Pancreatoduodenectomy with colon resection for cancer: A nationwide retrospective analysis

Pancreatoduodenectomy with colon-last approach for advanced pancreatic head cancer

PURPOSE

Margin-negative surgery is very important in surgical oncology. Considering margin-negative pancreatectomy is known to be essential for cure of the pancreatic cancer, pancreatoduodenectomy with combined venous vascular or arterial resection can be a potential option for margin-negative resection, especially, in era of neoadjuvant treatment with potent systemic chemotherapy. To the contrary, special attention was not paid on combined colonic resection during PD. In this article, safe surgical technique for PD with combined colonic resection is introduced, under the name of PD with "colon-last" approach.

METHODS

At Severance Hospital (Yonsei University College of Medicine, Seoul, Republic of Korea), between 2014 and 2021, a total of six patients underwent PD with "colon-last" approach. The surgical technique and surgical outcome are reviewed.

RESULTS

All patients recovered without major complications (Clavien-Dindo classification grade ≥ III) after surgery, and most of them recovered after conservative treatment with postoperative pancreatic fistula biochemical leak. None of the patients were readmitted. Only the first and second cases represent cancer-related mortality, and the other patients are still alive and are being followed up.

CONCLUSION

It is hoped that the present technique, PD with colon-last approach, could be helpful enhance the procedural safety in treating advanced cancer requiring PD with combined colon resection. However, its technical safety and oncologic role should be validated by many pancreatic surgeons' collaborative studies in the near future.

Pancreaticoduodenectomies with Concurrent Colectomies: Indications, Technical Issues, Complications, and Oncological Outcomes

Multi-visceral resections for colon and pancreatic cancer (PDAC) are feasible, safe, and justified for early and late outcomes. However, the use of pancreaticoduodenectomy (PD) with concurrent colectomies is highly debatable in terms of morbidity and oncological benefits. Based on current literature data, this review assesses the early and long-term outcomes of PD with colectomies. The association represents a challenging but feasible option for a few patients with PDAC or locally advanced right colon cancer when negative resection margins are anticipated because long-term survival can be achieved. Concurrent colectomies during PD should be cautiously approached because they may significantly increase complication rates, including severe ones. Thus, patients should be fit enough to overcome potential severe complications. Patients with PD and colectomies can be classified as borderline resectable, considering the high risk of developing postoperative complications. Carefully selecting patients suitable for PD with concurrent colectomies is paramount to mitigate the potentially severe complications of the two surgical procedures and maximize the oncological benefits. These procedures should be performed at high-volume centers with extensive experience in pancreatectomies and colectomies, and each patient situation should be assessed using a multimodal approach, including high-quality imaging and neoadjuvant therapies, in a multidisciplinary team discussion.

Long-term survival after esophagectomy with distal pancreatectomy for locally advanced esophageal cancer with pancreatic invasion: a case report

Background

The treatment for the locally advanced esophageal cancer invading adjacent organs is controversial. We performed a radical surgery for a patient suffering from lower esophageal cancer with pancreatic invasion, and led to long-term survival.

Case presentation

A 62-year-old man with dysphagia, was endoscopically diagnosed lower esophageal cancer. Abdominal computed tomography shows that the tumor formed a mass with the solitary metastatic abdominal lymph node, which invaded pancreas body and gastric body. He was diagnosed locally advanced esophageal cancer cStage IIIC. As chemoradiotherapy was difficult because of the high risk of gastric mucosal damage, radical esophagectomy with distal pancreatectomy and reconstruction of gastric conduit were performed. The postoperative course was uneventful and the patient was discharged 16 days after operation. At present, 7 years after surgery, he is still alive with disease-free condition.

Conclusion

Esophagectomy with distal pancreatectomy may be feasible for locally advanced esophageal cancer with pancreatic invasion in terms of curability and long-term survival.

European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma

BACKGROUND

Quality of surgical care as a crucial component of a comprehensive multi-disciplinary management improves outcomes in patients with endometrial carcinoma, notably helping to avoid suboptimal surgical treatment. Quality indicators (QIs) enable healthcare professionals to measure their clinical management with regard to ideal standards of care.

OBJECTIVE

In order to complete its set of QIs for the surgical management of gynecological cancers, the European Society of Gynaecological Oncology (ESGO) initiated the development of QIs for the surgical treatment of endometrial carcinoma.

METHODS

QIs were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for the identification of potential QIs and documentation of the scientific evidence, two consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians and patient representatives. QIs were defined using a structured format comprising metrics specifications, and targets. A scoring system was then developed to ensure applicability and feasibility of a future ESGO accreditation process based on these QIs for endometrial carcinoma surgery and support any institutional or governmental quality assurance programs.

