1
|
Steffani M, Jäger C, Hüser N, Friess H, Hartmann D, Demir IE, Scheufele F. Postoperative prophylactic antibiotic therapy after pancreaticoduodenectomy in bile duct-stented patients reduces postoperative major complications. Surgery 2024:S0039-6060(24)00190-9. [PMID: 38769037 DOI: 10.1016/j.surg.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/30/2024] [Accepted: 03/17/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Pancreaticoduodenectomy can entail a high complication rate, especially in patients who underwent preoperative bile duct drainage through bile duct stenting. Pancreaticoduodenectomy bile duct stenting patients frequently receive prophylactic antibiotic therapy in the postoperative period. However, the exact value and the benefit of prophylactic antibiotic therapy in pancreaticoduodenectomy bile duct stenting patients remains under-investigated and thus unclear. METHOD We conducted a retrospective single-center study of pancreaticoduodenectomy bile duct stenting patients between January 2007 and December 2022. Demographic, clinical, laboratory, and pathology data of 370 patients were collected, and intraoperative swab cultures of the bile were obtained from all patients upon transection of the common bile duct. The groups to be investigated were formed on the basis of postoperative antibiotic prophylaxis. Postoperative complications and antibiotic resistance analysis were recorded. RESULTS Postoperative antibiotic prophylaxis in stented patients after pancreaticoduodenectomy significantly reduced major complications (odds ratio: 0.547 [95% confidence interval 0.327-0.915]; P = .02) such as reoperation (P = .041) and readmission to the intensive care unit (P = .037). Patients with Enterococcus faecalis (odds ratio: 1.699 [95% confidence interval 0.978-2.950];P = .048), Enterococcus faecium (odds ratio: 1.808 [95% confidence interval 1.001-3.264]; P = .050), or Citrobacter (odds ratio: 2.211 [95% confidence interval 1.087-4.497]; P = .029) in their bile had a higher probability of developing wound infections. Appropriate antibiotic prophylaxis, according to the bile duct microbiome, significantly reduced the risk of wound infection (odds ratio: 2.239 [95% confidence interval 1.167-4.298]; P = .015). CONCLUSION Postoperative antibiotic prophylaxis in pancreaticoduodenectomy bile duct stenting patients significantly reduced major complications such as intensive care stay and reoperation. Targeted antibiotic treatment according to the biliary microbiome reduced the incidence of wound infections.
Collapse
Affiliation(s)
- Marcella Steffani
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Carsten Jäger
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Norbert Hüser
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Daniel Hartmann
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Florian Scheufele
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany.
| |
Collapse
|
2
|
Nakayama T, Ito K, Nakamura M, Inagaki F, Katagiri D, Yamamoto N, Mihara F, Takemura N, Kokudo N. Pancreaticoduodenectomy after bilirubin adsorption for distal cholangiocarcinoma with severe obstructive jaundice refractory to repeat preoperative endoscopic biliary drainage: a case report. Clin J Gastroenterol 2024:10.1007/s12328-024-01966-3. [PMID: 38589719 DOI: 10.1007/s12328-024-01966-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
The necessity of biliary drainage before pancreaticoduodenectomy remains controversial in cases involving malignant obstructive jaundice; however, the benefits of biliary drainage have been reported in cases with severe hyperbilirubinemia. Herein, we present the case of a 61-year-old man suffering from jaundice due to distal cholangiocarcinoma. In this case, obstructive jaundice was refractory to repeat endoscopic drainage and bilirubin adsorption. Hyperbilirubinemia persisted despite successful implementation of biliary endoscopic sphincterotomy and two rounds of plastic stent placements. Stent occlusion and migration were unlikely and oral cholagogues proved ineffective. Owing to the patient's surgical candidacy and his aversion to nasobiliary drainage due to discomfort, bilirubin adsorption was introduced as an alternative therapeutic intervention. Following repeated adsorption sessions, a gradual decline in serum total bilirubin levels was observed and pancreaticoduodenectomy was scheduled. The patient successfully underwent pancreaticoduodenectomy with portal vein resection and reconstruction and D2 lymph node dissection. After the surgery, the serum bilirubin levels gradually decreased and the patient remained alive, with no recurrence at 26 months postoperatively. Therefore, this case highlights the feasibility and safety of performing pancreaticoduodenectomy in patients with severe, refractory jaundice who have not responded to repeated endoscopic interventions and have partially responded to bilirubin adsorption.
Collapse
Affiliation(s)
- Toshihiro Nakayama
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Mai Nakamura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Fuyuki Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Daisuke Katagiri
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan.
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| |
Collapse
|
3
|
Mukai S, Itoi T. Preoperative endoscopic ultrasound-guided biliary drainage for primary drainage in obstructive jaundice. Expert Rev Gastroenterol Hepatol 2023; 17:1197-1204. [PMID: 38124621 DOI: 10.1080/17474124.2023.2293813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Endoscopic transpapillary approach by endoscopic retrograde cholangiopancreatography (ERCP) is the established technique for preoperative biliary drainage (PBD). Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been reported to be a useful alternative technique after ERCP fail. However, the optimal strategy remain controversial. AREA COVERED This review summarizes the literature on EUS-BD techniques for PBD with a literature search using PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials database between 2000 and 2023 using keywords for 'preoperative biliary drainage' and all types of EUS-BD techniques. EXPERT OPINION As there is no consensus on the optimal EUS-BD technique for PBD, selection of the EUS-BD approach depends on the patient's condition, the biliary obstruction site, the anastomosis after surgical intervention, and the preference of the endoscopist. However, we consider that EUS-HGS using a dedicated plastic stent may have some advantages in the adverse impact of surgical procedure because the location where the fistula is created by EUS-HGS is away from the site of the surgical procedure. Although there remain many issues that require further investigation, EUS-BD can be a feasible and safe alternative method of PBD for malignant biliary obstruction after ERCP fail.
Collapse
Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| |
Collapse
|
4
|
Mahaddevappa B, Muddasetty R, V S VS. Postoperative Infections in Hepatopancreatobiliary Malignancy: A Tertiary Care Center Experience. Cureus 2023; 15:e43449. [PMID: 37711913 PMCID: PMC10498339 DOI: 10.7759/cureus.43449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2023] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION Wound infection following surgery is not an uncommon entity in any malignancy. Various factors play a role in the development of infection like diabetes, the duration of surgery, intraoperative blood loss, and prior stenting. Obstructive jaundice is a common presentation in hepatopancreatobiliary malignancy, and most of the patients are being stented to relieve jaundice. The role of preoperative stenting and biopsy in these malignancies is a debatable topic. These procedures have a negative impact on the postoperative outcome. MATERIALS AND METHODS We have retrospectively analyzed the patients who have undergone surgery involving biliary enteric anastomosis from January 2013 to June 2023, and the following results have been formulated after using appropriate statistical tests for the level of significance. RESULTS One hundred and fifty patients had surgeries performed involving biliary enteric anastomosis, with M:F=14:11 and a mean age of 57.8 years (standard deviation (SD): 9.6). On performing binary regression analysis using various parameters. Preoperative stenting increases the risk of the growth of bacteria in bile by 12 times (OR: 12, 95% CI: 5.25-27.42, p<0.001) and the presence of bacteria in bile increased the risk of wound infection by 16.5 times (OR: 45, 95% CI: 7-38.89, p<0.001). The duration of hospital stay was significantly longer in patients who developed wound infections, thus increasing the cost of treatment and delaying the initiation of adjuvant treatment. CONCLUSION Various factors play a role in the development of wound infections following any surgery. From the analysis performed, we found that the duration of surgery and preoperative procedures in the form of stenting increased the risk of growing bacteria in the bile, which later increased the risk of developing a wound infection. Wound infections prolong the hospital stay and delay the initiation of adjuvant treatment. Thus, preoperative stenting should be performed after discussion in a multidisciplinary tumor board meeting.
Collapse
Affiliation(s)
- Basant Mahaddevappa
- Hepatopancreatobiliary Surgery and Liver Transplantation, Health Care Global (HCG) Hospital, Bangalore, IND
| | - Rohith Muddasetty
- Hepatopancreatobiliary Surgery and Liver Transplantation, Health Care Global (HCG) Hospital, Bangalore, IND
| | - Vinu Sankar V S
- Hepatopancreatobiliary Surgery and Liver Transplantation, Health Care Global (HCG) Hospital, Bangalore, IND
| |
Collapse
|
5
|
Bangolo AI, Trivedi C, Jani I, Pender S, Khalid H, Alqinai B, Intisar A, Randhawa K, Moore J, De Deugd N, Faisal S, Suresh SB, Gopani P, Nagesh VK, Proverbs-Singh T, Weissman S. Impact of gut microbiome in the development and treatment of pancreatic cancer: Newer insights. World J Gastroenterol 2023; 29:3984-3998. [PMID: 37476590 PMCID: PMC10354587 DOI: 10.3748/wjg.v29.i25.3984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023] Open
Abstract
The gut microbiome plays an important role in the variation of pharmacologic response. This aspect is especially important in the era of precision medicine, where understanding how and to what extent the gut microbiome interacts with drugs and their actions will be key to individualizing therapy. The impact of the composition of the gut microbiome on the efficacy of newer cancer therapies such as immune checkpoint inhibitors and chimeric antigen receptor T-cell treatment has become an active area of research. Pancreatic adenocarcinoma (PAC) has a poor prognosis even in those with potentially resectable disease, and treatment options are very limited. Newer studies have concluded that there is a synergistic effect for immunotherapy in combination with cytotoxic drugs, in the treatment of PAC. A variety of commensal microbiota can affect the efficacy of conventional chemotherapy and immunotherapy by modulating the tumor microenvironment in the treatment of PAC. This review will provide newer insights on the impact that alterations made in the gut microbial system have in the development and treatment of PAC.
Collapse
Affiliation(s)
- Ayrton I Bangolo
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Chinmay Trivedi
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Ishan Jani
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Silvanna Pender
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Hirra Khalid
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Budoor Alqinai
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Alina Intisar
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Karamvir Randhawa
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Joseph Moore
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Nicoleta De Deugd
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Shaji Faisal
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Suchith Boodgere Suresh
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Parva Gopani
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Vignesh K Nagesh
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Tracy Proverbs-Singh
- Department of Gastrointestinal Malignancies, John Theurer Cancer Center, Hackensack, NJ 07601, United States
| | - Simcha Weissman
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| |
Collapse
|
6
|
Svatoň R, Procházka V, Hanslianová M, Kala Z. Influence of bacteriobilia on postoperative complications in patients with periampullary tumors. Asian J Surg 2023; 46:1193-1198. [PMID: 36057492 DOI: 10.1016/j.asjsur.2022.08.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/21/2021] [Accepted: 08/17/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Periampullary tumours (PAT) may cause obstruction of distal choledochus. The bile stasis is a risk factor for microbial colonisation of bile (bacteriobilia), cholangitis, hepatic insufficiency and coagulopathy. PAT obstruction can be managed surgically or non-operatively - by inserting a biliary drain or stent (BDS). Although BDS allows for adequate bile drainage, liver function restitution and coagulopathy, increased bacteriobilia has been reported and this is associated with an increased incidence of postoperative complications. METHODS A monocentric, prospective, comparative study including 100 patients operated with PAT. The effects of bacteriobilia and the presence of a drain in the biliary tract on the development of postoperative complications were evaluated. RESULTS Positive microbial findings in bile were found in 67% of patients. It was 98% in the biliary drain group vs. 36% in non-drained patients (p = 0.0001). In 68% 2 or more different bacterial strains were simultaneously present (p = 0.0001). Patients with a positive microbial finding in bile had more frequent incidence of infectious complications 40.2% (27) vs. 9.1% (3); p = 0.0011. The most frequent infectious complication was wound infection 29.8% (20) vs. 3.03% (1); p = 0.0014. Similarly, a higher incidence of postoperative infectious complications occurred in patients with BDS - 36% (18) vs. 24% (12); p = 0.2752. CONCLUSION The presence of a drain or stent in the biliary tract significantly increases the microbial colonisation of bile. It is associated with a significant increase in infectious complications, especially infections in the wound.
