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Lee JS, Oh HL, Yoon YS, Han HS, Cho JY, Lee HW, Lee B, Kang M, Park Y, Kim J. Cost-effectiveness of open versus laparoscopic pancreatectomy: A nationwide, population-based study. Surgery 2024:S0039-6060(24)00212-5. [PMID: 38772778 DOI: 10.1016/j.surg.2024.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Laparoscopic pancreatic resection is comparable to open pancreatic resection; however, cost-effectiveness analyses of laparoscopic pancreatic resection are scarce. The authors performed a population-based study investigating the cost-effectiveness of laparoscopic pancreatic resection versus open pancreatic resection. METHODS Data from 9,256 patients who received pancreaticoduodenectomy (66.8%) and distal pancreatectomy (33.2%) from 2016 to 2018 were retrieved from the Korean National Health Insurance Service. Events after pancreatectomy were categorized as no complication, complication, and death. Probabilities of each event and average cost during index admission and 1 year were utilized to calculate incremental cost-effectiveness ratio, the cost difference between two interventions divided by quality-adjusted life year. Quality-adjusted life year, a function of length and quality of life, was measured with utility values determined by researching literature. RESULTS Laparoscopic pancreatic resection was performed in 12.4% of pancreaticoduodenectomies and 53.4% of distal pancreatectomies. For pancreaticoduodenectomy, laparoscopic pancreatic resection was associated with an increase of 0.0022 quality-adjusted life years for index admission and 0.0023 quality-adjusted life years for 1 year compared with open pancreatic resection. The incremental cost was $321 for index admission and -$1,414 for 1 year, leading to an incremental cost-effectiveness ratio of $147,429 per quality-adjusted life year gained for index admission and -$614,965 per quality-adjusted life year gained for 1 year. For distal pancreatectomy, laparoscopic pancreatic resection improved 0.0131 quality-adjusted life years for index admission and 0.0285 quality-adjusted life years for index admission. The incremental cost was -$1,240 for index admission and -$5,875 for 1 year, leading to an incremental cost-effectiveness ratio of -$94,519 per quality-adjusted life year gained for index admission and -$206,351 for 1 year. CONCLUSION laparoscopic pancreatic resection was a cost-effective alternative to open pancreatic resection for pancreaticoduodenectomy and distal pancreatectomy, except for the higher cost of index admission for pancreaticoduodenectomy.
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Affiliation(s)
- Jun Suh Lee
- Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Ha Lynn Oh
- Health Insurance Policy Research Institute, National Health Insurance Service, Wonju, Gangwon-do, Republic of Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hae-Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Boram Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - MeeYoung Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yeshong Park
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jinju Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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The Imperative of Assessing Quality of Life in Patients Presenting to a Pancreaticobiliary Surgery Clinic. Ann Surg 2023; 277:e136-e143. [PMID: 34225301 DOI: 10.1097/sla.0000000000005049] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine baseline health-related quality of life (QoL) in patients with pancreatic adenocarcinoma, periampullary cancers, and benign pancreaticobiliary (PB) conditions at the time of the first visit to a PB surgery clinic, and to explore the relationship between QoL, demographics, clinical parameters, complications, and survival. SUMMARY BACKGROUND DATA Few studies have examined baseline QoL measures, the impact of comorbidities, age, sex, and smoking on subsequent postoperative complications and survival in patients with pancreatic adenocarcinoma, related PB cancers, and with benign PB conditions. METHODS Data were collected from scheduled patients at a PB surgery clinic between 2013 and 2018. The Brief Pain Inventory, Fact-Hepatobiliary Scale, and Facit-Fatigue questionnaires were administered. QoL parameters were compared between PB cancer patients and those with benign disease. RESULTS A total of 462 individuals with PB cancers and benign diseases exhibited baseline physical well-being, functional well-being, fatigue, and overall QoL at or below the 75th percentile of wellness at the time of the first office visit. Younger age, smoking, and mental health comorbidities contributed significantly to decreased QoL. PA patients were 7 times more likely to die in the follow-up period than the benign disease group. Black patients had higher pain scores and were 3 times more likely to have a postsurgery complication. Sex differences were identified regarding fatigue, pain, and overall QoL. CONCLUSIONS This large cohort of PB cancer and benign disease patients exhibited significantly impaired baseline QoL. GI problems, weight loss, smoking, cardiovascular, pulmonary disease, and history of anxiety and depression contributed significantly to reduced QoL. The study sheds a cautionary light on the burden of PB disease at the time of surgical evaluation and its relationship to diminished QoL.
