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Gundavda K, Chopde A, Pujari A, Reddy B, Pawar A, Ramaswamy A, Ostwal V, Patkar S, Bhandare M, Shrikhande SV, Chaudhari VA. Prognostic Impact of Para-Aortic Lymph Node Metastasis in Resected Non-Pancreatic Periampullary Cancers. Ann Surg Oncol 2024:10.1245/s10434-024-15847-z. [PMID: 39031265 DOI: 10.1245/s10434-024-15847-z] [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: 02/05/2024] [Accepted: 07/02/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Surgery remains debatable in para-aortic lymph node (PALN, station 16b1) metastasis in non-pancreatic periampullary cancer (NPPAC). This study examined the impact of PALN metastasis on outcomes following pancreaticoduodenectomy (PD) in NPPAC. METHODS A retrospective analysis of patients with NPPAC who were explored for PD with PALN dissection was performed. Based on the extent of nodal involvement on final histopathology, they were stratified as node-negative (N0), regional node involved (N+) and metastatic PALN (N16+) and their outcomes were compared. RESULTS Between 2011 and 2022, 153/887 PD patients underwent a PALN dissection, revealing N16+ in 42 patients (27.4%), of whom 32 patients underwent resection. The 3-years overall survival (OS) for patients with N16+ was 28% (95% confidence interval [CI] 13-60%), notably lower than the 67% (95% CI 53-83.5%; p = 0.007) for those without PALN metastasis. Stratified by nodal involvement, the median OS for N+ and N16+ patients was similar (28.4 months and 26.2 months, respectively). The N0 subgroup had a significantly longer 3-years OS of 87.5% (95% CI 79-96.7%; p = 0.0051). Interestingly, 10 patients not offered resection following N16+ identified on frozen section had a median survival of only 9 months. The perioperative morbidity and mortality in patients undergoing PD with PALN dissection were similar to standard resections. CONCLUSION In a select group of patients with NPPAC, PD in isolated PALN metastasis was associated with improved OS. The survival in this group of patients was comparable with regional node-positive patients and significantly better than palliative treatment alone.
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Affiliation(s)
- Kaival Gundavda
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Amit Chopde
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Avinash Pujari
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Bhaskar Reddy
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Akash Pawar
- Department of Biostatistics, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Shraddha Patkar
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Manish Bhandare
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Shailesh V Shrikhande
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Vikram A Chaudhari
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India.
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Bhatti ABH, Dar FS, Ahmed IN. Pancreaticoduodenectomy with Para-aortic Lymph Node Dissection for Periampullary Cancer. Indian J Surg Oncol 2024; 15:338-343. [PMID: 38817990 PMCID: PMC11133244 DOI: 10.1007/s13193-023-01866-x] [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: 11/20/2023] [Accepted: 12/11/2023] [Indexed: 06/01/2024] Open
Abstract
There is no consensus on the utility of para-aortic lymph node dissection (PALND) in patients undergoing pancreaticoduodenectomy (PD) for periampullary cancer. The objective of this study was to assess survival in patients who underwent PD with PALND for pancreatic (PAC) and non-pancreatic (non-PAC) adenocarcinoma. All patients who underwent PD and PALND between 2011 and 2019 were reviewed (n = 114). We looked at the impact of tumor type (PAC versus non-PAC) and pathologically confirmed PALN metastasis (PALNM) on overall survival (OS). Out of 114 patients, PALNM were pathologically confirmed in 17(14.9%) patients. Without PALND, pathological staging would be pN0 in1(0.8%), pN1 in 3(2.5%), and pN2 in 13(11.2%) patients. The 30-day mortality was 3(2.6%) and 65(57%) patients received adjuvant treatment. The 4-year OS for PAC and non-PAC was 9% and 39% (P = 0.001). Advanced nodal involvement (pN2) was seen in 14/17(82.4%) and 21/97(21.6%) patients with and without PALNM, respectively (P < 0.001). For PAC, 4-year OS for patients with pN0-N1, pN2, and PALNM was 12%, 8%, and not reached (P = 0.067). For non-PAC, 4-year OS was 45%, 19%, and 12% (P = 0.006). In patients with non-PAC, despite metastatic involvement of PALN, acceptable long-term survival can be achieved with curative resection. For PAC, survival benefit with curative resection remains questionable.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