Collapse
Affiliation(s)
- Roman Svatoň
- Department of Surgery, University Hospital Brno Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Vladimír Procházka
- Department of Surgery, University Hospital Brno Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Markéta Hanslianová
- Department of Microbiology, University Hospital Brno Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Zdeněk Kala
- Department of Surgery, University Hospital Brno Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| |
Collapse
|
7
|
Mukai S, Itoi T, Tsuchiya T, Ishii K, Tonozuka R, Nagakawa Y, Kozono S, Takishita C, Osakabe H, Sofuni A. Clinical feasibility of endoscopic ultrasound-guided biliary drainage for preoperative management of malignant biliary obstruction (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022. [PMID: 36458423 DOI: 10.1002/jhbp.1292] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/18/2022] [Accepted: 11/26/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND/PURPOSE EUS-guided biliary drainage (EUS-BD) has recently been reported to be a useful salvage technique after ERCP fail. However, data on EUS-BD used for preoperative biliary drainage (PBD) are limited. The aim of this study was to verify the clinical feasibility of EUS-BD for PBD. METHODS PBD was performed for malignant biliary obstruction in 318 patients at our institution between July 2014 and April 2022. Fifteen (4.7%) of these patients underwent surgical resection after preoperative EUS-BD (HGS 13; HDS 1; AGS with HGS 1) and were retrospectively analyzed. RESULTS The stent was successfully placed in all 15 cases with a median procedure time of 15 min (technical success rate 100%). The median total bilirubin value decreased significantly from 3.7 before drainage to 0.9 after surgery (p < .001) and cholangitis was well managed (clinical success rate 100%). Surgery was performed at a median of 22 days after drainage, and there were no stent-related adverse events or recurrences of biliary obstruction. Severe surgery-related adverse events occurred in three cases, but none were associated with EUS-BD. The stent was removed during surgery in 12 cases. CONCLUSIONS EUS-BD can be a feasible and safe alternative method of PBD for malignant biliary obstruction after ERCP fail.
Collapse
Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kentaro Ishii
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Shingo Kozono
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Chie Takishita
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroaki Osakabe
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| |
Collapse
|
8
|
The effect of biliary stents implanted before pancreaticoduodenectomy in periampullary tumors on postoperative results: a retrospective analysis of 106 consecutive cases at a single medical center. Surg Today 2022; 53:499-506. [PMID: 36115929 DOI: 10.1007/s00595-022-02589-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/27/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The present study evaluated the potential effects of biliary drainage before pancreaticoduodenectomy on postoperative outcomes and presented the details of a surgeon's 6 years of experience. METHODS All consecutive pancreatoduodenectomies performed from 2015 to 2021 were retrospectively analyzed. The study population was divided into two groups: the stented group (Group I) and the nonstented group (Group II). Patient demographic data and clinical characteristics were compared between the two groups. RESULTS This study comprised 106 individuals who underwent pancreaticoduodenectomy for periampullary tumors. The median age of the patients was 64.41 ± 11.67 years, and 65 (61.3%) were males. Sixty-seven patients (63.2%) received biliary drains (stented group), and 39 (36.8%) patients did not (nonstented group). Total bilirubin values (6.39 mg/dl) were higher in the nonstented patient group than in the stented group. The rate of total complications was significantly higher in the stented group than in the nonstented group [please check this carefully] (p < 0.05). The length of stay, operation time and pancreatic fistula were found to be higher in the stented group than in the nonstented group. CONCLUSIONS Although the total bilirubin value was higher in the nonstented patient group than in the stented group, preoperative biliary drainage increased postoperative complication rates, operation time, and hospital stay. An advanced age and the presence of stents were independent risk factors influencing morbidity development according to the multivariate analysis.
Collapse
|
9
|
Olecki EJ, Swinarska J, Perez Holguin RA, Stahl KA, Wong WG, Peng JS, Dixon MEB. Is preoperative biliary stenting associated with increased rate of postoperative complications for patients undergoing pancreatoduodenectomy? A review of national surgical quality improvement program data. HPB (Oxford) 2022; 24:1501-1510. [PMID: 35135722 DOI: 10.1016/j.hpb.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 12/02/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Jaundice in the setting of periampullary neoplasms is often treated with biliary stenting. Level 1 data demonstrated an increase in perioperative complications after pancreaticoduodenectomy in patients undergoing stent placement. However, the impact of this data on practice patterns in the US remains unknown. METHODS The National Surgical Quality Improvement Program (NSQIP) Pancreatectomy Targeted Participant Use Data File was used to identify patients from 2014 to 2017 undergoing pancreatoduodenectomy. Chi-square test and multivariable logistic regression were used to compare outcomes between those with biliary stent and those without. RESULTS Of the 5524 patients, 3321 (60.1%) had biliary stent placement. The stent group was older, had a higher ASA class, and had preoperative weight loss compared to the group without biliary stenting (all p < 0.05). When adjusting for demographic and operative characteristics, the non-stent group had lower associated overall complications and postoperative infections. There was no significant difference in mortality and pancreatic fistula rate between groups. CONCLUSION Preoperative biliary stenting is still common prior to pancreaticoduodenectomy. With a trend toward increased utilization of neoadjuvant chemotherapy, stenting will likely remain a common practice. Recognition of increased rates of complications associated with stent placement allows for appropriate risk-benefit analysis.
Collapse
Affiliation(s)
- Elizabeth J Olecki
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Joanna Swinarska
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Rolfy A Perez Holguin
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Kelly A Stahl
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - William G Wong
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - June S Peng
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA; Division of Surgical Oncology, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Matthew E B Dixon
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA; Division of Surgical Oncology, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA.
| |
Collapse
|
10
|
Werba G, Napolitano MA, Sparks AD, Lin PP, Johnson LB, Vaziri K. Impact of preoperative biliary drainage on 30 Day outcomes of patients undergoing pancreaticoduodenectomy for malignancy. HPB (Oxford) 2022; 24:478-488. [PMID: 34538739 DOI: 10.1016/j.hpb.2021.08.942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 07/25/2021] [Accepted: 08/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative biliary drainage (PBD) has been advocated to address the plethora of physiologic derangements associated with cholestasis. However, available literature reports mixed outcomes and is based on largely outdated and/or single-institution studies. METHODS Patients undergoing PBD prior to pancreaticoduodenectomy (PD) for periampullary malignancy between 2014-2018 were identified in the ACS-NSQIP pancreatectomy dataset. Patients with PBD were propensity-score-matched to those without PBD and 30-day outcomes compared. RESULTS 8,970 patients met our inclusion criteria. 4,473 with obstruction and PBD were matched to 829 with no preoperative drainage procedure. In the non-jaundiced cohort, 711 stented patients were matched to 2,957 without prior intervention. PBD did not influence 30-day mortality (2.2% versus 2.4%) or major morbidity (19.8% versus 20%) in patients with obstructive jaundice. Superficial surgical site infections (SSIs) were more common with PBD (6.8% versus 9.2%), however, no differences in deep or organ-space SSIs were found. Patients without obstruction prior to PBD exhibited a 3-fold increase in wound dehiscence (0.5% versus 1.5%) additionally to increased superficial SSIs. CONCLUSION PBD was not associated with an increase in 30-day mortality or major morbidity but increased superficial SSIs. PBD should be limited to symptomatic, profoundly jaundiced patients or those with a delay prior to PD.
Collapse
Affiliation(s)
- Gregor Werba
- Department of Surgery, George Washington University, Washington, DC, USA.
| | | | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Paul P Lin
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Lynt B Johnson
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University, Washington, DC, USA
| |
Collapse
|
11
|
Trepák K, Vajda K, Albert E, Horti I, Sikorszki L. [The effect of preoperative biliary stent on postoperative complications after the resection of pancreatic head tumour]. Magy Seb 2022; 75:1-7. [PMID: 35333755 DOI: 10.1556/1046.2021.10001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 12/21/2021] [Indexed: 06/14/2023]
Abstract
Introduction. A preoperative biliary stent is often inserted because of obstructive jaundice due to pancreatic head tumour. However, it can also be the source of complications too. Aim and method. We retrospectively analyzed our operations which were performed between 01.10.2017 and 31.12.2019 for pancreatic tumour in association with stent related mortality and morbidity. The multiresistant bacteria and the spectrum of microorganism of intraoperative bile samples were investigated. Results. 82 patients were operated on with pancreatic tumour. There were 63 pancreatic head resections, and 19 palliative operations. 63 pancreatic head resections were analyzed. There were 36 open and 27 laparoscopic operations. Extended operation was needed in 12 cases (5 portal vein resections, 2 splenectomies, 1 right hepatolobectomy, 1 right hemicolectomy, 2 liver metastasectomies and 1 hepatic artery resection). The average age of 36 stented patients of which 24 were men and 12 women were 65 and 64 years respectively. The average age of 27 non-stented patients of which 14 were men and 13 were women, were 67.9 and 58 years respectively. The bile culture proved to be positive 30/36(83%) in the stented group and 13/27(48%) in the non-stented group (P = 0.005). The 3 most common bacteria were E coli, Enterococcus fecalis and Klebsiella pneumoniae in both groups followed by the yeast of Candida. 8 multiresistant bacteria were noticed in the stented group. 6 were ESBL producing (P = 0.033) and 2 vancomycine resistant (P = 0.5) bacteria. 3 patients of the stented group and 2 patients of the non-stented group were lost during the first 30 days. There were 4/0 wound infections, 6/2 haemorrhages, 2/2 pancreatic fistulas, and 2/3 abdominal abscesses in the stented vs. non stented groups. The average length of stay was 19.47 days in the stented and 14.62 days in the non-stented groups (P = 0.14). Conclusion. With regard to the fact that biliary stent changes the bacterial flora it is important to choose the proper antibiotic prophylaxis to reduce morbidity. On the basis of our own results and the literature an effective antibiotic therapy is suggested against enterococcus and ESBL producing bacteria. The prophylaxis against yeast in particularly in immunocompromised cases should also be considered. Regular antibiotic resistance check-up is essential.