RESULTS

Twenty-nine structural, process and outcome indicators were defined. QIs 1-5 are general indicators related to center case load, training, experience of the surgeon, structured multi-disciplinarity of the team and active participation in clinical research. QIs 6 and 7 are related to the adequate pre-operative investigations. QIs 8-22 are related to peri-operative standards of care. QI 23 is related to molecular markers for endometrial carcinoma diagnosis and as determinants for treatment decisions. QI 24 addresses the compliance of management of patients after primary surgical treatment with the standards of care. QIs 25-29 highlight the need for a systematic assessment of surgical morbidity and oncologic outcome as well as standardized and comprehensive documentation of surgical and pathological elements. Each QI was associated with a score. An assessment form including a scoring system was built as basis for ESGO accreditation of centers for endometrial cancer surgery.

Cumulative Burden of Postoperative Complications in Patients Undergoing Surgery for Primary Retroperitoneal Sarcoma

BACKGROUND

Correlations between postoperative complications and oncological outcomes have been reported in several malignancies, but their impact in retroperitoneal sarcoma (RPS) is unclear. Our study aimed to evaluate the association between postoperative complications and prognosis in patients with RPS.

METHODS

Patients undergoing surgery for primary RPS from 2008 to 2019 at a sarcoma center were evaluated. The cumulative burden of postoperative complications was quantified using the Comprehensive Complication Index (CCI), and associations with local recurrence (LR), distant metastases (DM) and overall survival (OS) were assessed.

RESULTS

Data were available for 191 patients, of whom 160 (82.9%) developed at least one postoperative complication, with a median CCI of 20.9 (interquartile range 8.7-33.5). After postoperative deaths were excluded (n = 3, 1.6%), the remaining patients were divided into those with a CCI of 0-20.9 (n = 97) and > 20.9 (n = 91). Patients with a CCI >20.9 had significantly shorter OS than those with a CCI of 0-20.9 (43.3% vs. 69.5% at 5 years; p = 0.005), and this difference remained significant after multivariable adjustment for patient- and treatment-related factors [hazard ratio (HR) 2.31, 95% confidence interval (CI) 1.30-4.09; p = 0.004]. However, CCI > 20.9 was not found to be a significant independent predictor of either LR (HR 1.30, 95% CI 0.76-2.23; p = 0.333) or DM (HR 1.08, 95% CI 0.61-1.93; p = 0.786).

CONCLUSION

Increasing complication burden, as quantified by the CCI, is a significant independent predictor of OS; however, there is no evidence of a significant association with either LR or DM, which may be more related to tumor biological factors.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: 5-year outcomes of merged data from two randomized clinical trials (SLEEVEPASS and SM-BOSS)

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB) are both effective surgical procedures to achieve weight reduction in patients with obesity. The trial objective was to merge individual-patient data from two RCTs to compare outcomes after LSG and LRYGB.

METHODS

Five-year outcomes of the Finnish SLEEVEPASS and Swiss SM-BOSS RCTs comparing LSG with LRYGB were analysed. Both original trials were designed to evaluate weight loss. Additional patient-level data on type 2 diabetes (T2DM), obstructive sleep apnoea, and complications were retrieved. The primary outcome was percentage excess BMI loss (%EBMIL). Secondary predefined outcomes in both trials included total weight loss, remission of co-morbidities, improvement in quality of life (QoL), and overall morbidity.

RESULTS

At baseline, 228 LSG and 229 LRYGB procedures were performed. Five-year follow-up was available for 199 of 228 patients (87.3 per cent) after LSG and 199 of 229 (87.1 per cent) after LRYGB. Model-based mean estimate of %EBMIL was 7.0 (95 per cent c.i. 3.5 to 10.5) percentage points better after LRYGB than after LSG  (62.7 versus 55.5 per cent respectively; P < 0.001). There was no difference in remission of T2DM, obstructive sleep apnoea or QoL improvement; remission for hypertension was better after LRYGB compared with LSG (60.3 versus 44.9 per cent; P = 0.049). The complication rate was higher after LRYGB than LSG (37.2 versus 22.5 per cent; P = 0.001), but there was no difference in mean Comprehensive Complication Index value (30.6 versus 31.0 points; P = 0.859).

CONCLUSION

Although LRYGB induced greater weight loss and better amelioration of hypertension than LSG, there was no difference in remission of T2DM, obstructive sleep apnoea, or QoL at 5 years. There were more complications after LRYGB, but the individual burden for patients with complications was similar after both operations.