- Department of Pathology, Shifa International Hospital, Islamabad, Pakistan
| | - Faisal Saud Dar
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Imran Nazer Ahmed
- Department of Pathology, Shifa International Hospital, Islamabad, Pakistan
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Bhatti ABH, Hameed Z, Almas T, Riyaz S, Ahmad A. Multivisceral central pancreatectomy for pancreatic neuroendocrine tumor: A case report on a novel surgical technique. Int J Surg Case Rep 2020; 78:292-295. [PMID: 33383284 PMCID: PMC7777176 DOI: 10.1016/j.ijscr.2020.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Central pancreatectomy (CP) is considered a viable alternative to subtotal distal pancreatectomy, for lesions involving the neck or proximal pancreatic body. Multivisceral central pancreatectomy (MVCP) for locally advanced tumors of the pancreatic body remains unreported. PRESENTATION OF CASE We hereby report a case of locally advanced pancreatic neuroendocrine tumor (NET) with gastric involvement. The patient underwent successful central pancreatectomy with subtotal gastrectomy for locally advanced NET of the pancreas. In the follow up period, relevant complications like pancreatic insufficiency or pancreatic fistula were not encountered. The patient is doing well more than ten months after resection. DISCUSSION A MVCP can be considered in patients with limited pancreatic involvement, as long as sufficient pancreatic parenchyma can be preserved. Additional organ involvement mandating resection should not be considered a contra indication to this procedure. With careful surgical planning and meticulous technique, risk of post operative complications after MVCP can be minimized with added benefit of long term endocrine and exocrine integrity. CONCLUSIONS CP is a viable alternative and can be performed with adjacent organ resection, with acceptable post operative outcomes.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan.
| | - Zujaja Hameed
- Department of Pathology, Shifa International Hospital Islamabad, Pakistan
| | - Talal Almas
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan
| | - Shahzad Riyaz
- Department of Gastroenterology and Hepatology, Shifa International Hospital Islamabad, Pakistan
| | - Adeel Ahmad
- Department of Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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Bhatti ABH, Jafri RZ, Khan MK, Dar FS. Preoperative Endoscopic Biliary Stenting Before Pancreaticoduodenectomy: Does Timing Matter? Surg Innov 2020; 28:567-572. [PMID: 33228482 DOI: 10.1177/1553350620975887] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background. The role of preoperative biliary stenting (PBS) before pancreaticoduodenectomy (PD) in patients with obstructive jaundice is debatable. The objective of the current study was to assess PD outcomes after upfront surgery or PBS and determine the impact of stent to surgery duration on PD outcomes. Methods. We reviewed patients who underwent PD between 2011 and 2019. Patients were grouped based on whether they underwent upfront surgery (n = 67) or PBS (n = 66). We further assessed outcomes based on stent to surgery duration. Results. There was no significant difference in 30-day mortality (3% vs. 2.9%, P = 1), 90-day mortality (7.5% vs. 4.4%, P = .4), and Grade B-C pancreatic fistula rates (7.5% vs. 4.4%, P = .4) in the PBS and upfront surgery groups, respectively. A significant increase in wound infections (22.7% vs. 7.4%, P = .01) and readmissions (10.6% vs. 0, P = .006) was seen in the PBS group. The highest rate of wound infection was seen when stent to surgery duration was 4-6 weeks (41.6%). The wound infection rates in the upfront surgery group, high-risk PBS group (4-6 weeks), and low-risk PBS group were 5/67(7.4%), 5/12(41.6%), and 7/36(19.4%), respectively (P = .008). Conclusions. PBS increases postoperative wound infections when compared with upfront surgery. Patients operated between 4 and 6 weeks after stenting have the highest rate of wound infection.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of Hepato-pancreatico-biliary Surgery and Liver Transplantation, 525444Shifa International Hospital, Pakistan
| | - Roshni Z Jafri
- Department of Hepato-pancreatico-biliary Surgery and Liver Transplantation, 525444Shifa International Hospital, Pakistan
| | | | - Faisal Saud Dar
- Department of Hepato-pancreatico-biliary Surgery and Liver Transplantation, 525444Shifa International Hospital, Pakistan