Collapse
Affiliation(s)
- Kornélia Trepák
- Bács-Kiskun Megyei Oktatókórház, Általános Sebészeti Osztály, Kecskemét, Magyarország(osztályvezető: prof. dr. Sikorszki László)
| | - Kornél Vajda
- Bács-Kiskun Megyei Oktatókórház, Általános Sebészeti Osztály, Kecskemét, Magyarország(osztályvezető: prof. dr. Sikorszki László)
| | - Emőke Albert
- Bács-Kiskun Megyei Oktatókórház, Általános Sebészeti Osztály, Kecskemét, Magyarország(osztályvezető: prof. dr. Sikorszki László)
| | - Ildikó Horti
- Bács-Kiskun Megyei Oktatókórház, Általános Sebészeti Osztály, Kecskemét, Magyarország(osztályvezető: prof. dr. Sikorszki László)
| | - László Sikorszki
- Bács-Kiskun Megyei Oktatókórház, Általános Sebészeti Osztály, Kecskemét, Magyarország(osztályvezető: prof. dr. Sikorszki László)
| |
Collapse
|
12
|
Nehme F, Lee JH. Preoperative biliary drainage for pancreatic cancer. Dig Endosc 2022; 34:428-438. [PMID: 34275165 DOI: 10.1111/den.14081] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/15/2021] [Indexed: 12/15/2022]
Abstract
Pancreatic adenocarcinoma is currently one of the leading causes of cancer-related morbidity and mortality with dismal long term survival after diagnosis. Nearly 85% of pancreatic cancer patients present with advanced disease precluding curative surgical resection. In those who are candidates for surgery, preoperative biliary drainage (PBD) has been developed since the 1960s in order to improve surgical outcomes. While obstructive jaundice in resectable pancreatic cancer has been traditionally treated before surgical resection in all patients, data over the past decade demonstrated increased perioperative complications and morbidity with systematic PBD compared to direct surgery. With new evidence of potential adverse events, the role of routine PBD is being reassessed. Current indications for PBD include cholangitis, delayed surgery, and relief of jaundice in patients planned to receive neoadjuvant therapy (NAT). NAT is being increasingly utilized in borderline resectable as well as resectable pancreatic cancer and a higher proportion of patients with likely require PBD in the future. The evidence for endoscopic retrograde cholangiopancreatography as first line for PBD is robust with supporting data from endoscopic ultrasound assisted biliary drainage. Self-expanding metal stent was shown to be cost-effective in recent studies without increase in morbidity compared to plastic stents in this setting. In this review, we will summarize the current evidence for PBD in patients with pancreatic cancer.
Collapse
Affiliation(s)
- Fredy Nehme
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, USA
| |
Collapse
|
13
|
Krueger CM, Chikhladze S, Adam U, Patrzyk M, Kramer A, Riediger H. The clinical impact of preoperative biliary drainage on isolated infectious complications (iiC) after pancreatic head resection—a retrospective study. BMC Surg 2022; 22:71. [PMID: 35219316 PMCID: PMC8882266 DOI: 10.1186/s12893-021-01366-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/11/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The perioperative morbidity after pancreatoduodenectomy (PD) is mostly influenced by intraabdominal complications which are often associated with infections. In patients with preoperative biliary drainage (PBD), the risk for postoperative infections may be even elevated. The aim of this study is to explore if isolated infectious complications without intraabdominal focus (iiC) can be observed after PD and if they are associated to PBD and antibiotic prophylaxis with potential conclusions for their treatment.
Methods
During a 10-year period from 2009 to 2019, all consecutive PD were enrolled prospectively in a database and analyzed retrospectively. Bacteriobilia (BB) and Fungibilia (FB) were examined by intraoperatively acquired smears. A perioperative antibiotic prophylaxis was performed by Ampicillin/Sulbactam. For this study, iiC were defined as postoperative infections like surgical site infection (SSI), pneumonia, unknown origin etc. Statistics were performed by Fisher’s exact test and Mann Whitney U test.
Results
A total of 426 PD were performed at the Vivantes Humboldt-hospital. The morbidity was 56% (n = 238). iiC occurred in 93 patients (22%) and accounted for 38% in the subgroup of patients with postoperative complications. They were not significantly related to BB and PBD but to FB. The subgroup of SSI, however, had a significant relationship to BB and FB with a poly microbial profile and an accumulation of E. faecalis, E. faecium, Enterobacter, and Candida. BB was significantly more frequent in longer lay of PBD. Resistance to standard PAP and co-existing resistance to broad spectrum antibiotics is frequently found in patients with iiC. The clinical severity of iiC was mostly low and non-invasive therapy was adequate. Their treatment led to a significant prolongation of the hospital stay.
Conclusions
iiC are a frequent problem after PD, but only in SSI a significant association to BB and FB can be found in our data. Therefore, the higher resistance of the bacterial species to routine PAP, does not justify broad spectrum prophylaxis. However, the identification of high-risk patients with BB and PBD (length of lay) is recommended. In case of postoperative infections, an early application of broad-spectrum antibiotics and adaption to microbiological findings from intraoperatively smears may be advantageous.
Collapse
|
14
|
Khan NN, Lewin T, Hatton A, Pilgrim C, Ioannou L, Te Marvelde L, Zalcberg J, Evans S. Systematic review of the predictors of health service use in pancreatic cancer. Am J Cancer Res 2022; 12:622-650. [PMID: 35261792 PMCID: PMC8900007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/21/2022] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Pancreatic cancer (PC) has a dismal prognosis, with identified disparities in survival outcomes based on demographic characteristics. These disparities may be ameliorated by equitable access to treatments and health services. This systematic review identifies patient and service-level characteristics associated with PC health service utilisation (HSU). METHODS Medline, Embase, CINAHL, PsycINFO and Scopus were systematically searched between 1st January, 2010 and 17 May, 2021 for population-based, PC studies which conducted univariable and/or multivariable regression analyses to identify patient and/or service-level characteristics associated with use of a treatment or health service. Direction of effect sizes were reported in an aggregate manner. RESULTS Sixty-two eligible studies were identified. Most (48/62) explored the predictors of surgery (n=25) and chemotherapy (n=23), and in populations predominantly based in the United States of America (n=50). Decreased HSU was observed among people belonging to older age groups, non-Caucasian ethnicities, lower socioeconomic status (SES) and lower education status. Non-metropolitan location of residence predicted decreased use of certain treatments, and was associated with reduced hospitalisations. People with comorbidities were less likely to use treatments and services, including specialist consultations and palliative care but were more likely to be hospitalised. A more recent year of diagnosis/year of death was generally associated with increased HSU. Academically affiliated and high-volume centres predicted increased treatment use and hospital readmissions. CONCLUSION Findings of this review may assist identification of vulnerable patient groups experiencing disparities in accessing and using treatments and therapies.
Collapse
Affiliation(s)
- Nadia N Khan
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Tennille Lewin
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Amy Hatton
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Charles Pilgrim
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Liane Ioannou
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Luc Te Marvelde
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - John Zalcberg
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Sue Evans
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| |
Collapse
|
15
|
Sugara M, Peruvaje V, Krishnamurthy S, Kumar KVV, Chowdappa R. Effect of Preoperative Biliary Stenting on Outcomes of Pancreaticoduodenectomy. Indian J Surg Oncol 2021; 12:554-560. [PMID: 34658585 DOI: 10.1007/s13193-021-01387-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022] Open
Abstract
Biliary drainage before pancreaticoduodenectomy was introduced to decrease morbidity from obstructive jaundice. Recent retrospective and randomised data show that preoperative biliary drainage (PBD) increases perioperative infectious complications. Most patients presenting to our tertiary care centre have undergone drainage procedures prior to surgical consultation. We analysed the impact of PBD, specifically endoscopic stent placement, on the postoperative outcome of pancreaticoduodenectomy at our centre. A cohort of 87 patients undergoing pancreaticoduodenectomy from 2012 to 2016 was identified. Data was collected retrospectively and a comparative analysis of stented and nonstented patients was done. Comparison of the 23 stented patients was done with 23 nonstented patients after matching them for age, sex and bilirubin levels. Median total bilirubin level in stented patients was 10.2 mg/dl versus 7.7 mg/dl in nonstented patients. The infectious complication rate in the stented group was 39.1% versus 12.7% in the nonstented group (P value < 0.05). There was no difference in the anastomotic leak rate between the two groups. Time to curative surgery in the stented group was significantly more than in the nonstented group. Stented patients are at a higher risk for postoperative infectious complications. Patients with obstructive jaundice awaiting surgery should undergo selective biliary drainage after careful planning and discussion between the operating surgeon and the endoscopist.
Collapse
Affiliation(s)
- Medha Sugara
- Department of Surgical Oncology, St. John's Medical College, Bengaluru, Karnataka 560034 India
| | - Vijay Peruvaje
- Department of ENT, Mandya Institute of Medical Sciences, Mandya, 571401 India
| | - S Krishnamurthy
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka 560029 India
| | - K V Veerendra Kumar
- Department of Surgical Oncology, Jawaharlal Nehru Medical College, Belgaum, Karnataka 590010 India
| | - Ramachandra Chowdappa
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka 560029 India
| |
Collapse
|
16
|
Johansen K, Khodakaram K, Lundgren L, Hasselgren K, Gasslander T, Sandström P, Bratlie SO, Björnsson B. Preoperative Biliary Drainage Does Not Independently Reduce Survival After Pancreaticoduodenectomy Among Patients With Pancreatic Ductal Adenocarcinoma: A National Registry Study. ANNALS OF SURGERY OPEN 2021; 2:e090. [PMID: 37635825 PMCID: PMC10455057 DOI: 10.1097/as9.0000000000000090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/18/2021] [Indexed: 11/26/2022] Open
Abstract
Objective This study aimed to explore a possible relationship between preoperative biliary drainage (PBD) and overall survival in a national cohort of Swedish patients who underwent pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). Background PBD has been shown to increase postoperative complications after PD, but its use is steadily increasing. There are a few small studies that have indicated that PBD might in itself negatively affect overall survival after PD. Methods Patients from the Swedish National Registry for tumors in the pancreatic and periampullary region diagnosed from 2010 to 2019 who underwent PD for PDAC were included. Kaplan-Meier curves, log-rank tests and Cox proportional hazards analyses were performed to investigate survival. Results Out of 15,818 patients in the registry, 3113 had undergone PD, of whom 1471 had a histopathological diagnosis of PDAC. Patients who had undergone PBD had significantly worse survival, but the effect of PBD disappeared in the multivariable analysis when elevated bilirubin at any time was included. Conclusions PBD does not independently influence survival after PD for PDAC, but this study implies that even a nominally increased preoperative bilirubin level might impair long-term survival.
