Pancreaticoduodenectomy (Whipple operation)

Machine Learning-based Prediction of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy

OBJECTIVE

The aim of this study was to develop a novel machine learning model to predict clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD).

BACKGROUND

Accurate prognostication of CR-POPF may allow for risk stratification and adaptive treatment strategies for potential PD candidates. However, antecedent models, such as the modified Fistula Risk Score (mFRS), are limited by poor discrimination and calibration.

METHODS

All records entailing PD within the 2014 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were identified. In addition, patients undergoing PD at our institution between 2013 and 2021 were queried from our local data repository. An eXtreme Gradient Boosting (XGBoost) model was developed to estimate the risk of CR-POPF using data from the ACS NSQIP and evaluated using institutional data. Model discrimination was estimated using the area under the receiver operating characteristic (AUROC) and area under the precision recall curve (AUPRC).

RESULTS

Overall, 12,281 and 445 patients undergoing PD were identified within the 2014 to 2018 ACS NSQIP and our institutional registry, respectively. Application of the XGBoost and mFRS scores to the internal validation dataset revealed that the former model had significantly greater AUROC (0.72 vs 0.68, P <0.001) and AUPRC (0.22 vs 0.18, P <0.001). Within the external validation dataset, the XGBoost model remained superior to the mFRS with an AUROC of 0.79 (95% CI: 0.74-0.84) versus 0.75 (95% CI: 0.70-0.80, P <0.001). In addition, AUPRC was higher for the XGBoost model, compared with the mFRS.

CONCLUSION

Our novel machine learning model consistently outperformed the previously validated mFRS within internal and external validation cohorts, thereby demonstrating its generalizability and utility for enhancing prediction of CR-POPF.

Assessment of the Predictive Value of Preoperative Serum Albumin and Postoperative Albumin Drop (ΔAlb) for Complications after Pancreas Surgery: A Single-Center Cross-Sectional Study

BACKGROUND

Serum albumin has been shown to be predictive of complications after various gastrointestinal operations. The present study aimed to assess whether preoperative serum albumin and serum albumin drop on postoperative day 1 are associated with postoperative complications after pancreatic surgery.

METHODS

A single-center cross-sectional study was performed. All patients who underwent pancreatectomy between January 2010 and June 2019 and had preoperative serum albumin value and serum albumin value on postoperative day 1 were included. ΔAlb was defined as the difference between preoperative serum albumin and serum albumin on postoperative day 1. Binary logistic regressions were performed to determine independent predictors of postoperative complications.

RESULTS

A total of 185 patients were included. Pancreatoduodenectomies were performed in 133 cases, left pancreatectomies in 36, and other pancreas operations in 16. The preoperative serum albumin value was found to be an independent predictor of complications (OR 0.9, 95%CI 0.9-1.0, p = 0.041), whereas ΔAlb was not significantly associated with postoperative complications (OR 1.0, 95%CI 0.9-1.1, p = 0.787). The threshold of 44.5 g/L for preoperative albumin level was found to have the highest combined sensitivity and specificity based on the maximum Youden index. Patients with preoperative albumin < 44.5 g/L had a higher incidence of postoperative complications and higher median comprehensive complication index than patients with preoperative albumin ≥ 44.5 g/L.

CONCLUSIONS

This study highlighted that preoperative serum albumin is an independent predictor of postoperative complications after pancreas surgery.

Is pancreatic head surgery safe in the elderly?

BACKGROUND

During the last century, life expectancy has doubled. As a result, senior patients with cancer are more frequently referred for possible surgery. Pancreatic surgery is a complex surgery associated with significant postoperative morbidity. Surgical decision-making in the elderly population can be difficult because outcomes in the elderly are poorly defined. Our objective is to characterize differences in mortality and morbidity for pancreatic surgery in the elderly population.

METHODS

A retrospective review of all patients undergoing pancreatic head surgery in our tertiary referral center from 2015 to 2021 was conducted. Analysis was performed for the entire cohort, classifying patients into three age groups: <70 years, 70-79 years, and ≥80 years. Data from these three groups were compared, including comorbidity, oncologic outcomes and postoperative complications.