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Bhatti ABH, Jafri RZ, Khan NA. Best achievable results need territorial familiarity: Impact of living donor liver transplant experience on outcomes after pancreaticodoudenectomy. Ann Med Surg (Lond) 2020; 55:213-218. [PMID: 32518644 PMCID: PMC7272504 DOI: 10.1016/j.amsu.2020.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 02/07/2023] Open
Abstract
Background Recently, benchmarks for pancreatic surgery have been proposed. Living donor liver transplantation (LDLT) is thought to have a positive impact on PD outcomes. The objective of the current study was to determine if the proposed benchmark cutoffs are achievable in an LDLT program with low to medium volumes for PD. Methods We retrospectively reviewed patients who underwent PD between 2011 and 2018 (N = 116). Their outcomes were assessed and compared with benchmark cutoffs for pancreatic surgery based on results from high volume centers (HVC) for PD. During the same period, 759 LDLTs were performed in our center. Outcomes were further compared based on whether PD was performed in low volume (≤76/year) (Group 1) or high volume (>76/year) (Group 2) transplant years. Results Out off 20 benchmarks, 15 (75%) were met while 19/20 (95%) were within range reported from HVC-PD. Benchmarks remained within range for biochemical leak (15.5% vs 13%, 1.3–22.7%), grade 4 complications (12.1% vs 5%, (0–14%), hospital mortality (3.8% vs 1.6%, 0–4%) and failure to rescue (24.4% vs 9%, 0–25%). There was a significant reduction in blood transfusion rate (69% vs 39.5%, P = 0.003) in group 2 while patients with at least one complication (45.5% vs 66.7%) (P = 0.04), median hospital stay (9 vs 11, P = 0.004), and median comprehensive complication index (CCI) (0 vs 20.9, P = 0.005) increased. Conclusion Best achievable results for PD can be reproduced in LDLT programs with low to moderate PD volumes. Transition to a high volume transplant center does not confer additional improvement in outcomes. This is the first study to objectively assess impact of living donor liver transplant (LDLT) experience on pancreaticdoudenectomy (PD) outcomes. ∙Even with low to moderate PD volumes, LDLT programs can achieve outcomes comparbale to high volume centers. ∙Transition from low to high annual LDLT volume does not confer any additional improvement in PD outcomes.
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Affiliation(s)
- Abu Bakar H Bhatti
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan
| | - Roshni Z Jafri
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan
| | - Nasir A Khan
- Department of Anesthesiology, Shifa International Hospital Islamabad, Pakistan
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Hempel S, Oehme F, Müssle B, Aust DE, Distler M, Saeger HD, Weitz J, Welsch T. Prognostic impact of para-aortic lymph node metastases in non-pancreatic periampullary cancer. World J Surg Oncol 2020; 18:16. [PMID: 31964383 PMCID: PMC6975057 DOI: 10.1186/s12957-020-1783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/31/2019] [Indexed: 11/29/2022] Open
Abstract
Background Resection of the para-aortic lymph node (PALN) group Ln16b1 during pancreatoduodenectomy remains controversial because PALN metastases are associated with a worse prognosis in pancreatic cancer patients. The present study aimed to analyze the impact of PALN metastases on outcome after non-pancreatic periampullary cancer resection. Methods One hundred sixty-four patients with non-pancreatic periampullary cancer who underwent curative pancreatoduodenectomy or total pancreatectomy between 2005 and 2016 were retrospectively investigated. The data were supplemented with a systematic literature review on this topic. Results In 67 cases, the PALNs were clearly assigned and could be histopathologically analyzed. In 10.4% of cases (7/67), tumor-infiltrated PALNs (PALN+) were found. Metastatic PALN+ stage was associated with increased tumor size (P = 0.03) and a positive nodal stage (P < 0.001). The median overall survival (OS) of patients with metastatic PALN and non-metastatic PALN (PALN–) was 24.8 and 29.5 months, respectively. There was no significant difference in the OS of PALN+ and pN1 PALN patients (P = 0.834). Patients who underwent palliative surgical treatment (n = 20) had a lower median OS of 13.6 (95% confidence interval 2.7–24.5) months. Including the systematic literature review, only 23 cases with PALN+ status and associated OS could be identified; the average survival was 19.8 months. Conclusion PALN metastasis reflects advanced tumor growth and lymph node spread; however, it did not limit overall survival in single-center series. The available evidence of the prognostic impact of PALN metastasis is scarce and a recommendation against resection in these cases cannot be given.