Collapse
Affiliation(s)
- Karin Johansen
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Kaveh Khodakaram
- Department of Gastrosurgical Research, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Linda Lundgren
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Kristina Hasselgren
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thomas Gasslander
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Per Sandström
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Svein Olav Bratlie
- Department of Gastrosurgical Research, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bergthor Björnsson
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
17
|
Scheufele F, Aichinger L, Jäger C, Demir IE, Schorn S, Demir E, Sargut M, Friess H, Ceyhan GO. INR and not bilirubin levels predict postoperative morbidity in patients with malignant obstructive jaundice. Am J Surg 2021; 222:976-982. [PMID: 34001332 DOI: 10.1016/j.amjsurg.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND There are no established predictors for deciding between upfront surgery and PBD in pancreatic head malignancy. Once PBD is present, the ideal drainage-time remains elusive. The aim was, to identify predictors in jaundiced patients and ideal PBD-duration. METHODS Analysis of 304 patients with pancreatic head malignancy (56% with PBD, n = 170) undergoing pancreaticoduodenectomy was performed. Postoperative morbidity and survival were analyzed. RESULTS Postoperative complications increased after PBD (98.2% vs. 88.8%; p < 0.001). Patients with PBD received more postoperative antibiotics (42.4% vs. 21.6%; p < 0.001) and wound infections were increased (21.4% vs. 9.4%; p = 0.006). INR predicted postoperative morbidity (p = 0.026), whereas serum-bilirubin (p = 0.708), leucocytes (p = 0.158) and MELD-score (p = 0.444) had no impact. Complications were not different between long (>4 weeks) and short (<4 weeks) PBD-duration (p = 0.608). No life-threatening complications (CDIV + V) occurred after long drainage (0.0% vs. 8.9%; p = 0.028) and long-term survival was not compromised. CONCLUSIONS INR is a suitable predictor for postoperative outcome, while serum-bilirubin levels had no predictive value. The INR can help deciding between PBD and upfront surgery. If PBD is inevitable, drainage duration of >4 weeks reduced major complications. CATEGORY Clinical study.
Collapse
Affiliation(s)
- Florian Scheufele
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Lena Aichinger
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Carsten Jäger
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany; Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Stephan Schorn
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Elke Demir
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Mine Sargut
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Güralp O Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.
| |
Collapse
|
18
|
Perioperative outcome of Whipple's procedure with special attention to the impact of preoperative biliary drainage: a real-life scenario. Updates Surg 2021; 73:1735-1745. [PMID: 33811607 DOI: 10.1007/s13304-021-01038-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
The aim of the present study is to report the overall perioperative outcome of Whipple's procedure (WP) with particular attention to the impact of preoperative biliary drainage (PBD) on postoperative clinical outcome. All the patients who underwent WP at our institution between August 2007 and December 2019 were retrospectively reviewed. Impact of PBD and the stent-surgery interval on the postoperative clinical outcome of WP were analyzed. Of the total 404 patients, 254 (63%) were male. The median age at operation was 50 years. The overall morbidity was 57.7%. The most common complication was surgical site infection (SSI) (28.7%). POPF developed in 57 (14.1%) patients. Delayed gastric emptying, intra-abdominal collection, and postpancreatectomy hemorrhage developed in 82 (20%), 23 (5.7%), and 18 (4.5%) patients, respectively. PBD was performed in 175 (43%) patients. The median stent-surgery interval was 59 days. Postoperative overall complications and SSI were significantly more common in PBD patients. No significant difference in postoperative major complications or mortality was observed between PBD and no-PBD patients. Stent-surgery interval more than 6 weeks was not associated with increased postoperative complications or hospital stay. Similarly, PBD solely based on serum bilirubin ≥ 15 mg/dl has no beneficial effect on surgical outcome. The operative mortality was 4.2% (n = 17). The median postoperative hospital stay was 13 (7-68) days. PBD is associated with increased incidence of postoperative overall complications and SSI, but does not affect major complications or mortality. PBD-surgery interval greater than 6 weeks does not have a negative impact on postoperative clinical outcomes.
Collapse
|
19
|
Varshney VK, Swami A. Impact of biliary intervention rates during neoadjuvant therapy for pancreatic head adenocarcinoma. HPB (Oxford) 2021; 23:644. [PMID: 33573878 DOI: 10.1016/j.hpb.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Vaibhav K Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
| | - Ashish Swami
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| |
Collapse
|
20
|
Latenstein AEJ, Mackay TM, van Huijgevoort NCM, Bonsing BA, Bosscha K, Hol L, Bruno MJ, van Coolsen MME, Festen S, van Geenen E, Groot Koerkamp B, Hemmink GJM, de Hingh IHJT, Kazemier G, Lubbinge H, de Meijer VE, Molenaar IQ, Quispel R, van Santvoort HC, Seerden TCJ, Stommel MWJ, Venneman NG, Verdonk RC, Besselink MG, van Hooft JE. Nationwide practice and outcomes of endoscopic biliary drainage in resectable pancreatic head and periampullary cancer. HPB (Oxford) 2021; 23:270-278. [PMID: 32682665 DOI: 10.1016/j.hpb.2020.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Guidelines advise self-expanding metal stents (SEMS) over plastic stents in preoperative endoscopic biliary drainage (EBD) for malignant extrahepatic biliary obstruction. This study aims to assess nationwide practice and outcomes. METHODS Patients with pancreatic head and periampullary cancer who underwent EBD before pancreatoduodenectomy were included from the Dutch Pancreatic Cancer Audit (2017-2018). Multivariable logistic and linear regression models were performed. RESULTS In total, 575/1056 patients (62.0%) underwent preoperative EBD: 246 SEMS (42.8%) and 329 plastic stents (57.2%). EBD-related complications were comparable between the groups (44/246 (17.9%) vs. 64/329 (19.5%), p = 0.607), including pancreatitis (22/246 (8.9%) vs. 25/329 (7.6%), p = 0.387). EBD-related cholangitis was reduced after SEMS placement (10/246 (4.1%) vs. 32/329 (9.7%), p = 0.043), which was confirmed in multivariable analysis (OR 0.36 95%CI 0.15-0.87, p = 0.023). Major postoperative complications did not differ (58/246 (23.6%) vs. 90/329 (27.4%), p = 0.316), whereas postoperative pancreatic fistula (24/246 (9.8%) vs. 61/329 (18.5%), p = 0.004; OR 0.50 95%CI 0.27-0.94, p = 0.031) and hospital stay (14.0 days vs. 17.4 days, p = 0.005; B 2.86 95%CI -5.16 to -0.57, p = 0.014) were less after SEMS placement. CONCLUSION This study found that preoperative EBD frequently involved plastic stents. SEMS seemed associated with lower risks of cholangitis and less postoperative pancreatic fistula, but without an increased pancreatitis risk.
Collapse
Affiliation(s)
- Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Tara M Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nadine C M van Huijgevoort
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Erwin van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Gerrit J M Hemmink
- Department of Gastroenterology and Hepatology, Isala, Zwolle, the Netherlands
| | | | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hans Lubbinge
- Department of Gastroenterology and Hepatology, Tjongerschans, Heerenveen, the Netherlands
| | - Vincent E de Meijer
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Ziekenhuis, Delft, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Niels G Venneman
- Department Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | | |
Collapse
|
21
|
Gál E, Veréb Z, Kemény L, Rakk D, Szekeres A, Becskeházi E, Tiszlavicz L, Takács T, Czakó L, Hegyi P, Venglovecz V. Bile accelerates carcinogenic processes in pancreatic ductal adenocarcinoma cells through the overexpression of MUC4. Sci Rep 2020; 10:22088. [PMID: 33328627 PMCID: PMC7744548 DOI: 10.1038/s41598-020-79181-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 12/04/2020] [Indexed: 11/17/2022] Open
Abstract
Pancreatic cancer (PC) is one of the leading causes of mortality rate globally and is usually associated with obstructive jaundice (OJ). Up to date, there is no clear consensus on whether biliary decompression should be performed prior to surgery and how high levels of serum bile affects the outcome of PC. Therefore, our study aims were to characterise the effect of bile acids (BAs) on carcinogenic processes using pancreatic ductal adenocarcinoma (PDAC) cell lines and to investigate the underlying mechanisms. Liquid chromatography-mass spectrometry was used to determine the serum concentrations of BAs. The effects of BAs on tumour progression were investigated using different assays. Mucin expressions were studied in normal and PDAC cell lines and in human samples at gene and protein levels and results were validated with gene silencing. The levels of BAs were significantly higher in the PDAC + OJ group compared to the healthy control. Treating PDAC cells with different BAs or with human serum obtained from PDAC + OJ patients enhanced the rate of proliferation, migration, adhesion, colony forming, and the expression of MUC4. In PDAC + OJ patients, MUC4 expression was higher and the 4-year survival rate was lower compare to PDAC patients. Silencing of MUC4 decreased BAs-induced carcinogenic processes in PDAC cells. Our results show that BAs promote carcinogenic process in PDAC cells, in which the increased expression of MUC4 plays an important role. Based on these results, we assume that in PC patients, where the disease is associated with OJ, the early treatment of biliary obstruction improves life expectancy.
Collapse
Affiliation(s)
- Eleonóra Gál
- Department of Pharmacology and Pharmacotherapy, University of Szeged, 6720, Szeged, Hungary
| | - Zoltán Veréb
- Regenerative Medicine and Cellular Pharmacology Research Laboratory, Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
- HCEMM SZTE Skin Research Group, University of Szeged, Szeged, Hungary
| | - Lajos Kemény
- Regenerative Medicine and Cellular Pharmacology Research Laboratory, Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
- HCEMM SZTE Skin Research Group, University of Szeged, Szeged, Hungary
| | - Dávid Rakk
- Department of Microbiology, University of Szeged, Szeged, Hungary
| | - András Szekeres
- Department of Microbiology, University of Szeged, Szeged, Hungary
| | - Eszter Becskeházi
- Department of Pharmacology and Pharmacotherapy, University of Szeged, 6720, Szeged, Hungary
| | | | - Tamás Takács
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- First Department of Medicine, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine, Medical School, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, 6720, Szeged, Hungary.
| |
Collapse
|
22
|
Shrader HR, Miller AM, Tomanek-Chalkley A, McCarthy A, Coleman KL, Ear PH, Mangalam AK, Salem AK, Chan CHF. Effect of bacterial contamination in bile on pancreatic cancer cell survival. Surgery 2020; 169:617-622. [PMID: 33268071 DOI: 10.1016/j.surg.2020.09.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/25/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Introduction of gut flora into the biliary system is common owing to biliary stenting in patients with obstructing pancreatic head cancer. We hypothesize that alteration of biliary microbiome modifies bile content that modulates pancreatic cancer cell survival. METHODS Human bile samples were collected during pancreaticoduodenectomy. Bacterial strains were isolated from contaminated (stented) bile and identified using 16S ribosomal RNA sequencing. Human pancreatic cancer cells (AsPC1, CFPAC, Panc1) were treated for 24 hours with sterile (nonstented) bile, contaminated (stented) bile, and sterile bile preincubated with 106 colony forming unit of live bacteria isolated from contaminated bile or a panel of bile acids for 24 hours at 37°C, and evaluated using CellTiter-Blue Cell Viability Assay (Promega Corp. Madison, WI). Human bile (30-50 μl/mouse) was coinjected intraperitoneally with 105 Panc02 mouse pancreatic cancer cells in C57BL6/N mice to evaluate the impact of bile on peritoneal metastasis 3 to 4 weeks after tumor challenge. RESULTS While all bile samples significantly reduced peritoneal metastasis of Panc02 cells in mice, some contaminated bile samples had diminished antitumor effect. All sterile bile (n = 4) reduced pancreatic cancer cell survival in vitro. Only 40% (2/5) of contaminated bile samples had significant effect. Preincubation of sterile bile with live Enterococcus faecalis or Streptococcus oralis modified the antitumor effect of sterile bile. These changes were not observed with culture media preincubated with live bacteria, suggesting live gut bacteria can modify the antitumor components present in bile. Conjugated bile acids were more potent than unconjugated cholic acid in reducing pancreatic cancer cell survival. CONCLUSION Alteration of bile microbiome from biliary stenting has a direct impact on pancreatic cancer cell survival. Further study is warranted to determine if this microbiome shift alters tumor microenvironment.