RESULTS

A total of 326 patients underwent pancreatic head resection. The 90-day mortality increased from 2.9% to 5.3% to 15.4% with increasing age (p = 0,015). There were no differences among the three groups in terms of postoperative morbidity. There was no difference in disease-free survival (DFS), but overall survival was better in patients under 70 years (p = 0,046).

CONCLUSION

Compared to younger patients, patients over 80 years old have a higher risk of mortality despite similar postoperative morbidity.

Understanding risk factors and microbial trends implicated in the development of Whipple-related surgical-site infections

Objective

The purpose of this study is to understand the role of risk factors and postoperative complications seen in patients undergoing Whipple procedures in the development of surgical site infections. Our secondary goal was to evaluate whether microbial patterns differed between preoperative antibiotic classes, offering insight into the effectiveness of current practices while promoting antibiotic stewardship.

Design

We performed a retrospective cohort study comparing patients with and without SSIs.

Setting

This study was conducted at a tertiary-care center in the southeastern United States.

Participants

Patients who underwent a Whipple procedure between 2012 and 2021 were acquired from the National Surgical Quality Improvement Program (NSQIP) database.

Results

Patients with a bleeding disorder reported higher SSI rates (P = .04), whereas patients with a biliary stent reported lower surgical site infection (SSI) rates (P = .02) Those with postoperative complications had higher SSI rates, including delayed gastric emptying (P < .001) and pancreatic fistula (P < .001). Patients with longer operative times were 1.002 times more likely to develop SSIs (adjusted odds ratio [aOR], 1.002; 95% confidence interval [CI], 1.001-1.004; P = .006) whereas surgical indications for malignancy correlated with decreased SSIs risk (aOR, 0.578; 95% CI, 0.386-866) when adjusting for body mass index, surgical indication, and duration of surgical procedure.

Conclusions

Optimizing preoperative management of modifiable risk factors for patients undergoing pancreatoduodenectomies and decreasing operative times may reduce SSI rates and patient and hospital burden. Further research is needed to understand whether stent placement reduces SSI risk in pancreatoduodenectomy.

Intraoperative gram staining of bile for the prevention of infectious complications in pancreaticoduodenectomy

INTRODUCTION

Infectious complications play a prominent role in pancreaticoduodenectomy. Their incidence increases in cases with preoperative biliary drainage (PBD), due to the higher risk of bacterobilia. The aim of this study is to evaluate an antibiotherapy protocol based on intraoperative gram staining of bile and its impact on postoperative infectious complications.

METHODS

A retrospective study analysing the incidence of infectious complications between two groups of 25 consecutive patients undergoing pancreaticoduodenectomy. In group 1, cefazolin prophylaxis was administered to patients without PBD. In cases with PBD a five days antibiotherapy with piperacillin-tazobactam was administered. In group 2, intraoperative gram staining of bile was routinely performed. If no microorganisms were detected, antibiotherapy was limited to cefazolin prophylaxis. If bacterobilia was detected, targeted antibiotherapy was administered for five days.

RESULTS

The incidence of sepsis and organ/space infection in group 2 was 4% compared to 32% and 24% in group 1 respectively (p < 0.05). No differences were observed in the remaining morbimortality variables. The most prevalent microorganisms in bile were Enterococcus spp. and Klebsiella spp. In postoperative samples, they only appeared in 4% of cases in group 2 (p < 0.05), in favour of S. epidermidis, although they were also prevalent in group 1 (28 and 24% respectively).

CONCLUSION

Intraoperative gram staining of bile fluid could be a useful tool to conduct personalised antibiotic therapy in pancreaticoduodenectomy and contribute to the control of infectious complications.