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Houghton EJ, Rubio JS. Surgical management of the postoperative complications of hepato-pancreato-biliary surgery. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Eduardo Javier Houghton
- Teaching and Research Department, DAICIM Foundation, Buenos Aires, Argentina
- Surgery Division, B. Rivadavia Hospital, Buenos Aires, Argentina
- Department of Surgery, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Juan Santiago Rubio
- Solid Organ Transplant Service, Hospital de Alta Complejidad en Red El Cruce Dr. Néstor Carlos Kirchner, Buenos Aires, Argentina
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Liu JB, Tam V, Zenati MS, Schwartz D, Ali A, Low CA, Smith LJ, Zeh HJ, Zureikat AH, Hogg ME. Association of robotic approach with patient-reported outcomes after pancreatectomy: a prospective cohort study. HPB (Oxford) 2022; 24:1659-1667. [PMID: 35568654 DOI: 10.1016/j.hpb.2022.04.008] [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: 11/30/2021] [Revised: 03/22/2022] [Accepted: 04/20/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Robotic-assisted pancreatectomy continues to proliferate despite limited evidence supporting its benefits from the patient's perspective. We compared patient-reported outcomes (PROs) between patients undergoing robotic and open pancreatectomies. METHODS PROs, measured with the FACT-Hep, FACT-G, and HCS, were assessed in the immediate postoperative (i.e., preoperative to discharge) and recovery (i.e., discharge to three months postoperative) periods. Linear mixed models estimated the association of operative approach on PROs. Minimally important differences (MIDs) were also considered. RESULTS Among 139 patients, 105 (75.5%) underwent robotic pancreatectomies. Compared to those who underwent open operations, those who underwent robotic operations experienced worse FACT-Hep scores that were both statistically and clinically significant (mean difference [MD] 8.6 points, 95% CI 1.0-16.3). Declines in FACT-G (MD 4.3, 95% CI -1.0 to 9.6) and HCS (MD 4.3, 95% CI 0.8-7.9) scores appeared to contribute equally in both operative approaches to the decline in total FACT-Hep score. Patients who underwent robotic versus open operations both statistically and clinically significantly improved due to improvements in HCS (MD 6.1, 95% CI 2.3-9.9) but not in FACT-G (MD 1.2, 95% CI - 5.1-7.4). CONCLUSION The robotic approach to pancreas surgery might offer, from the patient's perspective, greater improvement in symptoms over the open approach by three months postoperatively.
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Affiliation(s)
- Jason B Liu
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vernissia Tam
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Mazen S Zenati
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Danielle Schwartz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Areej Ali
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Carissa A Low
- Departments of Medicine and Psychology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lillian J Smith
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
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James NE, Chidambaram S, Gall TM, Sodergren MH. Quality of life after pancreatic surgery - A systematic review. HPB (Oxford) 2022; 24:1223-1237. [PMID: 35304039 DOI: 10.1016/j.hpb.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgery for patients with pancreatic cancer carries a high risk of major post-operative complications and only marginally improves overall survival. This review aims to assess the impact of surgical resection on health-related quality of life (HRQOL) of pancreatic cancer patients. METHODS A systematic review of the literature was performed according to the PRISMA guidelines. All studies assessing QOL using validated questionnaires in pancreatic cancer patients undergoing surgical resection were included. RESULTS Twenty-two studies were assessed. Patients reported a decrease in physical, social and global scales within the first 3 months after surgery. These values showed improvement and were comparable to baseline values by 6 months. Recovery in emotional functioning towards baseline figures was demonstrated in the first 3 months post-operatively. Symptom scales including pain, fatigue and diarrhoea deteriorated after surgery, but reverted to baseline after 3-6 months. CONCLUSIONS Surgical resection for pancreatic cancer has short-term negative impact on QOL. In the longer term, this will improve and eventually recover to baseline values after 6 months. Knowledge on the impact of surgery on QOL of pancreatic cancer patients is necessary to facilitate decision-making and tailoring of surgical techniques to the individual patient.
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Affiliation(s)
- Nicole E James
- Imperial College London, Exhibition Road, South Kensington, London SWC2AZ, UK
| | - Swathikan Chidambaram
- Imperial College London, Exhibition Road, South Kensington, London SWC2AZ, UK; Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College, London W12 0HS, UK
| | - Tamara Mh Gall
- Imperial College London, Exhibition Road, South Kensington, London SWC2AZ, UK; Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College, London W12 0HS, UK
| | - Mikael H Sodergren
- Imperial College London, Exhibition Road, South Kensington, London SWC2AZ, UK; Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College, London W12 0HS, UK.