Collapse
Affiliation(s)
| | - Ann M Miller
- Department of Surgery, University of Iowa, Iowa City, IA
| | | | - Ashley McCarthy
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Kristen L Coleman
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Po Hien Ear
- Department of Surgery, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Ashutosh K Mangalam
- Department of Pathology, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Aliasger K Salem
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Carlos H F Chan
- Department of Surgery, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA.
| |
Collapse
|
23
|
Itoyama R, Okabe H, Nakao Y, Yusa T, Nakagawa S, Imai K, Hayashi H, Yamashita YI, Baba H. The pivotal predictor of severe postoperative complications of pancreatoduodenectomy: complex links of bacterial contamination from preoperative biliary drainage. Surg Today 2020; 50:1594-1600. [DOI: 10.1007/s00595-020-02061-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/20/2020] [Indexed: 02/07/2023]
|
24
|
Sun Q, Zhang Y, Xu X. Comments: The Prognostic Index Independently Predicts Survival in Patients With Pancreatic Ductal Adenocarcinoma Undergoing Resection. Ann Surg Oncol 2020; 27:944-945. [PMID: 32277317 DOI: 10.1245/s10434-020-08369-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Qiqing Sun
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yiyin Zhang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xiaowu Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.
| |
Collapse
|
25
|
Abstract
Solid tumors of the pancreas encompass a variety of diagnoses with treatments ranging from observation to major abdominal surgery. Pancreatic ductal adenocarcinoma remains one of the most common and most lethal of these differential of diagnoses and requires a multimodality approach through a multidisciplinary team of specialists. This article reviews the classification, clinical presentation, and workup in differentiating solid tumors of the pancreas and serves as an additional tool for general surgeons faced with such a clinical finding, from a surgical oncology perspective.
Collapse
Affiliation(s)
- George Younan
- Department of Surgery, Inova Fair Oaks Hospital, Fairfax, VA, USA; Division of Hepato-Pancreato-Biliary Surgery, Virginia Surgery Associates, 13135 Lee Jackson Memorial Highway, Suite #305, Fairfax, VA 22033, USA.
| |
Collapse
|
26
|
Delaying surgery after preoperative biliary drainage does not increase surgical morbidity after pancreaticoduodenectomy. Surgery 2019; 166:1004-1010. [DOI: 10.1016/j.surg.2019.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 12/21/2022]
|
27
|
Krüger CM, Adam U, Adam T, Kramer A, Heidecke CD, Makowiec F, Riediger H. Bacterobilia in pancreatic surgery-conclusions for perioperative antibiotic prophylaxis. World J Gastroenterol 2019; 25:6238-6247. [PMID: 31749594 PMCID: PMC6848011 DOI: 10.3748/wjg.v25.i41.6238] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/10/2019] [Accepted: 10/17/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Jaundice or preoperative cholestasis (PC) are typical symptoms of pancreatic masses. Approximately 50% of patients undergo preoperative biliary drainage (PBD) placement. PBD is a common cause of bacterobilia (BB) and is a known surgical site infection risk factor. An adjustment of preoperative antibiotic prophylaxis (PAP) may be reasonable according to the profile of BB. For this, we examined the microbiological findings in routine series of patients.
AIM To investigate the incidence and profile of biliary bacterial colonization in patients undergoing pancreatic head resections.
METHODS In the period from January 2009 to December 2015, 285 consecutive pancreatic head resections were performed. Indications for surgery were malignancy (71%), chronic pancreatitis (18%), and others (11%). A PBD was in 51% and PC was in 42%. The standard PAP was ampicillin/sulbactam. Intraoperatively, a smear was taken from the hepatic duct. An analysis of the isolated species and resistograms was performed. Patients were categorized according to the presence or absence of PC (PC+/PC-) and PBD (PBD+/PBD-) into four groups. Antibiotic efficiency was analyzed for standard PAP and possible alternatives.
RESULTS BB was present in 150 patients (53%). BB was significantly more frequent in PBD+ (n =120) than in PBD- (n = 30), P < 0.01. BB was present both in patients with PC and without PC: (PBD-/PC-: 18%, PBD-/PC+: 30%, PBD+/PC-: 88%, PBD+/PC+: 80%). BB was more frequent in malignancy (56%) than in chronic pancreatitis (45%). PBD, however, was the only independent risk factor in multivariate analysis. In total, 357 pathogens (342 bacteria and 15 fungi) were detected. The five most common groups (n = 256, 74.8%) were Enterococcus spp. (28.4%), Streptococcus spp. (16.9%), Klebsiella spp. (12.6%), Escherichia coli (10.5%), and Enterobacter spp. (6.4%). A polymicrobial BB (PBD+: 77% vs PBD-: 40%, P < 0.01) and a more frequent detection of Enterococcus (P < 0.05) was significantly associated with PBD+. In PBD+, the efficiency of imipenem and piperacillin/tazobactam was significantly higher than that of the standard PAP (P < 0.01).
CONCLUSION PBD-/PC- and PBD-/PC+ were associated with a low rate of BB, while PBD+ was always associated with a high rate of BB. In PBD+ patients, BB was polymicrobial and more often associated with Enterococcus. In PBD+, the spectrum of potential bacteria may not be covered by standard PAP. A more potent alternative for prophylactic application, however, was not found.
Collapse
Affiliation(s)
| | - Ulrich Adam
- Department of General Surgery, Vivantes-Humboldt hospital, Berlin 13503, Germany
| | - Thomas Adam
- Department of Microbiology, Labor Berlin GmbH, Berlin 13353, Germany
| | - Axel Kramer
- Institute of Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald 17495, Mecklenburg Vorpommern, Germany
| | - Claus D Heidecke
- Department of Surgery, Clinic of General, Visceral, Vascular and Thoracic Surgery, University Medicine Greifswald, Greifswald 17475, Mecklenburg Vorpommern, Germany
| | - Frank Makowiec
- Section of clinical risk assessment, University hospital of Freiburg, Freiburg 79106, Baden-Württemberg, Germany
| | - Hartwig Riediger
- Department of General Surgery, Vivantes-Humboldt hospital, Berlin 13503, Germany
| |
Collapse
|
28
|
Chen B, Trudeau MT, Maggino L, Ecker BL, Keele LJ, DeMatteo RP, Drebin JA, Fraker DL, Lee MK, Roses RE, Vollmer CM. Defining the Safety Profile for Performing Pancreatoduodenectomy in the Setting of Hyperbilirubinemia. Ann Surg Oncol 2019; 27:1595-1605. [PMID: 31691110 DOI: 10.1245/s10434-019-08044-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hyperbilirubinemia is commonly observed in patients requiring pancreatoduodenectomy (PD). Thus far, literature regarding the danger of operating in the setting of hyperbilirubinemia is equivocal. What remains undefined is at what specific level of bilirubin there is an adverse safety profile for undergoing PD. The aim of this study is to identify the optimal safety profile of patients with hyperbilirubinemia undergoing PD. PATIENTS AND METHODS The present work analyzed 803 PDs from 2004 to 2018. A generalized additive model was used to determine cutoff values of total serum bilirubin (TB) that were associated with increases in adverse outcomes, including 90-day mortality. Subgroup comparisons and biliary stent-specific analyses were performed for patients with TB below and above the cutoff. RESULTS TB of 13 mg/dL was associated with an increase in 90-day mortality (P = 0.043) and was the dominant risk factor on multivariate logistic regression [odds ratio (OR) 8.193, P = 0.001]. Increased TB levels were also associated with reoperations, number of complications per patient, and length of stay. Patients with TB greater than or equal to 13 mg/dL (TB ≥ 13) who received successful biliary decompression through stenting had less combined death and serious morbidity (P = 0.048). CONCLUSIONS Preoperative TB ≥ 13 mg/dL was associated with increased 90-day mortality after PD. Reducing a TB ≥ 13 is generally recommended before proceeding to surgery.
Collapse
Affiliation(s)
- Bofeng Chen
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maxwell T Trudeau
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Surgery, University of Verona, The Pancreas Institute, Verona, Italy
| | - Brett L Ecker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Luke J Keele
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ronald P DeMatteo
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jeffrey A Drebin
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Major K Lee
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
29
|
Pamecha V, Sadashiv Patil N, Kumar S, Rajendran V, Gupta S, Vasantrao Sasturkar S, Kumar Sinha P, Arora A, Agarwal N, Baghmar S. Upfront pancreaticoduodenectomy in severely jaundiced patients: is it safe? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:524-533. [DOI: 10.1002/jhbp.671] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Viniyendra Pamecha
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Nilesh Sadashiv Patil
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Senthil Kumar
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Vivek Rajendran
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Sahil Gupta
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Shridhar Vasantrao Sasturkar
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Piyush Kumar Sinha
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Asit Arora
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Nikhil Agarwal
- Department of Liver Transplant and Hepato Pancreato Biliary Surgery Institute of Liver and Biliary Sciences D‐1, Acharya Shree Tulsi Marg, Vasant Kunj New Delhi 110070India
| | - Saphalta Baghmar
- Department of Medical Oncology Institute of Liver and Biliary Sciences New Delhi India
| |
Collapse
|
30
|
Kwon CI. [Relief of Obstruction in the Management of Pancreatic Cancer]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 74:69-80. [PMID: 31438658 DOI: 10.4166/kjg.2019.74.2.69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 11/03/2022]
Abstract
Pancreatic cancer is a major cause of cancer-related mortality and morbidity, and its incidence is increasing as the population is aging. On the other hand, significant improvement in the prognosis has not occurred. The absence of early diagnosis means that many patients are diagnosed only when they develop symptoms, such as jaundice, due to a biliary obstruction. The role of endoscopy in multidisciplinary care for patients with pancreatic cancer continues to evolve. Controversy remains regarding the best preoperative biliary drainage in patients with surgically resectable pancreatic head cancer. In general, patients undergoing a surgical resection usually do not require preoperative biliary drainage unless they have cholangitis or receive neoadjuvant chemotherapy. If biliary drainage is performed prior to surgery, the patient's condition and a multidisciplinary approach should be considered. With the increasing life expectancy of patients with pancreatic cancer, the need for more long-time biliary drainage or pre-operative biliary drainage is also increasing. Strong evidence of endoscopic retrograde cholangiopancreatography (ERCP) as a first-line and essential treatment for biliary decompression has been provided. On the other hand, the use of endoscopic ultrasound-guided biliary drainage as well as percutaneous biliary drainage has been also recommended. During ERCP, self-expandable metal stent could be recommended instead of a plastic stent for the purpose of long stent patency and minimizing stent-induced complications. In this review, several points of view regarding the relief of obstruction in patients with pancreatic cancer, and optimal techniques are being discussed.