Stereotactic Ablative Radiotherapy Using CALYPSO® Extracranial Tracking for Intrafractional Tumor Motion Management-A New Potential Local Treatment for Unresectable Locally Advanced Pancreatic Cancer? Results from a Retrospective Study

(1) Background: The aim of this study was to evaluate the efficacy and safety of SABR for LAPC using Calypso® Extracranial Tracking for intrafractional, fiducial-based motion management, to present this motion management technique, as there are yet no published data on usage of Calypso® during SABR for LAPC, and to report on our clinical outcomes. (2) Methods: Fifty-four patients were treated with SABR in one, three, or five fractions, receiving median BED10 = 112.5 Gy. Thirty-eight patients received systemic treatment. End points were OS, FFLP, PFS, and toxicity. Actuarial survival analysis and univariate analysis were investigated. (3) Results: Median follow-up was 20 months. Median OS was 24 months. One-year FFLP and one-year OS were 100% and 90.7%, respectively. Median PFS was 18 months, and one-year PFS was 72.2%. Twenty-five patients (46.3%) were alive at the time of analysis, and both median FU and OS for this subgroup were 26 months. No acute/late toxicity > G2 was reported. (4) Conclusions: SABR for LAPC using Calypso® presented as an effective and safe treatment and could be a promising local therapeutic option with very acceptable toxicity, either as a single treatment or in a multimodality regimen. Dose escalation to the tumor combined with systemic treatment could yield better clinical outcomes.

Intraoperative gram staining of bile for the prevention of infectious complications in pancreaticoduodenectomy

INTRODUCTION

Infectious complications play a prominent role in pancreaticoduodenectomy. Their incidence increases in cases with preoperative biliary drainage (PBD), due to the higher risk of bacterobilia. The aim of this study is to evaluate an antibiotherapy protocol based on intraoperative gram staining of bile and its impact on postoperative infectious complications.

METHODS

A retrospective study analysing the incidence of infectious complications between two groups of 25 consecutive patients undergoing pancreaticoduodenectomy. In group 1, cefazolin prophylaxis was administered to patients without PBD. In cases with PBD a five days antibiotherapy with piperacillin-tazobactam was administered. In group 2, intraoperative gram staining of bile was routinely performed. If no microorganisms were detected, antibiotherapy was limited to cefazolin prophylaxis. If bacterobilia was detected, targeted antibiotherapy was administered for five days.

RESULTS

The incidence of sepsis and organ/space infection in group 2 was 4% compared to 32% and 24% in group 1 respectively (p<0.05). No differences were observed in the remaining morbimortality variables. The most prevalent microorganisms in bile were Enterococcus spp and Klebsiella spp. In postoperative samples, they only appeared in 4% of cases in group 2 (p<0.05), in favour of S. epidermidis, although they were also prevalent in group 1 (28 and 24% respectively).

CONCLUSION

Intraoperative gram staining of bile fluid could be a useful tool to conduct personalised antibiotic therapy in pancreaticoduodenectomy and contribute to the control of infectious complications.

Survival impact based on hepatic artery lymph node status in pancreatic adenocarcinoma: A study of patients receiving modern chemotherapy

BACKGROUND

Chemotherapy for pancreatic adenocarcinoma (PDAC) has significantly improved in recent years. While the involvement of the hepatic artery lymph node (HALN; station 8a lymph node) likely represents advanced disease, a comparison to patients with metastases on modern chemotherapy is lacking.

METHODS

Patients who underwent pancreatoduodenectomy with HALN sent for pathologic review at a single institution from 2003 to 2018 were reviewed. Patients who presented with liver-only metastases at the time of PDAC diagnosis (Stage IV) and received chemotherapy were identified. Multivariate Cox proportional hazards regression modeling was utilized and overall survival (OS) was estimated using Kaplan-Meier analysis.

RESULTS

Of the 112 patients with a HALN sent for analysis, 17 (15%) were positive and 13 (76%) received chemotherapy. Ninety-four stage IV patients were identified and were significantly more likely to have received a multiagent rather than single-agent chemotherapy regimen compared to HALN positive patients (79.8% vs. 38.5%, p < .001). Median OS was significantly longer in all patients who underwent surgical resection, regardless of HALN status, compared to stage IV patients.