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Toms C, Steffens D, Yeo D, Pulitano C, Sandroussi C. Quality of Life Instruments and Trajectories After Pancreatic Cancer Resection: A Systematic Review. Pancreas 2021; 50:1137-1153. [PMID: 34714277 DOI: 10.1097/mpa.0000000000001896] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT This systematic review aimed to investigate the instruments available to measure quality of life (QOL) after pancreatic cancer surgery and to describe short- and long-term QOL outcomes. A comprehensive literature search was completed using PubMed, Embase, and Medline from inception to March 2019. Studies investigating QOL outcomes in patients undergoing pancreatic cancer surgery who were 18 years or older were included. The main outcomes of interest were QOL instruments and short (≤6 months) and long term (>6 months) QOL outcomes. The overarching domains of physical, psychosocial, overall QOL, symptoms, and other were used to summarize QOL outcomes. Thirty-five studies reporting on 3573 patients were included. Fifteen unique QOL instruments were identified, of which 4 were disease-specific instruments. Most of the included studies reported no changes in QOL at short- and long-term follow-ups for the overarching domains. No difference in QOL outcomes was reported between different surgical approaches, except laparoscopic versus open distal pancreatectomy, and pancreaticoduodenectomy versus distal pancreatectomy. There are a wide range of instruments available to measure QOL outcomes in pancreatic cancer surgical patients, although only few are disease-specific. Most of the included studies reported no significant changes in QOL outcomes at short- or long-term follow-ups.
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Affiliation(s)
- Clare Toms
- From the Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney Local Health District
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Chen Z, Yu B, Bai J, Li Q, Xu B, Dong Z, Zhi X, Li T. The Impact of Intraoperative Frozen Section on Resection Margin Status and Survival of Patients Underwent Pancreatoduodenectomy for Distal Cholangiocarcinoma. Front Oncol 2021; 11:650585. [PMID: 34012916 PMCID: PMC8127005 DOI: 10.3389/fonc.2021.650585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/15/2021] [Indexed: 01/03/2023] Open
Abstract
Background Intraoperative frozen section (FS) is broadly used during pancreaticoduodenectomy (PD) to ensure a negative margin status, but its survival benefits on obtaining a secondary R0 resection for distal cholangiocarcinoma (dCCA) is controversial and unclear. Methods Clinical data of 107 patients who underwent PD for dCCA was retrospectively collected and divided into different groups based on use of FS (FS and non-FS groups) and status of resection margin (pR0, sR0 and R1 groups), and clinical parameters and survival of patients were compared and analyzed accordingly. Results There were 50 patients in FS group with a median survival of 28 months, 57 patients in non-FS group with a median survival of 27 months. There was no statistical difference between the two groups with Kaplan-Meier survival analysis (P = 0.347). There were 98 patients in R0 group (88 in pR0 and 10 in sR0) and nine patients in R1 group, with a median survival of 29 months and 22 months respectively, which showed a better survival in R0 group than in R1 group (P = 0.006). Survival analyses between subgroups revealed difference between pR0 and R1 group (P = 0.005), while no statistical difference concerning pR0 vs. sR0 (P = 0.211) and sR0 vs. R1 groups (P = 0.262). Multivariate Cox regression analysis revealed resection margin status, pre-operative biliary drainage and lymph node invasion to be independent prognostic factors for dCCA patients. Conclusions Intraoperative FS should be recommended as it significantly increased the rate of R0 resection, which was positively related to a better survival. A primary R0 resection should also be encouraged and if not, a secondary R0 could be considered at the discretion of surgeons as it showed similar survival with primary R0 resection.
