Quality of life in patients after total pancreatectomy is comparable with quality of life in patients who undergo a partial pancreatic resection

Mapping global new-onset, worsening, and resolution of diabetes following partial pancreatectomy: a systematic review and meta-analysis

BACKGROUND AND AIMS

Partial pancreatectomy, commonly used for chronic pancreatitis, or pancreatic lesions, has diverse impacts on endocrine and metabolism system. The study aims to determine the global prevalence of new-onset, worsening, and resolution of diabetes following partial pancreatectomy.

METHODS

The authors searched PubMed, Embase, Web of Science, and Cochrane Library from inception to October, 2023. DerSimonian-Laird random-effects model with Logit transformation was used. Sensitivity analysis, meta-regression, and subgroup analysis were employed to investigate determinants of the prevalence of new-onset diabetes.

RESULTS

A total of 82 studies involving 13 257 patients were included. The overall prevalence of new-onset diabetes after partial pancreatectomy was 17.1%. Univariate meta-regression indicated that study size was the cause of heterogeneity. Multivariable analysis suggested that income of country or area had the highest predictor importance (49.7%). For subgroup analysis, the prevalence of new-onset diabetes varied from 7.6% (France, 95% CI: 4.3-13.0) to 38.0% (UK, 95% CI: 28.2-48.8, P <0.01) across different countries. Patients with surgical indications for chronic pancreatitis exhibited a higher prevalence (30.7%, 95% CI: 21.8-41.3) than those with pancreatic lesions (16.4%, 95% CI: 14.3-18.7, P <0.01). The type of surgical procedure also influenced the prevalence, with distal pancreatectomy having the highest prevalence (23.7%, 95% CI: 22.2-25.3, P <0.01). Moreover, the prevalence of worsening and resolution of preoperative diabetes was 41.1 and 25.8%, respectively.

CONCLUSIONS

Postoperative diabetes has a relatively high prevalence in patients undergoing partial pancreatectomy, which calls for attention and dedicated action from primary care physicians, specialists, and health policy makers alike.

Comparison of clinical outcomes and prognosis between total pancreatectomy and pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis

BACKGROUND

To compare the clinical outcomes and prognosis of total pancreatectomy (TP) and pancreaticoduodenectomy (PD) for the treatment of pancreatic ductal adenocarcinoma (PDAC), and to explore the safety and indications of TP.

METHODS

A systematic search was conducted on PubMed, Web of Science, and Embase databases from January 1943 to March 2023 for literatures comparing TP and PD in the treatment of PDAC. The primary outcome was postoperative overall survival (OS), and secondary outcomes included surgery time, blood loss, readmission, hospital stay, perioperative mortality, and overall morbidity. Fixed-effect or random-effect models were selected based on heterogeneity, and odds ratio (OR), mean difference (MD), or hazard ratio (HR) with 95% confidence intervals (CI) were calculated.

RESULTS

A total of six studies involving 8396 patients were included in the meta-analysis. There was no statistically significant difference in OS after surgery between the two groups (HR = 1.08, 95% CI: 0.91-1.27; P = 0.38). The TP group had a longer surgery time (MD = 13.66, 95% CI: 4.57-22.75; P = 0.003) and more blood loss (MD = 133.17, 95% CI: 8.00-258.33; P = 0.04) than the PD group. There were no significant differences between the two groups in terms of hospital stay (MD = 0.09, 95% CI: -2.04 to 2.22; P = 0.93), readmission rate (OR = 1.39; 95% CI: 1.00-1.92; P = 0.05), perioperative mortality (OR = 1.29, 95% CI: 0.98-1.69; P = 0.07), and overall morbidity (OR = 0.80, 95% CI: 0.50-1.26; P = 0.33).

CONCLUSION

The surgical process of TP is relatively complex, but there is no difference in short-term clinical outcomes and OS compared to PD, making it a safe and reliable procedure. Indications and treatment outcomes for planned TP and salvage TP may differ, and more research is needed in the future for further classification and verification.

Propensity Score Matching Analysis of the Safety of Completion Total Pancreatectomy for Remnant Pancreatic Tumors Versus that of Initial Total Pancreatectomy for Primary Pancreatic Tumors

BACKGROUND

The safety and feasibility of completion total pancreatectomy (TP) for remnant pancreatic neoplasms remain controversial and are rarely compared with that of initial TP. Thus, we aimed to compare the safety of these two procedures inducing a pancreatic state.

METHODS

Patients who underwent TP for pancreatic neoplasms between 2006 and 2018 at our institution were included in this study. Tumor pathologies were classified into three subgroups according to survival curves. We used 1:1 propensity score matching (PSM) to analyze age, sex, Charlson Comorbidity Index, and tumor stage. Finally, we analyzed the primary outcome Clavien-Dindo classification (CDC) grade, risks of other safety-related outcomes, and the survival rate of patients with invasive cancer.

RESULTS

Of 54 patients, 16 underwent completion TP (29.6%) and 38 (70.4%) underwent initial TP. Before PSM analysis, age and Charlson Comorbidity Index were significantly higher, and T category and stage were significantly lower for the completion TP group. Upon PSM analysis, these two groups were equivalent in CDC grade [initial TP vs. completion TP: 71.4% (10/14) vs. 78.6% (11/14); p = 0.678] and other safety-related outcomes. Additionally, while the overall survival and recurrence-free survival of patients with invasive cancer were not significantly different between these two groups, the T category and stage tended to be remarkably severe in the initial TP group.

CONCLUSIONS

PSM analysis for prognostic factors showed that completion TP and initial TP have similar safety-related outcomes that can be used as a decision-making reference in the surgery of pancreatic tumors.

Cost-utility advantage of interventional endoscopy

BACKGROUND

Gastroenterologists frequently face the dilemma of how to choose among different management options.

AIM

To develop a tool of medical decision analysis that helps choosing between competing management options of interventional endoscopy and surgery.

METHODS

Carcinoma-in-situ of the esophagus, large colonic polyps, and ampullary adenoma serve as three examples for disorders being managed by both techniques. A threshold analysis using a decision tree was modeled to compare the costs and utility values associated with managing the three examples. If the expected healing or success rate of interventional endoscopy exceeds a threshold calculated as the ratio of endoscopy costs over surgery costs, endoscopy becomes the preferred management option. A low threshold speaks in favor of endoscopic intervention as initial management strategy.

RESULTS

If the decision in favor of surgery is focused exclusively on preventing death from a given disease, surgical intervention may seem to provide the best treatment option. However, interventional endoscopy becomes a viable alternative, if the comparison is based on a broader perspective that includes adverse events and long-term disability, as well as the healthcare costs of both procedures. For carcinoma-in-situ of the esophagus, the threshold for the expected success rate is 24% (range in the sensitivity analysis: 7-29%); for large colonic polyps it is 10% (5-12%), and for duodenal papillary adenoma it is 17% (5-21%).

CONCLUSIONS

Even if a management strategy surpasses its alternative with respect to one important outcome parameter, there is often still room for the lesser alternative to be considered as viable option.

Comparison of oncologic outcomes between pancreaticoduodenectomy and total pancreatectomy for pancreatic adenocarcinoma

BACKGROUND

Pancreatoduodenectomy (PD) and total pancreatectomy (TP) are two surgical methods to treat patients with pancreatic head adenocarcinoma (PHAC). However, the oncologic outcomes of TP for PHAC remain controversial. In this study, we compared early mortality and long-term survival patients undergoing TP and those with PD.

METHODS

All patients diagnosed with non-metastatic PHAC who underwent PD or TP from 1988 to 2016 were retrieved from the Surveillance, Epidemiology, and End Results database. Propensity score matching (PSM) was used to balance the inter-group covariates. Cancer-specific survival (CSS) was the primary endpoint.

RESULTS

A total of 4748 patients (743 TP and 4005 PD) were included in the study. Some 740 patients who underwent TP were matched with 1479 who had PD. After PSM, there was no difference between TP and PD groups regarding 30-day mortality (3.5% vs. 2.7%, p = 0.290) and 90-day mortality (9.9% vs. 8%, p = 0.135). More importantly, TP showed comparable survival in comparison to PD, prior or after excluding patients who died within 30 and 90 days. Besides, multivariate analysis revealed that tumor size, tumor stage, N stage, chemotherapy, and radiation were significant prognostic factors.

CONCLUSION

PD and TP have similar early mortality and long-term survival for patients with PHAC. In selected patients, TP can be used when oncologically appropriate.

Pancreatic head cancer - Current surgery techniques

Pancreatic head cancer is a highly fatal disease. For now, surgery offers the only potential long-term cure albeit with a high risk of complications. However, the progress of surgical technique during the past decade has resulted in 5-year survival approaching 30% after resection and adjuvant chemotherapy. This paper presents current data on the recommended extent of lymphadenectomy, the resection margin, on the definition of resectable and borderline resectable tumors and mesopancreas. Surgical techniques proposed to improve PD are presented: the artery first approach, the uncinate process first, the mesopancreas first approach, the triangle operation, periarterial divestment, and multiorgan resection.

Total pancreatectomy as an alternative to high-risk pancreatojejunostomy after pancreatoduodenectomy: a propensity score analysis on surgical outcome and quality of life

BACKGROUND

Total pancreatectomy (TP) is mentioned as alternative to pancreatoduodenectomy (PD) with high-risk pancreatojejunostomy (PJ) to avoid severe pancreatic fistula-related complications, but its benefit is controversial and comparative studies are scarce.