CONCLUSIONS

Patients undergoing pancreatoduodenectomy with HALN positivity have significantly improved OS compared to patients with stage IV disease. HALN involvement does not significantly alter survival among resected patients and does not warrant preoperative endoscopic ultrasound-guided biopsy.

A Scoring System for Surgical Site Infection after Pancreaticoduodenectomy Using Clinical Data

Object: To analyze the factors influencing surgical site infection (SSI) after pancreaticoduodenectomy and to establish a scoring system for predicting such infections. Methods: Patients who underwent pancreaticoduodenectomy in the Department of Hepatobiliary Surgery of the Second Affiliated Hospital of Chongqing Medical University from January 2015 to March 2019 were divided randomly into a model group and a test group in a proportion of 3:1. According to whether an SSI occurred after operation, the model group was divided into an incision-infection group and a non-infection group. Univariable analysis and multivariable regression analysis were used to analyze factors related to post-operative incision infection and to establish a clinical predictive scoring system. The scoring system was evaluated for the test group. Results: A total of 236 patients, 177 in the model group and 59 in the test group, were included. In the model group, univariable and logistic regression analysis showed that tumor nature (benign versus malignant), post-operative albumin concentration, pancreatic fistula formation, post-operative cough, and peri-operative blood transfusion were the independent risk factors for incision infection. Then we established a clinical predictive scoring system. In the test group, the area under the receiver operator characteristic curve of the system was 0.768 (p < 0.001, with sensitivity = 59.1% and specificity = 94.6%). Conclusion: The scoring system had good clinical prediction ability and high specificity, so it was worth using in the clinic.

Factors Predictive of Reoperation After Pancreaticoduodenectomy for Pancreatic Cancer

While mortality is low, morbidity remains high for patients undergoing pancreas resections, especially for those who return to the operating room (RTOR). The aim of this study is to identify risk factors for RTOR following pancreaticoduodenectomy (PD) for ductal adenocarcinoma. Logistic regression models were constructed using the 2014 and 2015 National Surgical Quality Improvement Program (NSQIP) Pancreas Targeted database. Preoperative and procedure-related risk factors predictive of RTOR for patients undergoing either classic or pylorus-preserving pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) were identified. A total of 1736 patients were included. Multivariable analysis of patients undergoing classic PD demonstrated that an abnormally low preoperative WBC count was significantly associated with RTOR (OR 2.78, 95% CI 1.27-6.06, p = 0.010). For patients who underwent pylorus-preserving PD, the wound classification (OR 3.99, 95% CI 1.75-9.11, p = 0.001) and arterial resection (OR 26.3, 95% CI 7.96-87.20, p < 0.001) were associated with a higher rate of RTOR. When analyzing both approaches (classic and pylorus-preserving PD) together, only isolated arterial (OR 9.98, 95% CI 3.81-26.18, p < 0.001) and isolated venous (OR 1.79, 95% CI 1.05-3.05, p = 0.032) resections were independently associated with RTOR. The results of our study demonstrate that few factors are predictive of RTOR. Knowledge of these few variables in combination with a focus on the components of medical care in the immediate postoperative period may help identify individuals at risk for RTOR and improve patient care.

Surgery for Pancreatic Cancer

Surgical resection remains the only potentially curative therapy for pancreatic cancer, despite a high rate of systemic recurrence. Because of local invasion or distant spread, a minority of patients presenting with pancreatic cancer are candidates for surgery. Although perioperative mortality is low in high-volume settings, pancreatic surgery remains associated with considerable morbidity. Minimally invasive and robotic surgical techniques are increasingly used for pancreatic resection, although not always applicable to all patients. Strategies to extend the benefits of margin-negative surgical resection to more patients include surgery with vascular resection and reconstruction for locally invasive tumors, and resection after neoadjuvant therapy.