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Affiliation(s)
- Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Daniela E Aust
- Institute of Pathology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hans-Detlev Saeger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Successful outcome after Pancreaticodoudenectomy in an elderly cirrhotic patient: A case report. Int J Surg Case Rep 2019; 58:18-20. [PMID: 30999147 PMCID: PMC6468143 DOI: 10.1016/j.ijscr.2019.03.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/22/2019] [Indexed: 02/08/2023] Open
Abstract
Pancreaticodoudenectomy in cirrhotic patients is seldom attempted. It is associated with high morbidity and mortality rates. Careful patient selection allows its safe performance in cirrhotic patients. Preoperative biliary drainages should always be considered. Liver cirrhosis is not an absolute contraindication to PD.
Introduction Cirrhosis is a risk factor for poor outcomes in non-hepatic oncological resections. There are only a handful of cases demonstrating outcomes of pancreaticoduodenectomy (PD) in patients with pancreatic cancer and underlying cirrhosis. Moreover, pushing the limits of PD to elderly cirrhotic patients and demonstrating its safety remains under reported. Case presentation Here, we report successful management of a 71 year-old-lady with HCV related liver cirrhosis, obstructive jaundice and poor performance status, who was medically optimized and then underwent PD for adenocarcinoma of the head of pancreas. There was no major post-operative morbidity except minor chyle leak which resolved spontaneously. On her last follow up, she was doing well and undergoing adjuvant chemotherapy. Discussion Preoperative medical optimization and careful patient selection can yield successful outcomes even after a major abdominal surgery like PD in elderly patients with underlying liver cirrhosis. Conclusion Liver cirrhosis is not a contra indication to PD in elderly patients with good performance status.
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Sperti C, Gruppo M, Blandamura S, Valmasoni M, Pozza G, Passuello N, Beltrame V, Moletta L. Para-aortic node involvement is not an independent predictor of survival after resection for pancreatic cancer. World J Gastroenterol 2017; 23:4399-4406. [PMID: 28706422 PMCID: PMC5487503 DOI: 10.3748/wjg.v23.i24.4399] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 02/21/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the importance of para-aortic node status in a series of patients who underwent pancreaticoduodenectomy (PD) in a single Institution.
METHODS Between January 2000 and December 2012, 151 patients underwent PD with para-aortic node dissection for pancreatic adenocarcinoma in our Institution. Patients were divided into two groups: patients with negative PALNs (PALNs-), and patients with metastatic PALNs (PALNs+). Pathologic factors, including stage, nodal status, number of positive nodes and lymph node ratio, invasion of para-aortic nodes, tumor’s grading, and radicality of resection were studied by univariate and multivariate analysis. Survival curves were constructed with Kaplan-Meier method and compared with Log-rank test: significance was considered as P < 0.05.
RESULTS A total of 107 patients (74%) had nodal metastases. Median number of pathologically assessed lymph nodes was 26 (range 14-63). Twenty-five patients (16.5%) had para-aortic lymph node involvement. Thirty-three patients (23%) underwent R1 pancreatic resection. One-hundred forty-one patients recurred and died for tumor recurrence, one is alive with recurrence, and 9 are alive and free of disease. Overall survival was significantly influenced by grading (P = 0.0001), radicality of resection (P = 0.001), stage (P = 0.03), lymph node status (P = 0.04), para-aortic nodes metastases (P = 0.02). Multivariate analysis showed that grading was an independent prognostic factor for overall survival (P = 0.0001), while grading (P = 0.0001) and radicality of resection (P = 0.01) were prognostic parameters for disease-free survival. Number of metastatic nodes, node ratio, and para-aortic nodes involvement were not independent predictors of disease-free and overall survival.
CONCLUSION In this experience, lymph node status and para-aortic node metastases were associated with poor survival at univariate analysis, but they were not independent prognostic factors.
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