METHODS

Cross-sectional single-center study among patients after PD with high-risk PJ versus patients after single-stage elective TP for any indication (2015-2017), using propensity scores to evaluate surgical outcomes and long-term quality of life (QoL) in three risk strata. EORTC QLQ-C30 and EQ-5D-5L were used for QoL assessment.

RESULTS

Overall, 77 patients after TP (68.8%) and 102 patients after high-risk PD (34.5%) were included. Major morbidity (29.9% vs. 41.2%; p = 0.119) and 90-day mortality (5.2% vs. 8.8%; p = 0.354) did not differ significantly between TP and high-risk PD. Interventions for intra-abdominal fluid collections (9.1% vs. 23.5%, p = 0.011) and postpancreatectomy haemorrhage (6.5% vs. 18.6%; p = 0.018) were more often required after high-risk PD, but these differences did not remain after stratification. QoL was comparable after TP and high-risk PD (75% vs. 83%; p = 0.720), even after stratification.

CONCLUSIONS

TP seems not to be inferior to high-risk PD regarding surgical outcomes and QoL. TP could be considered as an alternative to a very high-risk PD, but reluctance persists since TP does not appear to reduce mortality.

Risk factors associated with hypoglycemic events after total pancreatectomy: A nationwide multicenter prospective study in Japan

BACKGROUND

The number of total pancreatectomy cases have increased worldwide, expanding the need for new insulin products and high-titer pancrelipases. However, the current data that is focused on hypoglycemic events after a total pancreatectomy from large nationwide series are still lacking. This study is aimed to assess the risk factors associated with hypoglycemic events after a total pancreatectomy.

METHODS

Data were prospectively collected from 216 consecutive patients who underwent total pancreatectomies between August 2015 and December 2017 from 68 Japanese centers. Of the 216 patients, 166 with a follow-up period of 1 year were analyzed. The risk factors for hypoglycemic events at 6 and 12 months (postoperative months 6 and 12) were investigated based on the results of a nationwide multicenter prospective study.

RESULTS

Of the 166 patients, 57 (34%) and 70 (42%) experienced moderate or severe hypoglycemic events or hypoglycemia unawareness on a monthly basis at postoperative months 6 and 12, respectively. Multivariate analysis revealed that body weight loss after surgery ≥0.3 kg and total cholesterol level ≤136 mg/dL at postoperative month 6, and glycated hemoglobin level ≤8.9% and rapid-acting insulin use at postoperative month 12 were independent risk factors for hypoglycemic events after a total pancreatectomy. There were different independent risk factors depending on the postoperative period.

CONCLUSION

Patients with body weight loss after surgery, low total cholesterol level, strict glycemic control, and using rapid-acting insulin should be aware of the occurrence of hypoglycemic events after their total pancreatectomy. In order to prevent hypoglycemic events after a total pancreatectomy, we need to consider optimal nutritional and glycemic control according to the postoperative period.

[Better Therapy for Pancreatic Cancer through More Radical Surgery?]

Despite advances in the treatment of pancreatic cancer, the survival of affected patients remains limited. A more radical surgical therapy could help to improve the prognosis, in particular by reducing the local recurrence rate, which is around 45% in patients with resected pancreatic cancer. In addition, patients with oligometastatic pancreatic cancer could also benefit from a more radical indication for surgery.Based on an analysis of the literature, important principles of pancreatic cancer surgery were examined.Even if even more radical surgical approaches such as an "extended" lymphadenectomy or a standard complete pancreatectomy do not bring any survival advantage, complete resection of the tumour (R0), a thorough locoregional lymphadenectomy and an adequate radical dissection in the area of the peripancreatic vessels including periarterial nerve plexuses should be the standard of pancreatic carcinoma resections. Whenever necessary to achieve an R0 resection, resections of the pancreas have to be extended, as well as additional venous vascular resections and multivisceral resections had to be performed. Simultaneous arterial vascular resections as part of pancreatic resections as well as surgical resections in oligometastatic patients should, however, be reserved for selected patients. These aspects of the surgical technique in pancreatic carcinoma mentioned above must not be neglected from the point of view of an "existing limited prognosis". On the contrary, they form the absolutely necessary basis in order to achieve good survival results in combination with system therapy. However, it may always be necessary to adapt these standards according to the age, comorbidities and wishes of the patient.

Contemporary indications for upfront total pancreatectomy

Currently, advances in surgical techniques, improvements in perioperative care, new formulations of intermediate and long-acting insulin and of modern pancreatic enzyme preparations have allowed obtaining good short and long-term results and quality of life, especially in high-volume centres in performing total pancreatectomy (TP).Thus, the surgeon's fear in performing TP is not justified and total pancreatectomy can be considered a viable option in selected patients in high-volume centres. The aim of this review was to define the current indications for this procedure, in particular for upfront TP, considering not only the pancreatic disease, but also the surgical approach (open, mini-invasive) and the relationship with vascular resection.

Total pancreatectomy sequelae and quality of life: results of islet autotransplantation as a possible mitigation strategy

Total pancreatectomy (TP) is a procedure weighed down not only by postoperative morbidity and mortality but also by long-term effects as a consequence of endocrine and exocrine pancreatic insufficiency. While the latter is now managed quite effectively with pancreatic enzyme replacement therapy, the former remains a challenge. The diabetes resulting after TP, with the complete loss of endogenous insulin and contraregulatory hormones, is characterized by important glycemic variations and is, therefore, frequently referred to as "brittle diabetes". One method to reduce the impact of brittle diabetes in patients undergoing TP is the re-infusion of autologous pancreatic islets isolated from the resected pancreas. Indications to islet autotransplantation (IAT), originally described for patients undergoing TP for chronic pancreatitis, have since been extended to selected patients with other benign and malignant diseases of pancreas. This review recaps on the literature regarding long-term postoperative complications, their impact on quality of life after TP and the role of IAT.

Development of a preoperative prediction model for new-onset diabetes mellitus after partial pancreatectomy: A retrospective cohort study

Pancreatectomy is an invasive surgery that is sometimes associated with complications. New-onset diabetes mellitus sometimes develops after partial pancreatectomy and severely affects the patient's quality of life. This study aimed to develop a preoperative prediction model of new-onset diabetes mellitus after partial pancreatectomy, which will help patients and surgeons to achieve more easily better common decisions on regarding whether to perform partial pancreatectomy. This retrospective cohort study analyzed medical records of patients who underwent partial pancreatectomy (total pancreatectomy excluded) from April 1, 2008, to February 28, 2016, which were available in the database provided by Medical Data Vision Co., Ltd. (Tokyo, Japan). The predictors were preoperative age, body mass index, hemoglobin A1c level, blood glucose level, and indication for partial pancreatectomy. The outcome was the development of new-onset diabetes mellitus at 1 to 12 months after partial pancreatectomy. We used a logistic regression model and calculated the scores of each predictor. To determine test performance, we assessed discrimination ability using the receiver operating characteristic curve and calibration with a calibration plot and the Hosmer-Lemeshow test. We also performed internal validation using the bootstrap method. Of 681 patients, 125 (18.4%) had new-onset diabetes mellitus after partial pancreatectomy. The developed prediction model had a possible range of 0 to 46 points. The median score was 13, and the interquartile range was 9 to 22. The C-statistics of the receiver operating characteristic curve on the score to predict the outcome was .70 (95% confidence interval [CI], .65-.75). Regarding the test performance, the Hosmer-Lemeshow test was not significant (P = .17), and calibration was good. In the bootstrapped cohorts, the C-statistics was .69 (95% CI, .62-.76). We developed a preoperative prediction model for new-onset diabetes mellitus after partial pancreatectomy. This would provide important information for surgeons and patients when deciding whether to perform partial pancreatectomy.

Long-term quality of life and global health following pancreatic surgery for benign and malignant pathologies

BACKGROUND

While the frequency of pancreatic operations are increasing, understanding quality of life is still insufficient. The aim was to evaluate global health and quality of life of long-term survivors from a range of pancreatic operations using internationally validated instruments.

METHODS

Patients surviving longer than 5 years after pancreatic operations were surveyed using the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Cancer-30 and Pancreatic Cancer-26 modules. Variables were analyzed according to demographic and clinical features.

RESULTS

Eighty patients completed questionnaires. The median follow-up was 9.3 years from the time of operation. The mean scores of global health status/quality of life, physical function, role function, emotional function, cognitive function, and social functioning were 73.9, 83.7, 84.6, 81.1, 80.2, and 86.3, respectively. The participants' reported quality of life was comparable or better than the general United States population. The summary score, which was defined as weighted average of function and symptom scores (excluding global health status/quality of life and financial impact scores), showed significant differences according to the level of education (70.1 no college vs 85.2 college and 85.7 grad school, P = .049), operation type (79.9 pancreatoduodenectomy vs 91.1 total, P = .043), additional endoscopic retrograde cholangiopancreatography (77.3 vs 86.0, P = .029), and additional abdominal operations related to the primary operation (79.0 vs 86.6, P = .026).

CONCLUSION

Long-term survivors of pancreatectomy had comparable or better global health status/quality of life, function scale, and lower symptom scores than the general population of the United States, though persistent gastrointestinal symptoms are common. These findings should help inform patients of the long-term consequences of pancreatectomy, so they can make better decisions especially when considering prophylactic operations.