Collapse
Affiliation(s)
- Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| |
Collapse
|
31
|
Pandé R, Hodson J, Murray A, Marcon F, Kalisvaart M, Marudanayagam R, Sutcliffe RP, Mirza DF, Isaac J, Roberts KJ. Evaluation of the clinical and economic impact of delays to surgery in patients with periampullary cancer. BJS Open 2019; 3:476-484. [PMID: 31388640 PMCID: PMC6677092 DOI: 10.1002/bjs5.50161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/22/2019] [Indexed: 12/11/2022] Open
Abstract
Background Early treatment is the only potential cure for periampullary cancer. The pathway to surgery is complex and involves multiple procedures across local and specialist hospitals. The aim of this study was to analyse variability within this pathway, and its impact on cost and outcomes. Methods Patients undergoing surgery for periampullary cancer (2011–2016) were identified retrospectively and their pathway to surgery was analysed. Patients who had early surgery (shortest quartile, Q1) were compared with those having late surgery (longest quartile, Q4). Results A total of 483 patients were included in the study, with 121 and 124 patients in Q1 and Q4 respectively. The median time from initial CT to surgery was 21 days for Q1 versus 112 days for Q4 (P < 0·001). Diagnostic delays were common in Q4; these patients required significantly more investigations than those in Q1 (endoscopic ultrasonography (EUS): 74·2 versus 18·2 per cent respectively, P < 0·001; MRI: 33·6 versus 20·6 per cent, P = 0·036). The median time to diagnostic EUS was 13 days in Q1 versus 59 days in Q4 (P < 0·001). Some 42·1 per cent of jaundiced patients in Q1 underwent preoperative biliary drainage, compared with all patients in Q4. There were significantly more unplanned admissions and associated longer duration of hospital stay per patient and costs in Q4 than in Q1 (median: 8 versus 3 days respectively; €5652 versus €2088; both P < 0·001). There was a higher likelihood of potentially curative surgery in Q1 (82·6 per cent versus 66·9 per cent in Q4; P = 0·005). Conclusion There is wide variation across the entire pathway, suggesting that multiple strategies are required to enable early surgery. Defining an effective pathway by anticipating the need for investigations and avoiding biliary drainage reduces unplanned admissions and costs and increases resection rates.
Collapse
Affiliation(s)
- R Pandé
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - J Hodson
- Institute of Translational Medicine University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - A Murray
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - F Marcon
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - M Kalisvaart
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | | | | | - D F Mirza
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - J Isaac
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - K J Roberts
- Liver Unit Queen Elizabeth Hospital Birmingham UK.,Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
| |
Collapse
|
32
|
Rustgi SD, Amin S, Yang A, Kim MK, Nagula S, Kumta NA, DiMaio CJ, Boffetta P, Lucas AL. Preoperative Endoscopic Retrograde Cholangiopancreatography Is Not Associated With Increased Pancreatic Cancer Mortality. Clin Gastroenterol Hepatol 2019; 17:1580-1586.e4. [PMID: 30529734 DOI: 10.1016/j.cgh.2018.11.056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 11/21/2018] [Accepted: 11/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic retrograde cholangiopancreatography (ERCP) before surgery for pancreatic cancer has been associated with infectious complications after surgery. Little is known about the effects of preoperative ERCP on the survival of patients with pancreatic cancer. We investigated whether ERCP before surgery affects overall survival, after controlling for confounding factors. METHODS We used Surveillance, Epidemiology, and End Results (SEER) and linked Medicare claims data to identify patients older than 65 years with cancer localized to the head of the pancreas, from 2000 through 2011. We used inverse propensity-weighted Cox proportional hazard models to assess the effects of ERCP on the survival of patients who underwent surgery for pancreatic cancer. RESULTS Among 16,670 patients with cancer of the head of the pancreas, 2890 (17.3%) underwent surgical resection; 1864 (64.5%) of these patients received preoperative ERCP. After we adjusted for confounders, we found that patients who received preoperative ERCP did not have an increased risk of death compared with patients who underwent resection alone (hazard ratio, 1.02; 95% CI, 0.96-1.08). CONCLUSIONS Patients with pancreatic cancer who underwent ERCP before surgery did not have an increased risk of death compared with patients who proceeded directly to surgery. Studies are needed to identify subsets of patients who may benefit from this procedure.
Collapse
Affiliation(s)
- Sheila D Rustgi
- Henry D Janowitz Division of Gastroenterology, New York, New York
| | - Sunil Amin
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington
| | - Anthony Yang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michelle K Kim
- Henry D Janowitz Division of Gastroenterology, New York, New York
| | - Satish Nagula
- Henry D Janowitz Division of Gastroenterology, New York, New York
| | - Nikhil A Kumta
- Henry D Janowitz Division of Gastroenterology, New York, New York
| | | | - Paolo Boffetta
- Tisch Cancer Institute, New York, New York; Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Aimee L Lucas
- Henry D Janowitz Division of Gastroenterology, New York, New York.
| |
Collapse
|
33
|
Bridge of preoperative biliary drainage is a useful management for patients undergoing pancreaticoduodenectomy. Pancreatology 2019; 19:775-780. [PMID: 31255445 DOI: 10.1016/j.pan.2019.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/04/2019] [Accepted: 06/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES The aims of this study were to clarify the effect of preoperative biliary drainage (PBD) on postoperative outcomes and the role of preoperative intentional exchange from endoscopic nasobiliary drainage (ENBD) to endoscopic retrograde biliary drainage (ERBD) for patients waiting to undergo pancreaticoduodenectomy (PD). METHODS We evaluated the effect of PBD and intentional exchange of PBD on the perioperative variables in 292 patients. RESULTS A total of 179 (61.3%) of 292 patients received PBD. There was no marked difference in the postoperative outcomes between the patients who did and did not receive PBD. Among the 160 patients who initially received endoscopic PBD, 10 (6.3%) underwent stent exchange for stent dysfunction, 59 (36.9%) who did not develop stent dysfunction underwent intentional stent exchange from ENBD to ERBD (bridge PBD group), and 91 (56.9%) did not receive any stent exchange (unchanged PBD group). The bridge PBD group had a longer duration of PBD (37 days) (p < 0.001) and a shorter preoperative hospital stay after PBD (32 days) (p < 0.001) than the unchanged PBD group (25 and 46 days, respectively); however, there were no significant differences in the postoperative variables. The incidence of stent exchange due to stent dysfunction in the bridge PBD group (11.9%) was lower than that in patients who initially received ERBD (36.0%) (p = 0.015). CONCLUSIONS Bridge PBD worked well for extending the duration of PBD without worsening the postoperative outcomes after PD.
Collapse
|
34
|
Tavakkoli A, Singal AG, Waljee AK, Scheiman JM, Murphy CC, Pruitt SL, Xuan L, Kwon RS, Law RJ, Elta GH, Wright-Slaughter P, Valley TS, Kubiliun N, Nathan H, Rubenstein JH, Elmunzer BJ. Regional and racial variations in the utilization of endoscopic retrograde cholangiopancreatography among pancreatic cancer patients in the United States. Cancer Med 2019; 8:3420-3427. [PMID: 31087545 PMCID: PMC6601581 DOI: 10.1002/cam4.2225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/11/2019] [Accepted: 04/23/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Pancreatic cancer is projected to become the second leading cause of cancer-related deaths by 2030. Endoscopic retrograde cholangiopancreatography (ERCP) is recommended as first-line therapy for biliary decompression in pancreatic cancer. The aim of our study was to characterize geographic and racial/ethnic disparities in ERCP utilization among patients with pancreatic cancer. METHODS Retrospective cohort study using the US Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify patients diagnosed with pancreatic cancer from 2003-2013. The primary outcome was receipt of ERCP, with or without stent placement, vs any non-ERCP biliary intervention. RESULTS Of the 36 619 patients with pancreatic cancer, 37.5% (n = 13 719) underwent an ERCP, percutaneous drainage, or surgical biliary bypass. The most common biliary intervention (82.6%) was ERCP. After adjusting for tumor location and stage, Blacks were significantly less likely to receive ERCP than Whites (aOR 0.84, 95% CI 0.72, 0.97) and more likely to receive percutaneous transhepatic biliary drainage (PTBD) (aOR 1.38, 95% CI 1.14, 1.66). Patients in the Southeast and the West were more likely to receive ERCP than those in the Northeast (Southeast aOR 1.21, 95% CI 1.04, 1.40; West aOR 1.16, 95% CI 1.01, 1.32). CONCLUSION Racial/ethnic and geographic disparities in access to biliary interventions including ERCP exist for patients with pancreatic cancer in the United States. Our results highlight the need for further research and policies to improve access to appropriate biliary intervention for all patients.
Collapse
Affiliation(s)
- Anna Tavakkoli
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas
| | - Akbar K Waljee
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan
| | - James M Scheiman
- Division of Gastroenterology, University of Virginia, Charlottesville, Virginia
| | - Caitlin C Murphy
- Department of Clinical Sciences, University of Texas Southwestern, Dallas, Texas
| | - Sandi L Pruitt
- Department of Clinical Sciences, University of Texas Southwestern, Dallas, Texas
| | - Lei Xuan
- Department of Clinical Sciences, University of Texas Southwestern, Dallas, Texas
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Ryan J Law
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Grace H Elta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | | | - Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Nisa Kubiliun
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas
| | - Hari Nathan
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Joel H Rubenstein
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
35
|
Rustgi SD, Amin SP, Kim MK, Nagula S, Kumta NA, DiMaio CJ, Boffetta P, Lucas AL. Age, socioeconomic features, and clinical factors predict receipt of endoscopic retrograde cholangiopancreatography in pancreatic cancer. World J Gastrointest Endosc 2019; 11:133-144. [PMID: 30788032 PMCID: PMC6379750 DOI: 10.4253/wjge.v11.i2.133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/01/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is the recommended technique for biliary decompression in pancreatic cancer. Previous studies have suggested racial, socioeconomic and geographic differences in diagnosis, treatment and outcomes of pancreatic cancer patients.
AIM To examine geographic, racial, socioeconomic and clinical factors associated with utilization of ERCP.
METHODS Surveillance, Epidemiology and End Results and linked Medicare claims data were used to identify pancreatic cancer patients between 2000-2011. Claims data were used to identify patients who had ERCP and other treatments. The primary outcome was receipt of ERCP. Chi-squared analyses were used to compare demographic information. Trends in use of ERCP over time were assessed using Cochran Armitage test. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for receipt ERCP were calculated using logistic regression, controlling for other characteristics.