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Affiliation(s)
- Zhiqiang Chen
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bingran Yu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jiaping Bai
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiong Li
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bowen Xu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zhaoru Dong
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xuting Zhi
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tao Li
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Staerkle RF, Vuille-Dit-Bille RN, Soll C, Troller R, Samra J, Puhan MA, Breitenstein S. Extended lymph node resection versus standard resection for pancreatic and periampullary adenocarcinoma. Cochrane Database Syst Rev 2021; 1:CD011490. [PMID: 33471373 PMCID: PMC8094380 DOI: 10.1002/14651858.cd011490.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pancreatic and periampullary adenocarcinomas account for some of the most aggressive malignancies, and the leading causes of cancer-related mortalities. Partial pancreaticoduodenectomy (PD) with negative resection margins is the only potentially curative therapy. The high prevalence of lymph node metastases has led to the hypothesis that wider excision with the removal of more lymphatic tissue could result in an improvement of survival, and higher rates of negative resection margins. OBJECTIVES To compare overall survival following standard (SLA) versus extended lymph lymphadenectomy (ELA) for pancreatic head and periampullary adenocarcinoma. We also compared secondary outcomes, such as morbidity, mortality, and tumour involvement of the resection margins between the two procedures. SEARCH METHODS We searched CENTRAL, MEDLINE, PubMed, and Embase from 1973 to September 2020; we applied no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCT) comparing PD with SLA versus PD with ELA, including participants with pancreatic head and periampullary adenocarcinoma. DATA COLLECTION AND ANALYSIS Two review authors independently screened references and extracted data from study reports. We calculated pooled risk ratios (RR) for most binary outcomes except for postoperative mortality, for which we estimated a Peto odds ratio (Peto OR), and mean differences (MD) for continuous outcomes. We used a fixed-effect model in the absence of substantial heterogeneity (I² < 25%), and a random-effects model in cases of substantial heterogeneity (I² > 25%). Two review authors independently assessed risk of bias, and we used GRADE to assess the quality of the evidence for important outcomes. MAIN RESULTS We included seven studies with 843 participants (421 ELA and 422 SLA). All seven studies included Kaplan-Meier curves for overall survival. There was little or no difference in survival between groups (log hazard ratio (log HR) 0.12, 95% confidence interval (CI) -3.06 to 3.31; P = 0.94; seven studies, 843 participants; very low-quality evidence). There was little or no difference in postoperative mortality between the groups (Peto odds ratio (OR) 1.20, 95% CI 0.51 to 2.80; seven studies, 843 participants; low-quality evidence). Operating time was probably longer for ELA (mean difference (MD) 50.13 minutes, 95% CI 19.19 to 81.06 minutes; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 88%; P < 0.00001). There may have been more blood loss during ELA (MD 137.43 mL, 95% CI 11.55 to 263.30 mL; two studies, 463 participants; very low-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P = 0.02). There may have been more lymph nodes retrieved during ELA (MD 11.09 nodes, 95% CI 7.16 to 15.02; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P < 0.00001). There was little or no difference in the incidence of positive resection margins between groups (RR 0.81, 95% CI 0.58 to 1.13; six studies, 783 participants; very low-quality evidence). AUTHORS' CONCLUSIONS There is no evidence of an impact on survival with extended versus standard lymph node resection. However, the operating time may have been longer and blood loss greater in the extended resection group. In conclusion, current evidence neither supports nor refutes the effect of extended lymph lymphadenectomy in people with adenocarcinoma of the head of the pancreas.
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Affiliation(s)
- Ralph F Staerkle
- Visceral Surgery, Hirslanden Klinik St. Anna, Luzern, Switzerland
- University Basel, Basel, Switzerland
| | - Raphael Nicolas Vuille-Dit-Bille
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
- Department of Pediatric Surgery, Children's University Hospital, Basel, Switzerland
| | - Christopher Soll
- Visceral Surgery, Hirslanden Klinik St. Anna, Luzern, Switzerland
| | - Rebekka Troller
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Jaswinder Samra
- Gastrointestinal Surgery, Royal North Shore Hospital, St. Leonards, Australia
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Stefan Breitenstein
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
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Patel BY, White L, Gavriilidis P, Satyadas T, Frampton AE, Pai M. A systematic review into patient reported outcomes following pancreaticoduodenectomy for malignancy. Eur J Surg Oncol 2020; 47:970-978. [PMID: 33339639 DOI: 10.1016/j.ejso.2020.11.146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pancreaticoduodenectomy is associated with high rates of morbidity. This combined with the psychological burden of cancer, may impact on a patient's quality of life (QoL), which can be measured by using patient-reported outcomes (PRO). OBJECTIVE To perform a systematic review to evaluate the measurement of PRO after pancreaticoduodenectomy for cancer. METHODS 7 different databases were searched using 2 groups of search terms, one relating to pancreaticoduodenectomy, and one to PRO. Three authors screened the search results independently in a systematic manner based on predefined inclusion and exclusion criteria. RESULTS 27 studies, with 2173 eligible patients were included in the final analysis. Most of the included studies used validated instruments. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire was most popular and used in 12 studies. The methodology of all included studies was also scrutinised. 12 studies were deemed to have high quality methodology according to pre-defined criteria. CONCLUSION The instruments and methods used to measure PRO are variable. The quality of PRO within the available literature has improved over time, as has the number of studies measuring PRO. PRO should be measured with uniformity in future trials so that patients can be provided with more comprehensive information regarding post-operative recovery and QoL during the shared decision-making process preoperatively.