Colo-pancreaticoduodenectomy for locally advanced colon carcinoma-feasibility in patients presenting with acute abdomen

BACKGROUND

En bloc right hemicolectomy plus pancreaticoduodenectomy (PD) is administered for locally advanced colon carcinoma that invades the duodenum and/or pancreatic head. This procedure may also be called colo-pancreaticoduodenectomy (cPD). Patients with such carcinomas may present with acute abdomen. Emergency PD often leads to high postoperative morbidity and mortality. Here, we aimed to evaluate the feasibility and outcomes of emergency cPD for patients with advanced colon carcinoma manifesting as acute abdomen.

METHODS

We retrospectively reviewed 4898 patients with colorectal cancer who underwent curative colectomy during the period from 1994 to 2018. Among them, 30 had locally advanced right colon cancer and had received cPD. Among them, surgery was performed in 11 patients in emergency conditions (bowel obstruction: 6, perforation: 3, tumor bleeding: 2). Selection criteria for emergency cPD were the following: (1) age ≤ 60 years, (2) body mass index < 35 kg/m², (3) no poorly controlled comorbidities, and (4) perforation time ≤ 6 h. Three patients did not meet the above criteria and received non-emergency cPD after a life-saving diverting ileostomy, followed by cPD performed 3 months later. We analyzed these patients in terms of their clinicopathological characteristics, the early and long-term postoperative outcomes, and compared findings between emergency cPD group (e-group, n = 11) and non-emergency cPD group (non-e-group, n = 19). After cPD, staged pancreaticojejunostomy was performed in all e-group patients, and on 15 of 19 patients in the non-e-group.

RESULTS

The non-e-group was older and had a higher incidence of associated comorbidities, while other clinicopathological characteristics were similar between the two groups. None of the patients in the two groups succumbed from cPD. The postoperative complication rate was 63.6% in the e-group and 42.1% in the non-e-group (p = 0.449). The 5-year overall survival rate were 15.9% in the e-group and 52.6% in the non-e-group (p = 0.192).

CONCLUSIONS

Emergency cPD is feasible in highly selected patients if performed by experienced surgeons. The early and long-term positive outcomes of emergency cPD are similar to those after non-emergency cPD in patients with acute abdominal conditions.

Pancreatoduodenectomy associated with colonic resections: indications, pitfalls, and outcomes

Pancreatoduodenectomy (PD) associated with colonic resections (CR) (PD-CR) might be a viable option in case of locally advanced periampullary tumors or right colon cancer. The aim of this review was to reappraise the indications and outcomes of PD-CR focusing on the occurrence of postoperative pancreatic fistula (POPF) and colonic anastomotic leak (CAL). A systematic literature search was performed in Medline and Cochrane Central Register of Controlled Trials (CENTRAL) for studies published between 2000 and 2020 concerning PD-CR for periampullary or colonic neoplasms. Twenty-seven studies were selected. Morbidity after PD-CR ranged from 12 to 65% and surgery-related mortality was approximately 10%. When reported, the rates of POPF and AL were as high as 40% and 33%, respectively. The oncological results were strictly linked to the nature of the primary tumor and did not significantly differ from those achieved with standard resections. Surgical radicality and nodal status resulted the main determinants of outcome for pancreatic and colonic cancer, respectively. Solid evidence about the surgical outcomes of PD-CR is lacking, mainly due to the small proportion of patients undergoing such combined resection. Given the elevated surgical risk, a multidisciplinary evaluation is recommended for patient's selection. The increasing use of neoadjuvant therapies is expected to further change the indications and outcomes of PD-CR in the next future.

European Society of Gynaecological Oncology quality indicators for surgical treatment of cervical cancer

BACKGROUND

Optimizing and ensuring the quality of surgical care is essential to improve the management and outcome of patients with cervical cancer.To develop a list of quality indicators for surgical treatment of cervical cancer that can be used to audit and improve clinical practice.

METHODS

Quality indicators were developed using a four-step evaluation process that included a systematic literature search to identify potential quality indicators, in-person meetings of an ad hoc group of international experts, an internal validation process, and external review by a large panel of European clinicians and patient representatives.

RESULTS

Fifteen structural, process, and outcome indicators were selected. Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are also detailed to define how the indicator will be measured in practice. Each indicator has a target which gives practitioners and health administrators a quantitative basis for improving care and organizational processes.

DISCUSSION

Implementation of institutional quality assurance programs can improve quality of care, even in high-volume centers. This set of quality indicators from the European Society of Gynaecological Cancer may be a major instrument to improve the quality of surgical treatment of cervical cancer.