RESULTS Among 32510 pancreatic cancer patients, 14704 (45.2%) underwent ERCP. Patients who had cancer located in the head of the pancreas (aOR 3.27, 95%CI: 2.99-3.57), had jaundice (aOR 7.59, 95%CI: 7.06-8.17), cholangitis (aOR 4.22, 95%CI: 3.71-4.81) or pruritus (aOR 1.42, 95%CI: 1.22-1.66) and lived in lower education zip codes (aOR 1.14, 95%CI: 1.04-1.24) were more likely to receive ERCP. In contrast, patients who were older (aOR 0.88, 95%CI: 0.83, 0.94), not married (aOR 0.92, 95%CI: 0.86, 0.98), and lived in a non-metropolitan area (aOR 0.89, 95%CI: 0.82, 0.98) were less likely to receive ERCP. Compared to white patients, non-white/non-black patients (aOR 0.83, 95%CI: 0.70-0.97) were less likely to receive ERCP. Patients diagnosed later in the study period were less likely to receive ERCP (aOR 2004-2007 0.85, 95%CI: 0.78-0.92; aOR 2008-2011 0.76, 95%CI: 0.70-0.83). After stratifying by indications for ERCP including jaundice, racial differences persisted (aOR black patients 0.80, 95%CI: 0.67-0.95, nonwhite/nonblack patients 0.73, 95%CI: 0.58-0.91). Among patients with jaundice, those who underwent surgery were less likely to undergo ERCP (aOR 0.60, 95%CI: 0.52, 0.69).
CONCLUSION ERCP utilization in pancreatic cancer varies based on patient age, marital status, and factors related to where the patient lives. Further studies are needed to guide appropriate biliary intervention for these patients.
Collapse
Affiliation(s)
- Sheila D Rustgi
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Sunil P Amin
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Michelle K Kim
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Satish Nagula
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Nikhil A Kumta
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Christopher J DiMaio
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Paolo Boffetta
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Aimee L Lucas
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| |
Collapse
|
36
|
Dimitriou I, Bultmann U, Niedergethmann M. Perioperative Antibiotikaprophylaxe bei Pankreasresektionen mit und ohne präoperative Galleableitung. Chirurg 2019; 90:557-563. [DOI: 10.1007/s00104-018-0781-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
37
|
Barman R, Talukdar A, Purkayastha J, Sarma A, Das S, Sharma J, Krishnatreya M, Kataki A. Bacteriological profile of patients with periampullary cancer and effect of preoperative biliary drainage on bacterial flora. CLINICAL CANCER INVESTIGATION JOURNAL 2019. [DOI: 10.4103/ccij.ccij_61_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
38
|
De Pastena M, Marchegiani G, Paiella S, Malleo G, Ciprani D, Gasparini C, Secchettin E, Salvia R, Gabbrielli A, Bassi C. Impact of preoperative biliary drainage on postoperative outcome after pancreaticoduodenectomy: An analysis of 1500 consecutive cases. Dig Endosc 2018; 30:777-784. [PMID: 29943483 DOI: 10.1111/den.13221] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/22/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Implications of preoperative biliary drain on morbidity and mortality after pancreatoduodenectomy are still controversial. The present study aims to assess the impact of preoperative biliary drain on postoperative outcome and to define optimal serum bilirubin cut-off to recommend biliary drainage in patients undergoing pancreatoduodenectomy. METHODS All consecutive pancreatoduodenectomies carried out at Verona Hospital from 2005 to 2016 were retrospectively analyzed. The study population was divided into three groups: preoperative biliary drained (Stented Group), preoperative jaundice without drainage (Jaundiced Group) and the control group of non-jaundiced, non-stented patients (Control Group). RESULTS A total of 1500 patients were included. Seven hundred and fourteen patients (47.6%) received biliary drain (stented group), 258 (17.2%) patients did not (jaundiced group) and 528 (35.2%) patients represented the (control group). Major complications and mortality rates did not differ between groups. Conversely, the risk of developing surgical site infections doubled in the stented group (18.1%) (OR = 2.1, 95% CI = 1.5-2.8). In jaundiced patients, a preoperative bilirubin value greater than 7.5 mg/dL (128 μmol/L) accurately predicted the likelihood of postoperative complications. CONCLUSION Preoperative biliary drain does not increase major complications and mortality rates after pancreatoduodenectomy, but it is associated with higher surgical site infection rates. In jaundiced patients, a bilirubin value greater than 7.5 mg/dL (128 μmol/L) should indicate biliary drainage.
Collapse
Affiliation(s)
- Matteo De Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Salvatore Paiella
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Debora Ciprani
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Clizia Gasparini
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Erica Secchettin
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Armando Gabbrielli
- Gastroenterology and Digestive Endoscopy Unit, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| |
Collapse
|
39
|
Barreto SG, Singh A, Perwaiz A, Singh T, Singh MK, Sharma S, Chaudhary A. Perioperative antimicrobial therapy in preventing infectious complications following pancreatoduodenectomy. Indian J Med Res 2018; 146:514-519. [PMID: 29434066 PMCID: PMC5819034 DOI: 10.4103/ijmr.ijmr_784_15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background & objectives: Infectious complications have been reported to occur in up to 45 per cent of patients, following pancreatoduodenectomy (PD). The incidence of perioperative infectious and overall complications is higher in patients undergoing preoperative invasive endoscopic procedures. The aim of the study was to compare the role of a carbapenem administered as three-once daily perioperative doses on infectious complications in patients at high risk for these complications versus those at low risk. Methods: A retrospective study with some secondary data collected from records was carried out on the data from a prospectively maintained surgical database of patients undergoing PD for pancreatic and periampullary lesions at a tertiary referral care centre, between June 2011 and May 2013. Patients were divided into two groups for comparison based on whether they underwent at least one preoperative endoscopic interventional procedure before PD (high-risk - intervention and low-risk - no intervention). All patients were administered three-once daily doses of ertapenem (1 g). Results: A total of 135 patients in two groups were comparable in terms of demographic and nutritional, surgical and histopathological factors. No significant difference between the two groups in terms of the overall morbidity (38.7 vs 35.7%), infectious complications (9.7 vs 4.8%), mortality (2.2 vs 2.4%) and mean post-operative hospital stay (9.2 vs 8.9 days) was observed. Interpretation & conclusions: Perioperative three-day course of once-daily administered ertapenem resulted in a non-significant difference in infectious and overall complications in high-risk patients undergoing PD as compared to the low-risk group.
Collapse
Affiliation(s)
- Savio George Barreto
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Gurgaon, India
| | - Amanjeet Singh
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Gurgaon, India
| | - Azhar Perwaiz
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Gurgaon, India
| | - Tanveer Singh
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Gurgaon, India
| | | | - Sunil Sharma
- Department of Microbiology, Indian Spinal Injuries Centre, Gurgaon, India
| | - Adarsh Chaudhary
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Gurgaon, India
| |
Collapse
|
40
|
Wu CH, Ho TW, Wu JM, Kuo TC, Yang CY, Lai FP, Tien YW. Preoperative biliary drainage associated with biliary stricture after pancreaticoduodenectomy: a population-based study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:308-318. [DOI: 10.1002/jhbp.559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Chien-Hui Wu
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital Yunlin Branch; Yunlin Taiwan
| | - Te-Wei Ho
- Graduate Institute of Biomedical Electronics and Bioinformatics; National Taiwan University; Taipei Taiwan
| | - Jin-Ming Wu
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
| | - Ting-Chun Kuo
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
| | - Ching-Yao Yang
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
| | - Fei-Pei Lai
- Graduate Institute of Biomedical Electronics and Bioinformatics; National Taiwan University; Taipei Taiwan
| | - Yu-Wen Tien
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
| |
Collapse
|
41
|
Potrc S, Ivanecz A, Pivec V, Marolt U, Rudolf S, Iljevec B, Jagric T. Impact Factors for Perioperative Morbidity and Mortality and Repercussion of Perioperative Morbidity and Long-term Survival in Pancreatic Head Resection. Radiol Oncol 2018. [PMID: 29520206 PMCID: PMC5839082 DOI: 10.1515/raon-2017-0036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background The focus of the present study was to reveal any impact factors for perioperative morbidity and mortality as well as repercussion of perioperative morbidity on long-term survival in pancreatic head resection. Patients and methods In a retrospective study, clinic-pathological factors of 240 patients after pancreatic head (PD) or total resection were analyzed for correlations with morbidity, 30- and 90-day mortality, and long-term survival. According to Clavien–Dindo classification, all complications with grade II and more were defined as overall complications (OAC). OAC, all surgical (ASC), general (AGC) and some specific types of complications like leaks from the pancreatoenteric anastomosis (PEA) or pancreatic fistula (PF, type A, B and C), leaks from other anastomoses (OL), bleeding (BC) and abscesses (AA) were studied for correlation with clinic-pathological factors. Results In the 9-year period, altogether 240 patients had pancreatic resection. The incidence of OAC was 37.1%, ASC 29.2% and AGC 15.8%. ASC presented themselves as PL, OL, BC and AA in 19% (of 208 PD), 5.8%, 5.8%, and 2.5% respectively. Age, ASA score, amylase on drains, and pancreatic fistulas B and C correlated significantly with different types of complications. Overall 30- and 90-day mortalities were 5 and 7.9% and decreased to 3.5 and 5% in P2. Conclusions High amylase on drains and higher mean age were independent indicators of morbidity, whereas PL and BC revealed as independent predictor for 30-day mortality, and physical status, OAC and PF C for 90-day mortality.
Collapse
Affiliation(s)
- Stojan Potrc
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Arpad Ivanecz
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Vid Pivec
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia.,Department of Radiology, University Medical Centre Maribor, Maribor, Slovenia
| | - Urska Marolt
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Sasa Rudolf
- Department of Radiology, University Medical Centre Maribor, Maribor, Slovenia
| | - Bojan Iljevec
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Tomaz Jagric
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| |
Collapse
|
42
|
Affiliation(s)
- Emad S. Aljahdli
- Division of Gastroenterology and Hepatology, Department of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia,Address for correspondence: Dr. Emad S. Aljahdli, Division of Gastroenterology and Hepatology, Department of Medicine, King Abdulaziz University Hospital, Jeddah - 21551, Saudi Arabia. E-mail:
| |
Collapse
|
43
|
Unnecessary preoperative biliary drainage: impact on perioperative outcomes of resectable periampullary tumors. Langenbecks Arch Surg 2017; 402:1187-1196. [DOI: 10.1007/s00423-017-1635-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/25/2017] [Indexed: 12/14/2022]
|
44
|
Shaib Y, Rahal MA, Rammal MO, Mailhac A, Tamim H. Preoperative biliary drainage for malignant biliary obstruction: results from a national database. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:637-642. [DOI: 10.1002/jhbp.505] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Yasser Shaib
- Division of Gastroenterology; Department of Internal Medicine; American University of Beirut Medical Center; Beirut Lebanon
| | - Mahmoud A. Rahal
- Division of Gastroenterology; Department of Internal Medicine; American University of Beirut Medical Center; Beirut Lebanon
| | - Mohammad O. Rammal
- Division of Gastroenterology; Department of Internal Medicine; American University of Beirut Medical Center; Beirut Lebanon
| | - Aurelie Mailhac
- Clinical Research Institute; Biostatistics Unit; American University of Beirut Medical Center; Beirut Lebanon
| | - Hani Tamim
- Clinical Research Institute; Biostatistics Unit; American University of Beirut Medical Center; Beirut Lebanon
| |
Collapse
|
45
|
Effectiveness and risk of biliary drainage prior to pancreatoduodenectomy: review of current status. Surg Today 2017; 48:371-379. [PMID: 28707170 DOI: 10.1007/s00595-017-1568-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 06/27/2017] [Indexed: 12/18/2022]
Abstract
Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) has gained popularity as bridge management to resolve jaundice, but its role is being challenged as it is thought to increase morbidity. To clarify the current recommendations for PBD prior to PD, we reviewed the literature, including all relevant articles published in English up until December, 2015. There is increasing evidence that PBD causes bile infection, which is related to the morbidity of infectious complications. Results of transhepatic drainage are poorer than those of endoscopic stenting, especially in an oncologic setting, although it is still unclear whether metallic stents are superior to nasobiliary drainage. PBD should be avoided whenever possible and performed only in selected cases, such as the emergency setting, an inevitable long delay (>4 weeks) before PD, and jaundice-related anorexia. Seemingly, transhepatic drainage should be reserved for refractory cases if endoscopic drainage is not possible. Further studies comparing endoscopic drainage techniques, such as metallic stents and nasobiliary drainage, are required to assess the most effective technique of PBD. Bile infection should be prevented by adequate antibiotic prophylaxis and treated even in the absence of symptoms, and bile status should be assessed systematically.