Efficacy of a dual-ring wound protector for prevention of incisional surgical site infection after Whipple's procedure (pancreaticoduodenectomy) with preoperatively-placed intrabiliary stents: protocol for a randomised controlled trial

INTRODUCTION

Among surgical oncology patients, incisional surgical site infection is associated with substantially increased morbidity, mortality and healthcare costs. Moreover, while adults undergoing pancreaticoduodenectomy with preoperative placement of an intrabiliary stent have a high risk of this type of infection, and wound protectors may significantly reduce its risk, no relevant studies of wound protectors yet exist involving this patient population. This study will evaluate the efficacy of a dual-ring wound protector for prevention of incisional surgical site infection among adults undergoing pancreaticoduodenectomy with preoperatively-placed intrabiliary stents.

METHODS AND ANALYSIS

This study will be a parallel, dual-arm, randomised controlled trial that will utilise a more explanatory than pragmatic attitude. All adults (≥18 years) undergoing a pancreaticoduodenectomy at the Foothills Medical Centre in Calgary, Alberta, Canada with preoperative placement of an intrabiliary stent will be considered eligible. Exclusion criteria will include patient age <18 years and those receiving long-term glucocorticoids. The trial will employ block randomisation to allocate patients to a commercial dual-ring wound protector (the Alexis Wound Protector) or no wound protector and the current standard of care. The main outcome measure will be the rate of surgical site infection as defined by the Centers for Disease Control and Prevention criteria within 30 days of the index operation date as determined by a research assistant blinded to treatment allocation. Outcomes will be analysed by a statistician blinded to allocation status by calculating risk ratios and 95% CIs and compared using Fisher's exact test.

ETHICS AND DISSEMINATION

This will be the first randomised trial to evaluate the efficacy of a dual-ring wound protector for prevention of incisional surgical site infection among patients undergoing pancreaticoduodenectomy. Results of this study are expected to be available in 2016/2017 and will be disseminated using an integrated and end-of-grant knowledge translation strategy.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT01836237.

Defining treatment and outcomes of hepaticojejunostomy failure following pancreaticoduodenectomy

BACKGROUND

The overall complication rate after pancreaticoduodenectomy (PD) approaches 50 %, with anastomotic failure being the most frequent cause of serious postoperative morbidity. Hepaticojejunostomy leaks (also called bile leaks) are the second most common type of leak, behind pancreaticojejunostomy leaks, yet have been the focus of only a single study as reported by Suzuki et al. (Hepatogastroenterology 50:254-257, 12).

METHODS

We reviewed the recent experience with bile leaks at a single, high-volume pancreatic surgery center over a six-year time period.

RESULTS

Bile leaks were identified in 16 out of 715 patients (2.2 %). Low preoperative albumin was associated with an increased risk. Bile leaks typically manifested within the first week after surgery as bilious drainage in a surgically placed drain. Associated warning signs included fever and leukocytosis. Patients with a bile leak frequently developed other complications, including a pancreatic fistula, wound infection, delayed gastric emptying, and sepsis. The impact on perioperative outcomes was comparable to patients with a pancreatic leak. A grading system is proposed based on the International Study Group on Pancreatic Fistula model. Grade A bile leaks were classified as those managed with prolonged drainage by operatively placed drains, grade B bile leaks with percutaneous abdominal drainage, and grade C bile leaks with insertion of a percutaneous transhepatic biliary drainage.

CONCLUSIONS

Hepaticojejunostomy leaks are rare after PD. The complication severity ranges from trivial to life threatening and is comparable overall to pancreaticojejunostomy leaks. Surgical intervention is rarely, if ever, required. With prompt and aggressive management, a full recovery can be expected.

Classic Whipple versus pylorus-preserving pancreaticoduodenectomy in the ACS NSQIP

BACKGROUND

The classic Whipple operation carries substantial risk of complications. A pylorus-preserving pancreaticoduodenectomy might confer the benefit of decreased perioperative morbidity, but existing data comparing both techniques are inconclusive.

METHODS

Using a propensity score model to adjust for potentially confounding differences in patient characteristics, 30-d mortality, operative time, red blood cell transfusion requirements, major complications, and length of hospital stay were compared between both techniques in the American College of Surgeons' National Surgical Quality Improvement Program database. Separate analyses were carried out for underlying malignancy or benign disease, as defined by International Classification of Diseases, Ninth Revision codes.