Long term quality of life amongst pancreatectomy patients with diabetes mellitus

BACKGROUND

Pancreatogenic diabetes is common after pancreatectomy, and the impact on quality of life (QOL) is poorly understood. The objective of this study was to investigate QOL between diabetic and non-diabetic patients at least five years after pancreatectomy.

METHODS

Patients were recruited from a prospectively maintained institutional database. Participants were administered the Audit of Diabetes-Dependent Quality of Life (ADDQOL). Quality of life was compared between diabetics and non-diabetics using validated European Organization for Research and Treatment of Cancer questionnaires.

RESULTS

80 individuals completed surveys. 55% were female, 80% non-Hispanic white, 44% underwent Whipple, 48% were cystic neoplasms and 39% were adenocarcinoma. Diabetic patients (42.5%) reported comparable EORTC QLQ-C30 and Pan26 scores to non-diabetic patients. Pre-operative diabetic patients reported more dyspnea (p = 0.02) and greater pain (p = 0.02) than new-onset diabetics. Diabetic patients reported an overall ADDQOL quality of life score 'very good' (IQR: excellent, good) though felt life would be much better without diabetes (IQR: very much better, little better). While operation type was not influential, patients diagnosed with cystic neoplasms were almost twice as likely as those with other pathologies to report that life would be much better without diabetes (p < 0.01).

CONCLUSION

At a median of 9.3 years from pancreatic surgery, ADDQoL scores of patients were similar to cohorts of non-pancreatogenic diabetics in the general population. Patients without cancer were more likely to report that diabetes affected their overall QOL, regardless of operation. This study provides nuanced understanding of long-term QOL to improve the informed consent process and post-operative long-term care.

Total pancreatectomy as alternative to pancreatico-jejunal anastomosis in patients with high fistula risk score: the choice of the fearful or of the wise?

PURPOSE

Patients with fistula risk score (FRS) ≥7 are at the highest risk of developing clinically relevant post-operative pancreatic fistula (CR-POPF). There is no agreement on the management of this subpopulation. The primary outcome of the study was the definition of the role of intraoperative completion pancreatectomy (ICP) in patients at high risk for CR-POPF, as an alternative to high-risk pancreaticoduodenectomy (PD).

METHODS

This is an observational study set in a single tertiary referral center. Patients scheduled for PD in our center between 2010 and 2019 with FRS ≥7 were included in the study. Data were prospectively collected.

RESULTS

A total of 738 patients were scheduled for between 2010 and 2019, and 62 had FRS ≥7. Thirty-five patients were managed with PD and pancreatico-jejunal anastomosis (group A), and 27 with ICP (group B). Overall complication rate was significantly higher in group A than group B (95 versus 59%; p=0.005) and there was a not significantly higher rate of major complications (Clavien-Dindo ≥3) (43 versus 26%; p=0.192). In group A, 49% of patients had a CR-POPF. Median post-operative length of stay was 15 days in group A and 12 in group B (p=0.043). Readmission was observed only in group A (26%). In multivariate analysis, PD was an independent predictive factor of major post-operative morbidity (RR 9.27; CI 1.74-49.31). No patients in either group suffered major adverse events related to endocrine and exocrine insufficiency.

CONCLUSION

In high-FRS patients, ICP has good short-term outcomes relative to PD without major long-term events related to endocrine and exocrine insufficiency. ICP could be considered as a feasible alternative in selected cases.

Changes in postoperative long-term nutritional status and quality of life after total pancreatectomy

Purpose

Quality of life (QoL) is widely known to be poor after total pancreatectomy (TP) due to the loss of pancreatic function and poor nutritional status, but prospective studies on changes in QoL over time are lacking. The aim of this study was to prospectively evaluate the short- and long-term consequences of pancreatic exocrine insufficiency, changes in nutritional status, and their associated effects on QoL after TP.

Methods

Prospective data were collected from patients who underwent TP between 2008 and 2018. Validated questionnaires (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ] Core 30, EORTC QLQ-pancreatic cancer module, and the Mini Nutritional Assessment), measured frequency of bowel movement, relative body weight (RBW), triceps skinfold thickness (TSFT), and serum levels of protein, albumin, transferrin, and hemoglobin A1c were collected serially for 1 year.

Results

Thirty patients who underwent TP were eligible for the study. Bowel movement frequency increased over time, and the RBW and TSFT were lowest by 1 year. The global health status score showed no significant difference over time. At 3 months, physical and role function scores as well as symptoms of fatigue, constipation, and digestive difficulties worsened significantly. Most indices recovered after 1 year, but poorer physical function scores, digestive difficulties, and altered bowel habits persisted.

Conclusion

Because some symptoms do not recover over time, careful follow-up and supportive postoperative management are needed for TP patients, including nutritional support with pancreatic enzyme replacement and education about medication adherence and diet.

Supplemental 18F-FDG-PET/CT for Detection of Malignant Transformation of IPMN-A Model-Based Cost-Effectiveness Analysis

Accurate detection of malignant transformation and risk-stratification of intraductal papillary mucinous neoplasms (IPMN) has remained a diagnostic challenge. Preliminary findings have indicated a promising role of positron emission tomography combined with computed tomography and 18F-fluorodeoxyglucose (18F-FDG-PET/CT) in detecting malignant IPMN. Therefore, the aim of this model-based economic evaluation was to analyze whether supplemental FDG-PET/CT could be cost-effective in patients with IPMN. Decision analysis and Markov modeling were applied to simulate patients' health states across a time frame of 15 years. CT/MRI based imaging was compared to a strategy with supplemental 18F-FDG-PET/CT. Cumulative costs in US-$ and outcomes in quality-adjusted life years (QALY) were computed based on input parameters extracted from recent literature. The stability of the model was evaluated by deterministic sensitivity analyses. In the base-case scenario, the CT/MRI-strategy resulted in cumulative discounted costs of USD $106,424 and 8.37 QALYs, while the strategy with supplemental FDG-PET/CT resulted in costs of USD $104,842 and a cumulative effectiveness of 8.48 QALYs and hence was cost-saving. A minimum specificity of FDG-PET/CT of 71.5% was required for the model to yield superior net monetary benefits compared to CT/MRI. This model-based economic evaluation indicates that supplemental 18F-FDG-PET/CT could have a favorable economic value in the management of IPMN and could be cost-saving in the chosen setting. Prospective studies with standardized protocols for FDG-PET/CT could help to better determine the value of FDG-PET/CT.

Partial pancreatic tail preserving subtotal pancreatectomy for pancreatic cancer: Improving glycemic control and quality of life without compromising oncological outcomes

BACKGROUND

Total pancreatectomy (TP) is usually considered a therapeutic option for pancreatic cancer in which Whipple surgery and distal pancreatectomy are undesirable, but brittle diabetes and poor quality of life (QoL) remain major concerns. A subset of patients who underwent TP even died due to severe hypoglycemia. For pancreatic cancer involving the pancreatic head and proximal body but without invasion to the pancreatic tail, we performed partial pancreatic tail preserving subtotal pancreatectomy (PPTP-SP) in selected patients, in order to improve postoperative glycemic control and QoL without compromising oncological outcomes.

AIM

To evaluate the efficacy of PPTP-SP for patients with pancreatic cancer.

METHODS

We retrospectively reviewed 56 patients with pancreatic ductal adenocarcinoma who underwent PPTP-SP (n = 18) or TP (n = 38) at our institution from May 2014 to January 2019. Clinical outcomes were compared between the two groups, with an emphasis on oncological outcomes, postoperative glycemic control, and QoL. QoL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30 and EORTC PAN26). All patients were followed until May 2019 or until death.

RESULTS

A total of 56 consecutive patients were enrolled in this study. Perioperative outcomes, recurrence-free survival, and overall survival were comparable between the two groups. No patients in the PPTP-SP group developed cancer recurrence in the pancreatic tail stump or splenic hilum, or a clinical pancreatic fistula. Patients who underwent PPTP-SP had significantly better glycemic control, based on their higher rate of insulin-independence (P = 0.014), lower hemoglobin A1c (HbA1c) level (P = 0.046), lower daily insulin dosage (P < 0.001), and less frequent hypoglycemic episodes (P < 0.001). Global health was similar in the two groups, but patients who underwent PPTP-SP had better functional status (P = 0.036), milder symptoms (P = 0.013), less severe diet restriction (P = 0.011), and higher confidence regarding future life (P = 0.035).

CONCLUSION

For pancreatic cancer involving the pancreatic head and proximal body, PPTP-SP achieves perioperative and oncological outcomes comparable to TP in selected patients while significantly improving long-term glycemic control and QoL.

Surgical Outcomes After Total Pancreatectomy: A High-Volume Center Experience

BACKGROUND

The impact of high-volume care in total pancreatectomy (TP) is barely explored since annual numbers are mostly low. This study evaluated surgical outcomes after TP over time in a high-volume center.

METHODS

All adult patients (age ≥ 18 years) who underwent an elective single-stage TP at Karolinska University Hospital were retrospectively analysed (2008-2017). High volume was defined as > 20 TPs/year.