Collapse
|
46
|
Schmocker RK, Vanness DJ, Greenberg CC, Havlena JA, LoConte NK, Weiss JM, Neuman HB, Leverson G, Smith MA, Winslow ER. Utilization of preoperative endoscopic ultrasound for pancreatic adenocarcinoma. HPB (Oxford) 2017; 19:465-472. [PMID: 28237627 PMCID: PMC5695546 DOI: 10.1016/j.hpb.2017.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 12/21/2016] [Accepted: 01/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is used for pancreatic adenocarcinoma staging and obtaining a tissue diagnosis. The objective was to determine patterns of preoperative EUS and the impact on downstream treatment. METHODS The Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database was used to identify patients with pancreatic adenocarcinoma. The staging period was the first staging procedure within 6 months of surgery until surgery. Logistic regression was used to determine factors associated with preoperative EUS. The main outcome was EUS in the staging period, with secondary outcomes including number of staging tests and time to surgery. RESULTS 2782 patients were included, 56% were treated at an academic hospital (n = 1563). 1204 patients underwent EUS (43.3%). The factors most associated with receipt of EUS were: earlier year of diagnosis, SEER area, and a NCI or academic hospital (all p < 0.0001). EUS was associated with a longer time to surgery (17.8 days; p < 0.0001), and a higher number of staging tests (40 tests/100 patients; p < 0.0001). CONCLUSIONS Factors most associated with receipt of EUS are geographic, temporal, and institutional, rather than clinical/disease factors. EUS is associated with a longer time to surgery and more preoperative testing, and additional study is needed to determine if EUS is overused.
Collapse
Affiliation(s)
- Ryan K Schmocker
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA
| | - David J Vanness
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, USA
| | - Caprice C Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA; Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, USA
| | - Jeff A Havlena
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA
| | - Noelle K LoConte
- Department of Medicine, Division of Oncology, University of Wisconsin School of Medicine and Public Health, USA
| | - Jennifer M Weiss
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Wisconsin School of Medicine and Public Health, USA
| | - Heather B Neuman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA
| | - Maureen A Smith
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA; Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, USA
| | - Emily R Winslow
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA.
| |
Collapse
|
47
|
Scheufele F, Aichinger L, Jäger C, Demir IE, Schorn S, Sargut M, Erkan M, Kleeff J, Friess H, Ceyhan GO. Effect of preoperative biliary drainage on bacterial flora in bile of patients with periampullary cancer. Br J Surg 2017; 104:e182-e188. [PMID: 28121036 DOI: 10.1002/bjs.10450] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/27/2016] [Accepted: 11/03/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with obstructive jaundice due to periampullary tumours may undergo preoperative biliary drainage (PBD). The effect of PBD on the microbiome of the biliary system and on postoperative outcome remains unclear. METHODS A single-centre retrospective study of patients with obstructive jaundice due to periampullary cancer, treated between July 2007 and July 2015, was undertaken. Intraoperative bile samples were obtained for microbiological analysis after transection of the common bile duct. Postoperative complications were registered. RESULTS Of 290 patients treated, intraoperative bile samples were present for 172 patients (59·3 per cent) who had PBD and 118 (40·7 per cent) who did not. Contamination of bile was increased significantly in patients who underwent stenting (97·1 per cent versus 18·6 per cent in those without stenting; P < 0·001). PBD resulted in a shift in the biliary microbiome from Escherichia coli in non-stented patients (45 per cent versus 19·2 per cent in stented patients; P = 0·009) towards increased contamination with Enterococcus faecalis (9 versus 37·7 per cent respectively; P = 0·008) and Enterobacter cloacae (0 versus 20·4 per cent; P = 0·033). This shift was associated with a high incidence of bacterial resistance against ampicillin-sulbactam (63·6 per cent versus 18 per cent in patients with no PBD; P < 0·001), piperacillin-tazobactam (30·1 versus 0 per cent respectively; P = 0·003), ciprofloxacin (28·5 versus 5 per cent; P = 0·047) and imipenem (26·6 versus 0 per cent; P = 0·011). The rate of wound infection was higher in patients with a positive bile culture (21·0 per cent versus 6 per cent in patients with sterile bile; P = 0·002). Regression analysis revealed the presence of Enterococcus faecium (odds ratio 2·83, 95 per cent c.i. 1·17 to 6·84; P = 0·021) and Citrobacter species (odds ratio 5·09, 1·65 to 15·71; P = 0·005) as independent risk factors for postoperative wound infection. CONCLUSION There are fundamental differences in the biliary microbiome of patients with periampullary cancer who undergo PBD and those who do not. PBD induces a shift of the biliary microbiome towards a more aggressive and resistant spectrum, which requires a differentiated perioperative antibiotic treatment strategy.
Collapse
Affiliation(s)
- F Scheufele
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - L Aichinger
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - C Jäger
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - I E Demir
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - S Schorn
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - M Sargut
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - M Erkan
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Surgery, Koç University Hospital, Istanbul, Turkey
| | - J Kleeff
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Surgery, University of Liverpool, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - H Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - G O Ceyhan
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| |
Collapse
|
48
|
Scheufele F, Schorn S, Demir IE, Sargut M, Tieftrunk E, Calavrezos L, Jäger C, Friess H, Ceyhan GO. Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in the pancreatic head: A meta-analysis of current literature. Surgery 2017; 161:939-950. [DOI: 10.1016/j.surg.2016.11.001] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 10/23/2016] [Accepted: 11/01/2016] [Indexed: 12/13/2022]
|
49
|
Pollom EL, Alagappan M, Park LS, Whittemore AS, Koong AC, Chang DT. Does radiotherapy still have a role in unresected biliary tract cancer? Cancer Med 2016; 6:129-141. [PMID: 27891822 PMCID: PMC5269698 DOI: 10.1002/cam4.975] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 10/29/2016] [Accepted: 10/31/2016] [Indexed: 01/02/2023] Open
Abstract
The benefits of radiotherapy for inoperable biliary tract cancer remain unclear due to the lack of randomized data. We evaluated the impact of radiotherapy on survival in elderly patients using the SEER‐Medicare database. Patients in the SEER‐Medicare database with inoperable biliary tract tumors diagnosed between 1998 and 2011 were included. We used multivariate logistic regression to evaluate factors associated with treatment selection, and multivariate Cox regression and propensity score matching to evaluate treatment selection in relation to subsequent survival. Of the 2343 patients included, 451 (19%) received radiotherapy within 4 months of diagnosis. The use of radiotherapy declined over time, and was influenced by receipt of chemotherapy and patient age, race, marital status, poverty status, and tumor stage and type. Median survival was 9.3 (95% CI 8.7–9.7) months among patients who did not receive radiation and 10.0 (95% CI 9.1–11.3) months among those who received radiation, conditional on having survived 4 months. In patients who received chemotherapy (n = 1053), receipt of radiation was associated with improved survival, with an adjusted hazard ratio of 0.82 (95% 0.70–0.97, P = 0.02). In patients who did not receive chemotherapy (n = 1290), receipt of radiation was not associated with improved survival, with an adjusted hazard ratio of 1.09 (95% 0.91–1.30, P = 0.34). Propensity‐scored matched analyses showed similar results. Despite the survival benefit associated with the addition of radiotherapy to chemotherapy, the use of radiation for unresectable biliary tract cancers has declined over time.
Collapse
Affiliation(s)
- Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Muthuraman Alagappan
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Lesley S Park
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Alice S Whittemore
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Albert C Koong
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
50
|
Costi R, De Pastena M, Malleo G, Marchegiani G, Butturini G, Violi V, Salvia R, Bassi C. Poor Results of Pancreatoduodenectomy in High-Risk Patients with Endoscopic Stent and Bile Colonization are Associated with E. coli, Diabetes and Advanced Age. J Gastrointest Surg 2016; 20:1359-67. [PMID: 27170172 DOI: 10.1007/s11605-016-3158-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/22/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic stenting has spread as bridge management before pancreatoduedenectomy (PD) to resolve jaundice, but its role is nowadays challenged as it is reported to increase morbidity. Although bile sampling is increasingly performed, its clinical role is unclear. The objective of the study is to assess bile colonization's impact on outcome. METHODS Results of pancreatoduodenectomy after endoscopic stenting are analyzed in 61 high-risk patients presenting bacterial bile colonization. The impact of 11 demographic, clinical, infectious, and laboratory parameters and outcome, including pancreatic leakage, morbidity, and mortality, is analyzed. RESULTS All stented patients present bacterial bile colonization and PD mortality approaches 10 %. The presence of E. coli in the bile is significantly related to poor outcome, including 23.5 % mortality (p = 0.034), whereas age (≥70 years) and diabetes present borderline results (p < 0.070 and p < 0.066, respectively). E. coli (p = 0.002) and age (p = 0.017) are also related to grade C pancreatic fistula. CONCLUSIONS In high-risk patients undergoing PD, bile colonization inevitably occurs after endoscopic stenting and is a major risk factor of poor outcome, reaching its maximum in the case of E. coli colonization and elderly patients, where the indication to stent and/or to perform PD should be accurately evaluated. E. coli-targeted antibiotic prophylaxis should be administered.
Collapse
Affiliation(s)
- Renato Costi
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia. .,Service de Chirurgie Digestive et Cancérologique, Hôpital Lariboisière, AP-HP, Université Paris 7 "Diderot", Paris, France. .,Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Azienda Ospedaliero-Universitaria di Parma, Parma, Via Gramsci 14, 43100, Parma, Italia.
| | - Matteo De Pastena
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giuseppe Malleo
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giovanni Marchegiani
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giovanni Butturini
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia.,Unità Operativa di Chirurgia del Pancreas, Casa di Cura "Pederzoli", Peschiera sul Garda, Verona, Italia
| | - Vincenzo Violi
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Azienda Ospedaliero-Universitaria di Parma, Parma, Via Gramsci 14, 43100, Parma, Italia
| | - Roberto Salvia
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Claudio Bassi
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| |
Collapse
|