RESULTS

A total of 6988 pancreaticoduodenectomies from 2005 through 2010 were included. In 5424 patients (77.6%) with underlying malignancy, there were no significant differences for 30-d mortality (2.4% versus 2.8%, P = 0.33) and major organ system complications (all P > 0.10). Patients undergoing the classic Whipple operation had a significantly longer operative time (389 versus 366 min, P < 0.01), longer length of hospital stay (13.1 versus 12.0 days, P < 0.01), and higher red blood cell transfusion requirements (1.0 versus 0.8 units, P < 0.01). Results were similar for 1564 patients (22.4%) with underlying benign disease, except for a higher occurrence of postoperative pulmonary (P = 0.02) and renal (P = 0.05) complications in patients undergoing the classic Whipple operation.

CONCLUSIONS

Short-term outcomes after classic and pylorus-preserving pancreaticoduodenectomy in this large, multicenter database are excellent, without significant differences in postoperative mortality and most major organ system complications. However, small advantages in resource and blood utilization may be accomplished with the pylorus-preserving technique.

Feasibility and reliability of pancreatic cancer staging using fiberoptic confocal fluorescence microscopy in rats

BACKGROUND & AIMS

Surgical management of pancreatic cancer depends on tumor resectability and staging. This study evaluated a new in vivo technique, fiberoptic confocal fluorescence microscopy (FCFM), for detection and staging of pancreatic tumors in rats.

METHODS

FCFM was used with a protease-activated fluorescent marker (ProSense; VisEn Medical Inc, Woburn, MA) for in vivo imaging of solid organs (1.8-microm resolution) in a rat model of pancreatic ductal adenocarcinoma. A preliminary study described the FCFM rendering of normal and pathologic tissues. Subsequently, 2 double-blind studies compared FCFM to standard histology in (1) detection of tumors in rat models of cancer and controls and (2) detection of nodal involvement (splenic, celiac, mesenteric, and colic) 4, 5, and 6 weeks after tumor induction vs controls.

RESULTS

Tumor cells displayed a fluorescent ductal pattern compared with non-fluorescent normal pancreas or normal follicular pattern of lymph nodes (LNs). FCFM detected all the pancreatic tumors (1.7-mm mean diameter) and identified 23 LNs that contained metastases of 99 LNs examined. Standard histologic analyses resulted in 1 false-negative result in tumor detection and 2 false negatives in LN detection, whereas FCFM produced no false-negative results. Additional serial sectioning confirmed all tumors and 16 metastatic LNs; FCFM had a negative predictive value of 100% and a positive predictive value of 69.6%.

CONCLUSIONS

Real-time "virtual biopsy" using FCFM detects tumors and LN metastases with 100% sensitivity and 92.2% specificity in rats, making it a reliable technique for detection and staging of pancreatic cancer.

Duodenojejunostomy leaks after pancreaticoduodenectomy

BACKGROUND

A duodenojejunostomy (DJ) or gastrojejunostomy (GJ) leak is a potentially fatal complication after pancreaticoduodenectomy (PD). However, due to its rarity, this complication has not been fully characterized.

METHODS

We reviewed 3,029 PDs performed at our institution over a 26-year period and identified patients who suffered a leak at the DJ or GJ anastomosis. Perioperative data from patients with such a leak were examined in detail and were compared to patients who did not experience such a leak after PD.

RESULTS

A total of 13 patients experienced a DJ or GJ leak after PD, amounting to a 0.4% leak rate. Common clinical signs of a leak included an acute abdomen, enterocutaneous fistula, and a fever. Twelve of thirteen patients also had a leukocytosis, with five patients having a peak white blood cell count exceeding 30,000 cells/mm(3). The median time interval between surgery and diagnosis of the DJ or GJ leak was 10 days; three patients were diagnosed after being discharged from the hospital and one patient was diagnosed on the day of their planned discharge. In a multivariate model, perioperative risk factors for a DJ or GJ leak included a preoperative BUN-to-creatinine ratio > 20 (odds ratio = 6, p = 0.01), intraoperative blood loss > or =1 l (odds ratio = 6, p = 0.03), and a total pancreatectomy (odds ratio = 7, p = 0.005). In the DJ or GJ leak group, 12 of 13 patients were managed operatively. The median postoperative length of stay was 35 days after PD, and four patients died within 4 months of surgery as a result of their complicated postoperative course.