RESULTS

Overall, 145 patients after TP were included, including 86 (59.3%) extended resections. Major morbidity was 34.5% (50/145) and 90-day mortality 5.5% (8/145). The relative use of TP within all pancreatectomies increased from 5.4% (63/1175) in 2008-2015 to 17.3% (82/473) in 2016-2017 (p < 0.001). Over time, TP was more often performed to achieve radicality (n = 11, 17.5% to n = 31, 37.8%; p = 0.007). In multivariable logistic regression analysis, an annual TP-volume of > 20 was associated with reduced major morbidity (odds ratio [OR] = 0.225, 95% confidence interval [CI], 0.097-0.521; p < 0.001). In the high-volume years (2016-2017), major morbidity (n = 31, 49.2% to n = 19, 23.2%; p = 0.001) and relaparotomy rate (n = 13, 20.6% to n = 5, 6.1%; p = 0.009) improved. Improvements occurred mainly after extended TP, including lower major morbidity (n = 22, 57.9% to n = 12, 25.0%; p = 0.002) and in-hospital mortality (n = 3, 7.9% to n = 0, 0%; p = 0.082).

CONCLUSIONS

In a single, high-volume center study, an increase in surgical volume of TP was associated with improved perioperative outcomes, especially for extended resections.

Prophylactic total pancreatectomy in individuals at high risk of pancreatic ductal adenocarcinoma (PROPAN): systematic review and shared decision-making programme using decision tables

Background

Individuals with a very high lifetime risk of developing pancreatic ductal adenocarcinoma; for example, hereditary pancreatitis and main-duct or mixed-type intraductal papillary mucinous neoplasm, may wish to discuss prophylactic total pancreatectomy but strategies to do so are lacking.

Objective

To develop a shared decision-making programme for prophylactic total pancreatectomy using decision tables.

Methods

Focus group meetings with patients were used to identify relevant questions. Systematic reviews were performed to answer these questions.

Results

The first tables included hereditary pancreatitis and main-duct or mixed-type intraductal papillary mucinous neoplasm. No studies focused on prophylactic total pancreatectomy in these groups. In 52 studies (3570 patients), major morbidity after total pancreatectomy was 25% and 30-day mortality was 6%. After minimally invasive total pancreatectomy (seven studies, 35 patients) this was, respectively, 13% and 0%. Exocrine insufficiency-related symptoms occurred in 33%. Quality of life after total pancreatectomy was slightly lower compared with the general population.

Conclusion

The decision tables can be helpful for discussing prophylactic total pancreatectomy with individuals at high risk of pancreatic ductal adenocarcinoma.

The role of total pancreatectomy with islet autotransplantation in the treatment of chronic pancreatitis: A report from the International Consensus Guidelines in chronic pancreatitis

BACKGROUND

Advances in our understanding of total pancreatectomy with islet autotransplantation (TPIAT) have been made. We aimed to define indications and outcomes of TPIAT.

METHODS

Expert physician-scientists from North America, Asia, and Europe reviewed the literature to address six questions selected by the writing group as high priority topics. A consensus was reached by voting on statements generated from the review.

RESULTS

Consensus statements were voted upon with strong agreement reached that (Q1) TPIAT may improve quality of life, reduce pain and opioid use, and potentially reduce medical utilization; that (Q3) TPIAT offers glycemic benefit over TP alone; that (Q4) the main indication for TPIAT is disabling pain, in the absence of certain medical and psychological contraindications; and that (Q6) islet mass transplanted and other disease features may impact diabetes mellitus outcomes. Conditional agreement was reached that (Q2) the role of TPIAT for all forms of CP is not yet identified and that head-to-head comparative studies are lacking, and that (Q5) early surgery is likely to improve outcomes as compared to late surgery.

CONCLUSIONS

Agreement on TPIAT indications and outcomes has been reached through this working group. Further studies are needed to answer the long-term outcomes and maximize efforts to optimize patient selection.

Total Pancreatectomy: Indications, Advantages and Disadvantages - A Review

Background: Total pancreatectomy is an obligatory surgical procedure in locally advanced or centrally located pancreatic neoplasms to achieve complete tumour clearance. Owing to sound understanding of tumour biology and evolution in intervention technique and improved postoperative care, nowadays the indications of total pancreatectomy have taken a significant change. Aim: To review the indications of total pancreatectomy and its advantages and disadvantages under current perspectives. Method: Major databases, including PubMed, EMBASE, Science Citation Index Expanded, Scopus and the Cochrane Library, were searched for studies of total pancreatectomy and the results reported by various authors were summarized. Results: The indications of total pancreatectomy in subjects diagnosed with chronic pancreatitis were classified into four subgroups, including "Tumour", "Trouble", "Technical difficulties" and "Therapy-refractory pain". Today, total pancreatectomy has more specific and different indications than before. Currently, IPMN (intraductal papillary mucinous neoplasm) seems to have the most essential indication quantitatively. Morbidity and mortality related to total pancreatectomy are more profoundly decreased than before due to improvements in the operative techniques and post-operative managements. Some of the metabolic disorders are reported as major disadvantages of total pancreatectomy. Conclusion: Despite the disadvantages of total pancreatectomy, it remains an inevitable procedure for subjects with chronic pancreatitis, improvements in operative techniques and postoperative management ensuring long-term survival, a better quality of life, and diminished mortality and morbidity rates.

Landscape of Health-Related Quality of Life in Patients With Early-Stage Pancreatic Cancer Receiving Adjuvant or Neoadjuvant Chemotherapy: A Systematic Literature Review

OBJECTIVES

Pancreatic resection is associated with postoperative morbidity and reduced quality of life (QoL). A systematic literature review was conducted to understand the patient-reported outcome measure (PROM) landscape in early-stage pancreatic cancer (PC).

METHODS

Databases/registries (through January 24, 2019) and conference abstracts (2014-2017) were searched. Study quality was assessed using the Newcastle-Ottawa Scale/Cochrane risk-of-bias tool. Searches were for general (resectable PC, adjuvant/neoadjuvant, QoL) and supplemental studies (resectable PC, European Organisation for Research and Treatment of Cancer QoL Questionnaire [QLQ] - Pancreatic Cancer [PAN26]).

RESULTS

Of 750 studies identified, 39 (general, 22; supplemental, 17) were eligible: 32 used QLQ Core 30 (C30) and/or QLQ-PAN26, and 15 used other PROMs. Baseline QLQ-C30 global health status/QoL scores in early-stage PC were similar to all-stage PC reference values but lower than all-stage-all-cancer values. The QoL declined after surgery, recovered to baseline in 3 to 6 months, and then generally stabilized. A minimally important difference (MID) of 10 was commonly used for QLQ-C30 but was not established for QLQ-PAN26.

CONCLUSIONS

In early-stage PC, QLQ-C30 and QLQ-PAN26 are the most commonly used PROMs. Baseline QLQ-C30 global health status/QoL scores suggested a high humanistic burden. Immediately after surgery, QoL declined but seemed stable over the longer term. The QLQ-C30 MID may elucidate the clinical impact of treatment on QoL; MID for QLQ-PAN26 needs to be established.

Prognostic impact of lymph node status in patients after total pancreatectomy for pancreatic ductal adenocarcinoma: A strobe-compliant study

The optimal number of examined lymph nodes (ELN) for staging and impact of nodal status on survival following total pancreatectomy (TP) for pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim of this study was to evaluate the prognostic impact of different lymph node status after TP for PDAC.The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients who underwent TP for PDAC from 2004 to 2015. We calculated overall survival (OS) of these patients using Kaplan-Meier analysis and Cox proportional hazards model.Overall, 1291 patients were included in the study, with 869 node-positive patients (49.5%). A cut-off points analysis revealed that 19, 19, and 13 lymph nodes best discriminated OS for all patients, node-negative patients, and node-positive patients, respectively. Higher number of ELN than the corresponding cut-off points was an independent predictor for better prognosis [all patients: hazard ratios (HR) 0.786, P = .002; node-negative patients: HR 0.714, P = .043; node-positive patients: HR 0.678, P < .001]. For node-positive patients, 1 to 3 positive lymph nodes (PLN) correlated independently with better survival compared with those with 4 or more PLN (HR 1.433, P = .002). Moreover, when analyzed in node-positive patients with less than 13 ELN, neither the number of PLN nor lymph node ratio (LNR) was associated with survival. However, when limited node-positive patients with at least 13 ELN, univariate analyses showed that both the number of PLN and LNR were associated with survival, whereas multivariate analyses demonstrated that only number of PLN was consistently associated with survival (HR 1.556, P = .004).Evaluation at least 19 lymph nodes should be considered as quality metric of surgery in patients who underwent TP for PDAC. For node-negative patients, a minimal number of 19 lymph nodes is adequate to avoid stage migration. For node-positive patients, PLN is superior to LNR in predicting survival after TP, predominantly for those with high number of ELN.

Pancreatic resections for metastases: A twenty-year experience from a tertiary care center

BACKGROUND

Literature data about pancreatic resections for metastases are limited to small series, so that the role of surgery in this setting remains unclear. We herein report our experience from a tertiary care center, analyzing the outcomes of patients who underwent pancreatic resections for metastases and discussing the role of surgical resection in their management.

MATERIALS AND METHODS

From January 1999 to January 2019, 26 patients underwent pancreatic resections for metastases from renal cell carcinoma (RCC-group) or other primitive tumors (non-RCC-group). Details regarding pre-, intra-, post-operative course, and follow-up, prospectively collected in a database of pancreatic resection, were retrospectively analyzed and compared.

