk groups, showing an area under curve (AUC) of 0.736 (95% CI: 0.586-0.887; P = 0.007) and 0.712 (95% CI: 0.555-0.869; P = 0.015), respectively. PREPARE was significant in multivariate analysis. Median LOS was statistically higher as PREPARE category increases (9, 11 and 15 days in low-, intermediate- and high-risk groups, respectively; P = 0.009). Readmission was not associated with any variables. CONCLUSIONS PREPARE behaves as an independent risk factor for severe morbidity after pancreatic surgery. Score validation shows good accuracy prediction. Increasing PREPARE category is also associated with longer LOS.
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Affiliation(s)
- Mario Rodriguez-Lopez
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain.
| | | | - Baltasar Perez-Saborido
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - Asterio Barrera-Rebollo
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - Martin Bailon-Cuadrado
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - David Pacheco-Sanchez
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
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24
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Scholten L, Mungroop TH, Haijtink SAL, Issa Y, van Rijssen LB, Koerkamp BG, van Eijck CH, Busch OR, DeVries JH, Besselink MG. New-onset diabetes after pancreatoduodenectomy: A systematic review and meta-analysis. Surgery 2018; 164:S0039-6060(18)30081-3. [PMID: 29779868 DOI: 10.1016/j.surg.2018.01.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 01/07/2018] [Accepted: 01/29/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatoduodenectomy may lead to new-onset diabetes mellitus, also known as type 3c diabetes, but the exact risk of this complication is unknown. The aim of this review was to assess the risk of new-onset diabetes mellitus after pancreatoduodenectomy. METHODS A literature search was performed in PubMed, Embase (Ovid), and the Cochrane Library for English articles published from March 1993 until March 2017 (PROSPERO registry number: CRD42016039784). Studies reporting on the risk of new-onset diabetes mellitus after pancreatoduodenectomy were included. For meta-analysis, studies were pooled using the random-effects model. All studies were appraised according to the Newcastle-Ottawa Scale. RESULTS After screening 1,523 studies, 22 studies involving 1,121 patients were eligible. The mean weighted overall proportion of new-onset diabetes mellitus after pancreatoduodenectomy was 16% (95% confidence interval, 12%-20%). We found no significant difference in risk of new-onset diabetes mellitus when pancreatoduodenectomy was performed for nonmalignant disease after excluding patients with chronic pancreatitis (19% risk; 95% confidence interval, 7%-43%; 6 studies) or for malignant disease (22% risk; 95% confidence interval, 14%-32%; 11 studies), P = .71. Among all patients, 6% (95% confidence interval, 4%-10%) developed insulin-dependent new-onset diabetes mellitus. CONCLUSION This systematic review identified a clinically relevant risk of new-onset diabetes mellitus after pancreatoduodenectomy of which patients should be informed preoperatively.
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Affiliation(s)
- Lianne Scholten
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Timothy H Mungroop
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Simone A L Haijtink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Yama Issa
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - L Bengt van Rijssen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Academic Medical Center, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands.
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25
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Ri M, Aikou S, Seto Y. Obesity as a surgical risk factor. Ann Gastroenterol Surg 2017; 2:13-21. [PMID: 29863119 PMCID: PMC5881295 DOI: 10.1002/ags3.12049] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/14/2017] [Indexed: 12/15/2022] Open
Abstract
In recent years, both the actual number of overweight/obese individuals and their proportion of the population have steadily been rising worldwide and obesity-related diseases have become major health concerns. In addition, as obesity is associated with an increased incidence of gastroenterological cancer, the number of obese patients has also been increasing in the field of gastroenterological surgery. While the influence of obesity on gastroenterological surgery has been widely studied, very few reports have focused on individual organs or surgical procedures, using a cross-sectional study design. In the present review, we aimed to summarize the impacts of obesity on surgeries for the esophagus, stomach, colorectum, liver and pancreas. In general, obesity prolongs operative time. As to short-term postoperative outcomes, obesity might be a risk for certain complications, depending on the procedure carried out. In contrast, it is possible that obesity doesn't adversely impact long-term surgical outcomes. The influences of obesity on surgery are made even more complex by various categories of operative outcomes, surgical procedures, and differences in obesity among races. Therefore, it is important to appropriately evaluate perioperative risk factors, including obesity.
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Affiliation(s)
- Motonari Ri
- Department of Gastrointestinal Surgery Graduate School of Medicine The University of Tokyo Tokyo Japan
| | - Susumu Aikou
- Department of Gastrointestinal Surgery Graduate School of Medicine The University of Tokyo Tokyo Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery Graduate School of Medicine The University of Tokyo Tokyo Japan
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26
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Henriksen SD, Madsen PH, Larsen AC, Johansen MB, Pedersen IS, Krarup H, Thorlacius-Ussing O. Cell-free DNA promoter hypermethylation in plasma as a predictive marker for survival of patients with pancreatic adenocarcinoma. Oncotarget 2017; 8:93942-93956. [PMID: 29212200 PMCID: PMC5706846 DOI: 10.18632/oncotarget.21397] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 09/13/2017] [Indexed: 12/11/2022] Open
Abstract
Introduction Few prognostic biomarkers are available for pancreatic cancer. The aim of this study is to examine the correlation between the survival of pancreatic adenocarcinoma patients and hypermethylated genes in plasma-derived cell-free DNA. Methods Consecutive patients with pancreatic adenocarcinoma were prospectively included and staged according to the TNM classification. Methylation-specific PCR of 28 genes was conducted. A survival prediction model independent of cancer stage and stage-specific survival prediction models were developed by multivariable Cox regression analysis using backward stepwise selection. Results Ninety-five patients with pancreatic adenocarcinoma were included. Patients with more than 10 hypermethylated genes had a HR of 2.03 (95% CI; 1.15-3.57) compared to patients with fewer hypermethylated genes. Three survival prediction models were developed: Total group; (American Society of Anesthesiologists score (ASA)=3, GSTP1, SFRP2, BNC1, SFRP1, TFPI2, and WNT5A) Risk groups 2, 3 and 4 had a HR of 2.65 (95% CI; 1.24-5.66), 4.34 (95% CI; 1.98-9.51) and 21.19 (95% CI; 8.61-52.15), respectively, compared to risk group 1. Stage I-II; (ASA=3, SFRP2, and MESTv2) Risk groups 2, 3 and 4 had a HR of 4.83 (95% CI; 2.01-11.57), 9.12 (95% CI; 2.18-38.25) and 70.90 (95% CI; 12.63-397.96), respectively, compared to risk group 1. Stage IV; (BMP3, NPTX2, SFRP1, and MGMT) Risk group 2 had a HR of 5.23 (95% CI; 2.13-12.82) compared to risk group 1. Conclusion Prediction models based on cell-free DNA hypermethylation stratified pancreatic adenocarcinoma patients into risk groups according to survival. The models have the potential to work as prognostic biomarkers. However, further validation of the results is required to substantiate the findings.
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Affiliation(s)
- Stine Dam Henriksen
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark.,Department of General Surgery, Hospital of Vendsyssel, Hjørring, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Poul Henning Madsen
- Section of Molecular Diagnostics, Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | | | - Martin Berg Johansen
- Unit of Clinical Biostatistics and Bioinformatics, Aalborg University Hospital, Aalborg, Denmark
| | - Inge Søkilde Pedersen
- Section of Molecular Diagnostics, Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Krarup
- Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.,Section of Molecular Diagnostics, Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Ole Thorlacius-Ussing
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
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