CONCLUSION

DJ or GJ leaks occur infrequently after PD, but are associated with substantial morbidity. The clinical presentation is usually delayed, and surgical management is the preferred approach. Early diagnosis, attention to preoperative volume status, and continued efforts to control blood loss may minimize the impact of DJ or GJ leaks in some instances.

Significance of Common Hepatic Artery Lymph Node Metastases During Pancreaticoduodenectomy for Pancreatic Head Adenocarcinoma

BACKGROUND

Common hepatic artery lymph nodes (CHALN) are frequently sampled during pancreaticoduodenectomy for adenocarcinomas of the head of the pancreas. In some institutions, if metastatic disease is detected intraoperatively in these lymph nodes, the tumor is considered unresectable and a curative operation is not performed. No solid data exist to support this practice.

METHODS

A retrospective review of a prospectively collected database was conducted of the records of all patients who underwent a pancreaticoduodenectomy for pancreatic adenocarcinoma between September 1991 and April 2005. Clinical and pathologic factors were analyzed to determine their influence on survival.

RESULTS

Fifty-five of 175 patients had CHALN separately identified and evaluated; these patients constituted the study population. Thirty-eight patients (69%) had one or more lymph nodes with metastatic involvement; 10 of these had disease in CHALN. The median overall survival for patients with node-negative, node-positive (but CHALN-negative), and CHALN-positive disease were 22.9, 16.1, and 14.7 months, respectively. The 5-year overall survival rates for the respective groups were 22%, 17%, and 0%.

CONCLUSIONS

CHALN metastases correlate with poor prognosis and no long-term survival. Further studies examining CHALN status are indicated and could lead to modifications of pancreatic cancer staging and management.

Duodenopancreatectomias: análise de 39 pacientes

OBJETIVO: Pretendemos neste estudo analisar 39 pacientes submetidos à duodenopancreatectomia. MÉTODO: No período de julho de 1998 a março de 2004, trinta e nove pacientes foram submetidos a duodenopancreatectomia no Hospital Universitário da Universidade Federal do Maranhão. Foram analisados os dados epidemiológicos, o quadro clínico, os métodos radiológicos, as indicações da operação e as complicações encontradas . RESULTADOS: Havia 22 pacientes do sexo masculino (56,4%) e 17 pacientes do sexo feminino (43,6%) com média de idade de 54,9 anos (variação de 21-82 anos). O exame radiológico mais utilizado foi a tomografia computadorizada. O diagnóstico histológico definitivo revelou adenocarcinoma periampolar em 35 pacientes (89,7%), pancreatite crônica (três pacientes - 7,7%) e adenocarcinoma colo-retal (um paciente - 2,6%). O adenocarcinoma periampolar mais freqüente foi o carcinoma ductal do pâncreas (27 pacientes - 69,2%), seguido por carcinoma de papila de Vater ( cinco pacientes - 12,8%), adenocarcinoma duodenal (dois pacientes - 5,1%) e carcinoma de via biliar distal (um paciente - 2,6%). As complicações pulmonares foram as mais freqüentes sendo encontradas em cinco pacientes (12,8%), a sepse peritoneal em quatro pacientes (10,2%), fístula pancreática em três pacientes (7,6%) e a hemorragia0 intra-abdominal em três pacientes (7,6%). A mortalidade intra-hospitalar em 30 dias foi 10,2 % (quatro pacientes). CONCLUSÃO: A duodenopancreatectomia ainda está associada a morbidade considerável. Entretanto com uma seleção adequada destes pacientes este procedimento pode ser realizado de forma segura com melhores resultados.