RESULTS

RCC-group was composed of 21 patients, non-RCC-group of 5 patients. RCC-group presented a longer disease-free interval: 96.4 vs. 5.4 months (p < 0.001). In 9/21 patients (42.9%) of RCC-group the surgical resection of other organs or vascular structures was performed, while in non-RCC-group pancreatic resection alone was performed in all cases, p = 0.070. No local recurrence was reported in all cases. The systemic recurrence rate was 42.9% (9/21 patients) in RCC-group and 80% (4/5 patients) in non-RCC-group, p = 0.135. RCC-group presented a longer DFS and OS: 107.5 vs. 25.2 months (p = 0.002), and 109.1 vs. 36.2 months (p = 0.016), respectively.

CONCLUSIONS

Radical pancreatic resection may confer a survival benefit for RCC metastases, while for other primitive tumors it should be applied more selectively. For RCC pancreatic metastases, an aggressive surgical approach, even in patient with locally advanced tumors, or associated extra-pancreatic localizations, or recurrent metastases should be taken in consideration.

A CARE-compliant case report: total pancreatectomy and total gastrectomy to treat pancreatic ductal adenocarcinoma

RATIONALE

Total pancreatectomy (TP) is performed in cases of multifocal and large invasive tumors of the pancreas, and is associated with high rates of mortality and morbidity. Previously, the limitations and unsatisfactory effect of this surgery rendered it rarely performed; however, with improvements in surgical techniques and blood sugar management, TP is now more frequently performed. TP has a similar long-term survival rate as that for pancreatoduodenectomy (PD). However, the application of TP plus total gastrectomy (TG) for the treatment of invasive pancreatic ductal adenocarcinoma has not been reported previously.

PATIENT CONCERNS

The patient was a 64-year-old man with epigastric discomfort. Physical examination showed a hard mass. Preoperative computed tomography and magnetic resonance imaging revealed a solid mass located in the pancreatic body and involving the portal vein and stomach.

DIAGNOSIS

Pancreatic cancer.

INTERVENTIONS

The patient was treated with TP combined with TG and portal vein reconstruction.

OUTCOMES

The patient had a smooth post-operative recovery but, regretfully, developed metastases 2 months after discharge.

LESSONS

Considering the poor outcome of the present case, the validity of the operation should be reevaluated. Although a single case does not elicit a convincing conclusion, the current case might serve as a warning against performing a similar surgery.

Systematic review of functional outcome and quality of life after total pancreatectomy

BACKGROUND

Surgeons have traditionally been reluctant to perform total pancreatectomy because of concerns for brittle diabetes and poor quality of life (QoL). Several recent studies have suggested that outcomes following total pancreatectomy have improved, but a systematic review is lacking.

METHODS

A systematic review was undertaken of studies reporting on outcomes after total pancreatectomy for all indications, except chronic pancreatitis. PubMed, EMBASE (Ovid), and Cochrane Library were searched (2005-2018). Endpoints included functional outcome and QoL.

RESULTS

A total of 21 studies, including 1536 patients, fulfilled the eligibility criteria. During a median follow-up of 20·8 (range 1·5-96·0) months, 18·6 per cent (45 of 242 patients) were readmitted for endocrine-related morbidity, with associated mortality in 1·6 per cent (6 of 365 patients). No diabetes-related mortality was reported in studies including only patients treated after 2005. Symptoms related to exocrine insufficiency were reported by 43·5 per cent (143 of 329 patients) during a median follow-up of 15·9 (1·5-96·0) months. Overall QoL, reported by 102 patients with a median follow-up of 28·6 (6·0-66·0) months, using the EORTC QLQ-C30 questionnaire, showed a moderately reduced summary score of 76 per cent, compared with a general population score of 86 per cent (P = 0·004).

CONCLUSION

Overall QoL after total pancreatectomy is affected adversely, in particular by the considerable impact of diarrhoea that requires better treatment. There is also room for improvement in the management of diabetes after total pancreatectomy, particularly with regards to prevention of diabetes-related morbidity.

Outcome and long-term quality of life after total pancreatectomy (PANORAMA): a nationwide cohort study

BACKGROUND

The threshold to perform total pancreatectomy is rather high, predominantly because of concerns for long-term consequences of brittle diabetes on patients' quality of life. Contemporary data on postoperative outcomes, diabetes management, and long-term quality of life after total pancreatectomy from large nationwide series are, however, lacking.

METHODS

We performed a nationwide, retrospective cohort study among adults who underwent total pancreatectomy in 17 Dutch centers (2006-2016). Morbidity and mortality were analyzed, and long-term quality of life was assessed cross-sectionally using the following generic and disease-specific questionnaires: the 5-level version European quality of life 5-dimension and the European Organization for Research and Treatment in Cancer Quality of Life Questionnaire Cancer. Several questionnaires specifically addressing diabetic quality of life included the Problem Areas in Diabetes Scale 20, the Diabetes Treatment Satisfaction Questionnaire-status version, and the Hypoglycemia Fear Survey-II. Results were compared with the general population and patients with type 1 diabetes.

RESULTS

Overall, 148 patients after total pancreatectomy were included. The annual nationwide volume of total pancreatectomy increased from 5 in 2006 to 32 in 2015 (P < .05). The 30-day and 90-day mortality were 5% and 8%, respectively. The major complication rate was 32%. Quality of life questionnaires were completed by 60 patients (85%, median follow-up of 36 months). Participants reported lower global (73 vs 78, P = .03) and daily health status (0.83 vs 0.87, P < .01) compared to the general population. Quality of life did not differ based on time after total pancreatectomy (<3, 3-5, or >5 years). In general, patients were satisfied with their diabetes therapy and experienced similar diabetes-related distress as patients with type 1 diabetes.

CONCLUSION

This nationwide study found increased use of total pancreatectomy with a relatively high 90-day mortality. Long-term quality of life was lower compared to the general population, although differences were small. Diabetes-related distress and treatment satisfaction were similar to patients with type 1 diabetes.

Multicentric study on total pancreatectomies

INTRODUCTION

Total pancreatectomy (TP) is an uncommon operation, with indications that have not been clearly defined and non-standardized postoperative results. We present a national multicentric study on TP and a comparison with the existing literature METHODS: A prospective observational study using data from the national registry of patients after pancreaticoduodenectomy and TP performed for any indication during the study period: January 1 to December 31, 2015 RESULTS: 1016 patients were included from 73 hospitals, 112 of whom had undergone TP. The percentage of TP from the total number of cases was 11%. The mean age was 63.5 years, and 57.2% were males. The most frequently suspected radiological diagnosis was pancreatic cancer (58/112 cases). The most common TP technique was "mesentery artery first" (43/112 cases). Venous resections were performed in 23 patients (20.5%). The percentage of postoperative complications within 90 days was 50%, but major complications (>IIIA) were only 20.7%. The overall 90-day mortality was 8% (9 patients). The average stay was 20.7 days. The 3most frequent definitive histological diagnoses were: adenocarcinoma of the pancreas, intraductal papillary mucinous neoplasm and chronic pancreatitis. The R0 rate was 67.8%.

CONCLUSIONS

This study shows that the morbidity and mortality results of TP in Spain are similar or superior to previous publications. More precise TP studies are necessary, focused on specific complications such as endocrine insufficiency.

Role of total pancreatectomy in the treatment of paraduodenal pancreatitis: A case report

BACKGROUND

Paraduodenal pancreatitis (PP) is a rare form of chronic pancreatitis presenting with symptoms of duodenal obstruction. Conservative treatment is often unsuccessful and pancreaticoduodenectomy is the preferred surgical approach. A mini review of the outcomes of surgical therapy for PP shows that the results of pancreaticoduodenectomy are predominantly favorable.

CASE SUMMARY

In our case report of PP, we describe an unusual course first presenting with the symptoms of chronic pancreatitis and a pseudocyst of the pancreatic tail. A pseudocystojejunostomy was performed and the late postoperative course was complicated with the symptoms of duodenal obstruction. At laparotomy, PP was found and the patient was treated with a total pancreatectomy. The postoperative course was uneventful and good weight gain with resolution of pain was demonstrated at follow up visits.

CONCLUSION

Surgery is currently the optimal treatment option for PP. It is also the best diagnostic tool in distinguishing between pancreatitis and pancreatic adenocarcinoma.

Impact of different surgical procedures on survival outcomes of patients with adenocarcinoma of pancreatic neck

Background

The only curative treatment for pancreatic adenocarcinoma is radical surgical resection. Because of the special anatomic features of pancreatic neck, the selection of optimal surgical procedure for treatment of adenocarcinoma of pancreatic neck has always been a dilemma for surgeons. In this paper, we aim to investigate whether different surgical procedures can affect prognosis in the patient with adenocarcinoma of pancreatic neck.

Methods

We used the surveillance, epidemiology, and end results database to review patients with adenocarcinoma of pancreatic neck diagnosed between 1998 and 2015. We calculated overall survival (OS) and cancer-specific survival (CSS) of these patients using Kaplan-Meier analysis and Cox regression model.