Pancreatoduodenectomy with colon resection for pancreatic cancer: a systematic review

BACKGROUND

Radical resection of advanced pancreatic cancer may occasionally require a simultaneous colon resection. The risks and benefits of this combined procedure are largely unknown. This systematic review aimed to assess short and long term outcome after pancreatoduodenectomy with colon resection (PD-colon) for pancreatic ductal adenocarcinoma (PDAC).

METHODS

A systematic literature search was performed in PubMed, Embase, and the Cochrane Library for studies published between 1994 and 2017 concerning PD-colon for PDAC.

RESULTS

After screening 2038 articles, 5 articles with a total of 181 patients undergoing PD-colon were eligible for inclusion. Included studies showed a relatively low risk of bias. The pooled complication rate was 73% (95% CI 61-84) including a pooled colonic anastomotic leak rate of 5.5%. Pooled mortality was 10% (95% CI 6-15). Pooled mean survival (data from 86 patients) was 18 months (95% CI 13-23) with pooled 3- and 5-year survival of 31% (95% CI 20-72) and 19% (95% CI 6-38).

CONCLUSION

Based on the available data, PD-colon for PDAC seems to be associated with an increased morbidity and mortality but with survival comparable with standard PD in selected patients. Future large series are needed to allow for better patient selection for PD-colon.

The Comprehensive Complication Index: a New Measure of the Burden of Complications After Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) are complex surgeries with multiple comorbidities. The Clavien-Dindo classification (CDC) is the most commonly used method to report surgical morbidity, but limits it to the highest-grade complication. The Comprehensive Complication Index (CCI) is a score ranging from 0 to 100, calculated using all 30-day complications and their treatment after abdominal surgery. The aim of this study is to assess the CCI's validity in the HIPEC patient population.

METHODS

A review of our institutional cytoreduction database from 2009 to 2015 was undertaken. Patient demographics, pathology, Peritoneal Carcinomatosis Index (PCI), complications and their treatments, and length of stay (LOS) were reviewed. The CCI was calculated for each patient. Linear regression was used to assess whether the CCI and CDC were predictors of LOS.

RESULTS

Of 157 patients reviewed, 110 (70.1%) underwent HIPEC. The majority were female (77, 66.9%), and the mean age was 53.7 years. Mean PCI was 13.2 [interquartile range (IQR) 7-18]. Median CDC was grade 2 (IQR 0-2), and only 9.8% had CDC of grade 4 or higher. Mean CCI was 21.4, while the median was 20.9 (IQR 0-30.8). Mean LOS was 16.2 days, while the median was 11 days (IQR 8-15 days). The CCI strongly correlated with LOS with coefficient of 0.46 [95% confidence interval (CI) 0.38-0.54, p = 0.000].

CONCLUSIONS

The CCI is an adequate tool to capture all complications and their overall burden in patients having undergone HIPEC. This study shows that the CCI can predict LOS and could be used to quantify and compare the burden of multiple complications.

The Comprehensive Complication Index (CCI®): Added Value and Clinical Perspectives 3 Years "Down the Line"

OBJECTIVE

To explore the added value of the comprehensive complication index (CCI) to standard assessment of postoperative morbidity, and to clarify potential controversies for its application.

BACKGROUND

The CCI was introduced about 3 years ago as a novel metric of postoperative morbidity, integrating in a single formula all complications by severity, ranging from 0 (uneventful course) to 100 (death). It remains unclear, how often the CCI adds to standard reporting of complications and how to apply it in complex postoperative courses.

METHODS

CCI data were prospectively collected over a 1-year period at our institution. The proportion of patients with more than 1 complication and the severity of those complications were assessed to determine the additional value of the CCI compared to the Clavien-Dindo classification. Complex and controversial cases were presented to 90 surgeons worldwide to achieve consensus in weighing each postoperative event. Descriptive statistics were used to evaluate agreement among surgeons and to suggest solutions for consistent use of the CCI.

RESULTS

Complications were identified in 24% (290/1212) of the general surgical population. Of those, 44% (127/290) developed more than 1 complication by the time of discharge, and thereby CCI added information to the standard grading system of complications. Information gained by the CCI increased with the complexity of surgery and observation time.

CONCLUSIONS

The CCI adds information on postoperative morbidity in almost half of the patients developing complications, with particular value following extensive surgery and longer postoperative observation up to 3 months. Each single complication, independently of their inter-connection, should be included in the CCI calculation to best mirror the patients' postoperative morbidity.