Results

Overall, 1443 patients were included in the study, with 12.5% treated with surgical resection. Among them, 30 (18.8%) patients underwent distal pancreatectomy (DP), 105 (65.6%) patients underwent pancreatoduodenectomy (PD), and 25 (15.6%) patients underwent total pancreatectomy (TP). Patients underwent DP were older than these underwent TP (70.5±10.7 vs. 62.2±14.1, P = 0.027). Patients underwent TP had higher percentages of nodal metastasis (N1 stage) than these underwent DP (68.0% vs. 34.5%, P = 0.014). The surgical procedures did not significantly affect either OS times (P = 0.924) or CSS times (P = 0.786) in Kaplan-Meier analysis, even if in any subgroup of AJCC stage. The multivariate Cox regression model showed that types of surgery were not associated with OS and CSS. Higher tumor grade and AJCC stage are independent prognostic factors for OS and CSS. No radiotherapy was associated with a worse CSS (HR 1.610, 95% CI 1.016–2.554, P = 0.043).

Conclusion

Different surgical procedures did not affect prognosis in the patients with adenocarcinoma of pancreatic neck. TP should be performed in carefully selective patients in high-volume pancreatic centers.

Total pancreatectomy compared with pancreaticoduodenectomy: a systematic review and meta-analysis

Aim: To assess whether total pancreatectomy (TP) is as feasible, safe, and efficacious as pancreaticoduodenectomy (PD). Materials and Methods: Major databases, including PubMed, EMBASE, Science Citation Index Expanded, Scopus and the Cochrane Library, were searched for studies comparing TP and PD between January 1943 and June 2018. The meta-analysis only included studies that were conducted after 2000. The primary outcomes were morbidity and mortality. Pooled odds ratios (ORs), weighted mean differences (WMDs) or hazard ratios (HRs) with 95 percent confidence intervals (CIs) were calculated using fixed effects or random effects models. The methodological quality of the included studies was evaluated by the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. Results: In total, 45 studies were included in this systematic review, and 5 non-randomized comparative studies with 786 patients (TP: 270, PD: 516) were included in the meta-analysis. There were no differences in terms of mortality (OR: 1.44, 95% CI: 0.66-3.16; P=0.36), hospital stay (WMD: -0.60, 95% CI: -1.78-0.59; P=0.32) and rates of reoperation (OR: 1.12; 95% CI: 0.55-2.31; P=0.75) between the two groups. In addition, morbidity was not significantly different between the two groups (OR: 1.41, 95% CI: 1.01-1.97; P=0.05); however, the results showed that the TP group tended to have more complications than the PD group. Furthermore, the operation time (WMD: 29.56, 95% CI: 8.23-50.89; P=0.007) was longer in the TP group. Blood loss (WMD: 339.96, 95% CI: 117.74-562.18; P=0.003) and blood transfusion (OR: 4.86, 95% CI: 1.93-12.29; P=0.0008) were more common in the TP group than in the PD group. There were no differences in the long-term survival rates between the two groups. Conclusion: This systematic review and meta-analysis suggested that TP may not be as feasible and safe as PD. However, TP and PD may have the same efficacy.

Total pancreatectomy for pancreatic malignancy with preservation of the spleen

BACKGROUND

Total pancreatectomy may be necessary to achieve margin-negative resection for pancreatic cancer. However, despite the desirability of saving the spleen, the feasibility, safety, and oncological outcomes of spleen-preserving total pancreatectomy have not been studied in patients with malignancy involving the pancreatic neck or proximal body. The aim of this study was to report the efficacy of spleen-preserving total pancreatectomy using the Warshaw technique for patients with pancreatic malignancies.

METHODS

A retrospective analysis of patients who underwent total pancreatectomy for malignant pancreatic diseases between December 2006 and January 2018 focused on comparing the clinical outcomes between conventional operations with splenectomy and spleen-preserving total pancreatectomy using the Warshaw technique.

RESULTS

Thirty-eight patients among a total of 59 total pancreatectomies had the spleen preservation by the Warshaw operation. In this series, the pancreatic ductal adenocarcinomas resected with the Warshaw technique were of smaller tumor size but had greater rates of vascular invasion, resulting in the more frequent vascular resection. No patients had splenic complications requiring splenectomy, but two patients intended to have the Warshaw operation were converted to splenectomy because of splenic malperfusion. Asymptomatic perigastric varices were noted in 4 patients. Postoperative morbidity and mortality were comparable between the Warshaw and conventional operation groups. Recurrence-free and overall survival was similar in both groups.

CONCLUSION

In patients with pancreatic malignancy, total pancreatectomy with preservation of the spleen using the Warshaw technique achieves outcomes comparable with conventional total pancreatectomy with splenectomy in selected patients.

EUS-guided celiac ganglion radiofrequency ablation versus celiac plexus neurolysis for palliation of pain in pancreatic cancer: a randomized controlled trial (with videos)

BACKGROUND AND AIMS

Although EUS-guided celiac plexus neurolysis (EUS-CPN) is frequently performed, its efficacy for palliation of pain in pancreatic cancer is suboptimal. Recently, EUS-guided radiofrequency ablation (EUS-RFA) has been proposed as a palliative treatment option for pancreatic neoplasms. We performed a single-blind, randomized trial to compare the effectiveness of EUS-CPN and EUS-RFA for palliation of pain in pancreatic cancer.

METHODS

Patients with abdominal pain because of locally advanced or metastatic pancreatic cancer underwent EUS-CPN (n = 14) or EUS-RFA (n = 12). EUS-RFA was performed using a 1F monopolar probe passed via a 19-gauge FNA needle, by targeting the area of celiac plexus or visualized ganglia. Primary outcome was pain severity as measured by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire pancreatic cancer module (PAN26) administered pretreatment and at 2 and 4 weeks post-treatment. Secondary outcome measures were comparison of quality of life as determined by the PAN26 and EORTC Quality of Life Questionnaire core questionnaire (C30) and opioid analgesia use between the 2 groups.

RESULTS

Both the PAN26 (49.0 vs 57.0, P < .001) and C30 (51.9 vs 64.4, P = .032) revealed less pain for EUS-RFA than for EUS-CPN. Also, the EUS-RFA cohort experienced significantly less-severe GI symptoms, were able to plan more for the future, and had better emotional functioning compared with the EUS-CPN group.

CONCLUSIONS

Compared with EUS-CPN, EUS-RFA provided more pain relief and improved the quality of life for patients with pancreatic cancer. (Clinical trials registration number: NCT03152487.).

Surgical management of intraductal papillary mucinous neoplasm with main duct involvement: an international expert survey and case-vignette study

BACKGROUND

The risk of invasive cancer in resected intraductal papillary mucinous neoplasm with main pancreatic duct involvement is 33%-60%. Most guidelines, therefore, advise resection of main duct intraductal papillary mucinous neoplasm and mixed type intraductal papillary mucinous neoplasm in surgically fit patients, although advice on the surgical strategy (partial or total pancreatectomy) differs. We performed a survey amongst international experts to guide the design of future studies and help to prepare for a single international set of guidelines.

METHODS

An online survey including case vignettes was sent to 221 international experts who had published on main duct/mixed type intraductal papillary mucinous neoplasm in the previous decade and to all surgeon and gastroenterologist members of the pancreatic cyst guideline committees of the European Study Group and the International Association of Pancreatology.

RESULTS

Overall, 97 experts (67 surgeons, 30 gastroenterologists) from 19 countries replied (44% response rate). Most (93%) worked in an academic hospital, with a median of 15 years' experience with intraductal papillary mucinous neoplasm treatment. In main duct/mixed type intraductal papillary mucinous neoplasm patients with pancreatic duct dilation (>5 mm) in the entire pancreas, 41% (n = 37) advised nonoperative surveillance every 3-6 months, whereas 59% (n = 54) advised operative intervention. Of those who advised operative intervention, 46% (n = 25) would perform a total pancreatectomy and 31% (n = 17) pancreatoduodenectomy with follow-up. No structural differences in advice were seen between surgeons and gastroenterologists, between continents where the respondents lived, and based on years of experience.

CONCLUSION

This international survey identified a clinically relevant lack of consensus in the treatment strategy in main duct/mixed type intraductal papillary mucinous neoplasm among experts. Studies with long-term follow-up including quality of life after partial and total pancreatectomy for main duct/mixed type intraductal papillary mucinous neoplasm are required.

Quality of life after esophageal resection

Introduction

Esophageal resection is the primary treatment for malignant esophageal disease and the last resort for benign end-stage esophageal disease. There is a paucity of research comparing the long-term quality of life (QoL) following surgery among these two populations. The aim of this study was to examine the patient reported QoL after esophageal resection using questionnaires focusing on general well-being and esophageal-specific symptoms.

Methods

A prospectively maintained database of post-operatively administered European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) with supplemental esophageal cancer-specific questionnaires (OES-18) was queried after institutional review board approval through Creighton University School of Medicine. Inclusions were made if patients received an esophageal resection for benign or malignant esophageal disease. Emergency procedures, delayed reconstructions, and stage IV disease were excluded. Student’s t-test was used for domains of function, symptoms, QoL, and esophageal-specific complaints to compare the groups with each other and with the general population.

Results

A total of 39 out of 248 patients with malignant disease and 24 out of 46 with benign disease completed the questionnaire. A mean post-operative follow-up of 53 months with a response rate of 40% was obtained. There was no difference in physical (p=0.81), role (p =0.37), conditional (p=0.73), emotional (p=0.06), or social functions (p=0.42) between the general population and the esophageal resection groups. There was also no significant difference in generalized pain (p=0.86), nausea/vomiting (p=0.27), fatigue (p=0.86), swallowing (p=0.35), or esophageal pain (p=0.12). The malignant cohort had better outcomes than the benign cohort with respect to eating (p=0.04), indigestion (p=0.04), and QoL (p=<0.01).

Discussion

The underlying disease between these cohorts is drastically different, but postoperative functional status, generalized symptoms, swallowing ability, and esophageal pain were similar. There was no difference in functional status between the general population and the esophageal resection cohorts. Patients with malignant disease reported less problems with eating and a better QoL than their benign counterparts.

A case-matched comparison study of total pancreatectomy versus pancreaticoduodenectomy for patients with pancreatic ductal adenocarcinoma

BACKGROUND

Total pancreatectomy (TP) is considered a viable option in some selected patients with pancreatic ductaladenocarcinoma (PDAC). The aim of this study was to compare the clinical outcomes between TP and pancreaticoduodenectomy (PD) in patients with PDAC.

MATERIALS AND METHODS

A total of 375 patients were selected from our center's database in China and classified into two groups: the PD group (n = 325) and the TP group (n = 50). A matched-pair analysis of the patients was conducted with a ratio of 1:1. Univariate and multivariate survival analyses were performed for overall survival.

RESULTS

Overall morbidity was lower in the PD group than in the TP group (31.4% vs 52%, respectively, P = 0.004). However, no significant difference was observed in major morbidity between the two groups (24.9% vs 30%, P = 0.455). The rates of 5-year overall (P = 0.043) and disease-free (P = 0.037) survival were significantly higher in the PD group. Furthermore, the univariate and multivariate analyses revealed that adjuvant chemotherapy (HR = 0.684, 95%CI = 0.545-0.860, P = 0.001) and margin resection status (HR = 1.666, 95%CI = 1.196-2.321, P = 0.003) were significant prognostic factors. After the matched-pair analysis, there were no significant differences between the two groups regarding postoperative complications and overall survival. However, the matched PD group had greater estimated blood loss (P = 0.037) and blood transfusion (56% vs 36%, P = 0.045).

CONCLUSION

From our study, the postoperative outcomes and survival time of TP are similar to those of matched PD. It seems reasonable to suggest that TP can be considered as safe, feasible, and efficacious as PD for patients with PDAC.

A Contemporary Evaluation of the Cause of Death and Long-Term Quality of Life After Total Pancreatectomy

OBJECTIVE

Total pancreatectomy (TP) may be considered for diffuse disease of the pancreas. However, the quality of life (QOL) implications of TP have not been well studied in the contemporary era. We report the QOL and cause of death after TP.

METHODS

186 patients underwent TP between 2000 and 2013. The 100 who were still alive at last follow-up were sent a questionnaire including the Short Form-36 (SF-36), the Audit of Diabetes Dependent QoL (ADD QoL), and the European Organization for Research and Treatment in Cancer Pancreas 26 (EORTC-PAN-26). The cause of death was determined for the 86 patients who were dead at last follow-up.

RESULTS

While the majority of deaths of the 86 patients were cancer related (n = 65), only one patient died of diabetes complications. Among the 100 surviving patients, the median follow-up was 5.9 years. Among the 36 patients who responded to the survey, every patient required pancreatic enzymes and insulin; four patients required seven total hospitalizations for hypoglycemia. The SF-36 survey indicated a worse QOL in six domains compared with a national population matched with age and gender. However, only physical and emotional domains were decreased compared with self-matched preoperative state (p < 0.01 and p < 0.05, respectively). The ADD QoL survey showed an overall decrease in diabetes-related QoL (p < 0.01). When compared to other types of insulin-dependent diabetes, no significant difference in QoL were found in 14 of 19 domains. The EORTC-PAN-26 survey demonstrated that more than 50 % of patients had moderate to severe changes in three of seven domains.

CONCLUSIONS

Mortality from diabetic complications following TP is uncommon. The decreasing QoL after TP is comparable to self-matched preoperative assessment or insulin-dependent diabetes from other causes. Accounting for the overall health changes, TP should be considered in carefully selected patients.

Laparoscopic total pancreatectomy for multiple endocrine neoplasia type 1 syndrome-associated multifocal, non-functioning pancreatic neuroendocrine tumor: A case report

Pancreatic neuroendocrine tumors are rare, accounting for less than 3% of all pancreatic tumors. Although laparoscopic pancreas-preserving surgery for managing sporadic pancreatic neuroendocrine tumors has been described in the literature, laparoscopic total pancreatectomy has rarely been reported. We present a 30-year-old man who was incidentally diagnosed with multiple endocrine neoplasia type 1 syndrome with parathyroid hyperplasia and a non-functioning pancreatic neuroendocrine tumor. He underwent laparoscopic total pancreatectomy with splenectomy. This report highlights the technical details of laparoscopic total pancreatectomy, which appears to be a feasible and safe option in select cases.

Impact of Treatments on Diabetic Control and Gastrointestinal Symptoms After Total Pancreatectomy

OBJECTIVES

The aims of this study were to compare the safety, efficacy, and patients' quality of life with continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDIs) in type 3c diabetes mellitus (T3cDM) following total pancreatectomy (TP) and pancreatic enzyme usage.

METHODS

Thirty-nine patients with T3cDM (18 CSII patients vs 21 MDI patients) who underwent TP between 2000 and 2016 at 3 Harvard-affiliated hospitals and the University of Minnesota returned prospectively obtained questionnaires examining quality of life and both endocrine and exocrine pancreatic functions.

RESULTS

Main indications for TP were as follows: chronic pancreatitis (n = 19), intraductal papillary mucinous neoplasm (n = 12), and adenocarcinoma (n = 4). Median hemoglobin A1c using MDIs was 8.1% versus 7.3% in CSII. Severe hypoglycemic events using MDIs were increased compared with CSII (P = 0.02). There were no significant differences in quality-of-life measures with CSII versus MDIs. Pancreatic enzyme dose per meal (P < 0.05) differed between the hospitals. Gastrointestinal symptoms and unintended weight loss (P < 0.01) were more common with low doses of pancreatic enzymes.

CONCLUSIONS

After TP, CSII therapy is safe compared with MDIs in T3cDM and not associated with an increase in severe hypoglycemic events. Pancreatic enzyme replacement therapy is highly variable with low doses associated with unintentional weight loss and gastrointestinal symptoms.

Duodenum and ventral pancreas preserving subtotal pancreatectomy for low-grade malignant neoplasms of the pancreas: An alternative procedure to total pancreatectomy for low-grade pancreatic neoplasms

AIM

To describe the indications, technique and outcomes of the novel surgical procedure of duodenum and ventral pancreas preserving subtotal pancreatectomy (DVPPSP).

METHODS

Data collected retrospectively from 43 patients who underwent DVPPSP and TP between 2009 and 2015 in our single centre were analysed. For enrolment, only patients with low-grade pancreatic neoplasms, such as pancreatic neuroendocrine tumors, intraductal papillary mucinous neoplasms (IPMNs), and solid pseudo-papillary tumors, were included. Ten DVPPSP (group 1) and 13 TP (group 2) patients were selected in this study.

RESULTS

There were no significant differences in age, gender, comorbidities, preoperative symptoms, American Society of Anesthesiologists score or indications for surgery between the two groups. The most common indication was IPMN for DVPPSP and TP (60% vs 85%, P = 0.411). Compared with the TP group, the DVPPSP group had comparable postoperative morbidities (P = 0.405) and mortalities (both nil), but significantly shorter operative time (232 ± 19.6 min vs 335 ± 32.3 min, P < 0.001). DVPPSP preserved better long-term pancreatic function with less supplementary therapy (P < 0.001) and better quality of life (QoL) after surgery, including better scores in social (P = 0.042) and global health (P = 0.047) on functional scales and less appetite loss (P = 0.049) on the symptom scale.

CONCLUSION

DVPPSP is a feasible and safe procedure that could be an alternative to TP for low-grade neoplasms arising from the body and tail region but across the neck region of the pancreas; DVPPSP had better metabolic function and QoL after surgery.

Perioperative management of endocrine insufficiency after total pancreatectomy for neoplasia

PURPOSE

Indications for total pancreatectomy (TP) have increased, including for diffuse main duct intrapapillary mucinous neoplasms of the pancreas and malignancy; therefore, the need persists for surgeons to develop appropriate endocrine post-operative management strategies. The brittle diabetes after TP differs from type 1/2 diabetes in that patients have absolute deficiency of insulin and functional glucagon. This makes glucose management challenging, complicates recovery, and predisposes to hospital readmissions. This article aims to define the disease, describe the cause for its occurrence, review the anatomy of the endocrine pancreas, and explain how this condition differs from diabetes mellitus in the setting of post-operative management. The morbidity and mortality of post-TP endocrine insufficiency and practical treatment strategies are systematically reviewed from the literature. Finally, an evidence-based treatment algorithm is created for the practicing pancreatic surgeon and their care team of endocrinologists to aid in managing these complex patients.

METHODS

A PubMed, Science Citation Index/Social sciences Citation Index, and Cochrane Evidence-Based Medicine database search was undertaken along with extensive backward search of the references of published articles to identify studies evaluating endocrine morbidity and treatment after TP and to establish an evidence-based treatment strategy.

RESULTS

Indications for TP and the etiology of pancreatogenic diabetes are reviewed. After TP, ~80% patients develop hypoglycemic episodes and 40% experience severe hypoglycemia, resulting in 0-8% mortality and 25-45% morbidity. Referral to a nutritionist and endocrinologist for patient education before surgery followed by surgical reevaluation to determine if the patient has the appropriate understanding, support, and resources preoperatively has significantly reduced morbidity and mortality. The use of modern recombinant long-acting insulin analogues, continuous subcutaneous insulin infusion, and glucagon rescue therapy has greatly improved management in the modern era and constitute the current standard of care. A simple immediate post-operative algorithm was constructed.

CONCLUSION

Successful perioperative surgical management of total pancreatectomy and resulting pancreatogenic diabetes is critical to achieve acceptable post-operative outcomes, and we review the pertinent literature and provide a simple, evidence-based algorithm for immediate post-resection glycemic control.

Clinicophysiological outcomes after total pancreatectomy

PURPOSE

Total pancreatectomy (TP) for pancreatic neoplasms is associated with high morbidity and mortality rates. However, with recent advances in surgical techniques and improved postoperative management, the number of cases with clinical indications for TP is increasing. Here, we evaluated the clinical outcomes post-TP.

MATERIALS AND METHODS

Patients (n = 41) who underwent TP between 2004 and 2011 at Tokyo Women's Medical University were retrospectively examined. Pre- and postoperative clinicophysiological data were collected up to 12 months post-TP and then analyzed.

RESULTS

Only glycated hemoglobin (HbA1c), percentage of lymphocytes and hepatic Hounsfield unit level on computed tomography (CT) were significantly different between the preoperative state and at 12 months post-TP, while other clinicophysiological parameters remained unchanged. The quantity of the pancreatic enzyme administered significantly influenced glycemic control at 12 months post-TP (p < 0.05).

CONCLUSIONS

All clinicophysiological parameters except for HbA1c were temporarily decreased after TP but normalized by 12 months. Thus, TP is a feasible surgical approach to treating pancreatic neoplasms with the potential to spread across the entire pancreas when adequately supplemented by synthetic insulin and pancreatic enzymes.

Is total pancreatectomy as feasible, safe, efficacious, and cost-effective as pancreaticoduodenectomy? A single center, prospective, observational study

BACKGROUND

Total pancreatectomy is actually considered a viable option in selected patients even if large comparative studies between partial versus total pancreatectomy are not currently available. Our aim was to evaluate whether total pancreatectomy can be considered as feasible, safe, efficacious, and cost-effective as pancreaticoduodenectomy.

METHODS

A single center, prospective, observational trial, regarding postoperative outcomes, long-term results, and cost-effectiveness, in a tertiary referral center was conducted, comparing consecutive patients who underwent elective total pancreatectomy and/or pancreaticoduodenectomy.

RESULTS

Seventy-three consecutive elective total pancreatectomies and 184 pancreaticoduodenectomies were compared. There were no significant differences regarding postoperative outcomes and overall survival. The quality of life, evaluated in 119 patients according to the EQ-5D-5L questionnaire, showed that there were no significant differences regarding the five items considered. The mean EQ-5D-5L score was similar in the two procedures (total pancreatectomy = 0.872, range 0.345-1.000; pancreaticoduodenectomy = 0.832, range 0.393-1.000; P = 0.320). The impact of diabetes according to the Problem Areas in Diabetes (PAID) questionnaire did not show any significant differences except for question 13 (total pancreatectomy = 0.60; pancreaticoduodenectomy = 0.19; P = 0.022). The cost-effectiveness analysis suggested that the quality-adjusted life year was not significantly different between the two procedures (total pancreatectomy = 0.910, range 0.345-1.000; pancreaticoduodenectomy = 0.910, range -0.393-1.000; P = 0.320).

CONCLUSIONS

From this study, it seems reasonable to suggest that total pancreatectomy can be considered as safe, feasible, and efficacious as PD and acceptable in terms of cost-effectiveness.

Autologous Islet Transplantation in Patients Requiring Pancreatectomy: A Broader Spectrum of Indications Beyond Chronic Pancreatitis

Islet autotransplantation (IAT) is usually performed in patients undergoing pancreatic surgery for chronic pancreatitis. In the present series, IAT was offered also to patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, having either completion pancreatectomy as treatment for severe pancreatic fistulas (n = 21) or extensive distal pancreatectomy for neoplasms of the pancreatic neck (n = 19) or pancreatoduodenectomy because of the high risk of pancreatic fistula (n = 32). Fifty-eight of 72 patients who were eligible to this broader spectrum of indication actually received IAT. There was no evidence of a higher-than-expected rate of major complications for pancreatectomy. Forty-five patients receiving IAT were still alive at the time of the last scheduled follow-up (1375 ± 365 days). Eighteen (95%) of 19 and 11 (28%) of 39 patients reached insulin independence after partial or total pancreatectomy, respectively. The metabolic results were dependent on the transplanted islet mass. Thirty-one of 58 patients had malignant diseases of the pancreas or periampullary region, and only three patients developed ex novo liver metastases after IAT (median follow-up 914 ± 382 days). Our data demonstrate the feasibility, efficacy, and safety of IAT for a broader spectrum of clinical indications beyond chronic pancreatitis.

Is It Time to Expand the Role of Total Pancreatectomy for IPMN?

Intraductal papillary mucinous neoplasms (IPMN) are cystic precursors to pancreatic cancer believed to arise within a widespread neoplastic field defect. The tendency for some patients to present with multifocal disease and/or develop additional lesions over time argues in favor of a field defect and complicates surgical management decisions. Surgery usually consists of partial pancreatic resection, which leaves behind a pancreatic remnant at risk for recurrent disease and progression to cancer. As an alternative, total pancreatectomy (TP) provides the most complete oncologic resection, but postoperative morbidity and quality of life (QoL) issues have generally limited its use to only the highest risk patients. Significant progress has been made in the management of the post-TP apancreatic state and studies now show less morbidity with acceptable QoL comparable to type 1 diabetic and post-pancreaticoduodenectomy patients. These improvements do not yet justify the routine use of TP, but they have opened the door for expansion to additional subsets of non-invasive IPMN. Here, we have identified several groups of patients that we believe would benefit from TP over partial resection based on the most current literature.

Are There Indications for Total Pancreatectomy in 2016?

An elective total pancreatectomy (TP) was first performed by Eugene Rockey of Portland, Oregon, in 1942. In the 1960s and 1970s, TP was the routine resection for pancreatic cancer in many centers because of fear of a leaking pancreatojejunostomy and multicentricity of the disease but the result used to be dreadful (in today's perspective). However, more recently, postoperative mortality and morbidity after pancreatic resections have improved due to better anastomotic technique and pre-, peri- and postoperative care. Today, TP - despite being a more extensive operation - can be offered with about the same operation risk as that of a Whipple procedure. Also, major improvements in the control of diabetes have been seen and there is actually an ongoing discussion on the actual severity of the diabetic state after TP. Also, the development of modern pancreatic enzyme preparations with sufficient control of endocrine and exocrine pancreatic insufficiency provides options for overcoming the postoperative problems following TP. Due to the improved results, there are today different - and more specific - indications than before for TP: malignant tumors growing from the pancreatic head into the left pancreas, pancreatic head cancer where it is not possible to secure a tumor-free resection margin with extended resection or with dubious changes in the pancreatic main duct at frozen section, recurrent malignancy in the pancreatic remnant, at cancer surgery with resection of the celiac trunk, rescue pancreatectomy after a leaking pancreatojejunostomy with sepsis or bleeding after a Whipple-type first resection, multifocal intraductal papillary mucinous neoplasm with potentially malignant foci present in all parts of the gland, multiple metastases of renal cell carcinoma and melanoma without any residual tumor outside the pancreatic gland (possibly also other specified but uncommon metastatic tumors with a potential for cure by pancreatectomy), multifocal neuroendocrine tumors including multiple endocrine neoplasia and hereditary pancreatic cancer with a high grade of cancer penetration risk for the bearers.

Thirty-day outcomes underestimate endocrine and exocrine insufficiency after pancreatic resection

BACKGROUND

Long-term incidence of endocrine and exocrine insufficiency after pancreatectomy is poorly described. We analyze the long-term risks of pancreatic insufficiency after pancreatectomy.

METHODS

Subjects who underwent pancreatectomy from 2002 to 2012 were identified from a prospective database (n = 227). Subjects who underwent total pancreatectomy or pancreatitis surgery were excluded. New post-operative endocrine and exocrine insufficiency was defined as the need for new pharmacologic intervention within 1000 days from resection.

RESULTS

28 (16%) of 178 subjects without pre-existing endocrine insufficiency developed post-operative endocrine insufficiency: 7 (25%) did so within 30 days, 8 (29%) between 30 and 90 days, and 13 (46%) after 90 days. 94 (43%) of 214 subjects without pre-operative exocrine insufficiency developed exocrine insufficiency: 20 (21%) did so within 30 days, 29 (31%) between 30 and 90 days, and 45 (48%) after 90 days. Adjuvant radiation was associated with new endocrine insufficiency. On multivariate regression, pancreaticoduodenectomy and chemotherapy were associated with a greater risk of exocrine insufficiency.

CONCLUSION

Reporting 30-day functional outcomes for pancreatic resection is insufficient, as nearly 45% of subjects who develop disease do so after 90 days. Reporting of at least 90-day outcomes may more reliably assess risk for post-operative endocrine and exocrine insufficiency.