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Affiliation(s)
- Bhavik Y Patel
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - Laura White
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - Paschalis Gavriilidis
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - Thomas Satyadas
- Manchester Royal Infirmary, Manchester University Foundation Trust, Manchester, UK
| | - Adam E Frampton
- HPB Surgical Unit, Royal Surrey County Hospital Foundation NHS Trust, Guildford, Surrey, GU2 7XX, UK; Dept. of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, The Leggett Building, Daphne Jackson Road, Guildford, University of Surrey, Surrey, GU2 7WG, UK; Division of Cancer, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0NN, UK
| | - Madhava Pai
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK.
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Navez J, Hubert C, Dokmak S, Frick De La Maza I, Tabchouri N, Benoit O, Hermand H, Zech F, Gigot JF, Sauvanet A. Early Versus Late Oral Refeeding After Pancreaticoduodenectomy for Malignancy: a Comparative Belgian-French Study in Two Tertiary Centers. J Gastrointest Surg 2020; 24:1597-1604. [PMID: 31325133 DOI: 10.1007/s11605-019-04316-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/19/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND In the era of fast-track surgery, because pancreaticoduodenectomy (PD) carries a significant morbidity, surgeons hesitate to begin early oral feeding and achieve early discharge. We compared the outcome of two different approaches to the postoperative management of PD in two tertiary centers. METHODS Of patients having undergone PD for malignancy from 2008 to 2017, 100 patients who received early postoperative oral feeding (group A) were compared to 100 patients from another center who received early enteral feeding and a delayed oral diet (group B). Surgical indication and approach and type of pancreatic anastomosis were similar between both groups. Postoperative outcomes were retrospectively reviewed. RESULTS Patient characteristics were similar between both groups, except significantly more neoadjuvant treatment in group A (A = 20% vs. B = 9%, p < 0.01). Mortality rates were 3% and 4% in groups A and B, respectively (p = 0.71). The rate of severe postoperative morbidity was significantly lower in group A (13% vs. 26%, p = 0.02), resulting in a lower reoperation rate (p < 0.01). Delayed gastric emptying and clinically relevant pancreatic fistula were similar between both groups but chyle leaks were more frequent in group A (10% vs. 3%, p = 0.04). The median hospital stay was shorter in group A (16 vs. 20 days, p < 0.01). CONCLUSION In the present study, early postoperative oral feeding after PD was associated with a shorter hospital stay and did not increase severe postoperative morbidity or the rate of pancreatic fistula. However, it resulted in more chyle leaks and did not prevent delayed gastric emptying.
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Affiliation(s)
- Julie Navez
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Catherine Hubert
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Safi Dokmak
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Isadora Frick De La Maza
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Nicolas Tabchouri
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Olivier Benoit
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Hélène Hermand
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Francis Zech
- Institute of Experimental and Clinical Research, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Jean-François Gigot
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Alain Sauvanet
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France.
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Björkman P, Kantonen I, Blomqvist C, Venermo M, Albäck A. En bloc resection of visceral aorta and right kidney due to aortic sarcoma using temporary extracorporeal bypass grafting. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:589-592. [PMID: 31799487 PMCID: PMC6881628 DOI: 10.1016/j.jvscit.2019.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 08/02/2019] [Indexed: 11/29/2022]
Abstract
Aortic sarcomas have not been linked to Lynch syndrome in humans, although other soft tissue malignancies have been. We report the case of a 31-year-old man with Lynch syndrome, who presented with abdominal pain and severe claudication. The clinical and diagnostic workup revealed near occlusion of the infrarenal aorta due to aortic angiosarcoma. En bloc resection of the visceral and infrarenal aorta with right nephrectomy was performed, facilitated by temporary extracorporeal bypass to the visceral arteries. The aorta was reconstructed with a bifurcated Dacron graft. At the 24-month follow-up examination, the patient was free of disease but was experiencing chronic diarrhea.
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Affiliation(s)
- Patrick Björkman
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Kantonen
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Carl Blomqvist
- Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Anders Albäck
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
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Inoue Y, Saiura A, Oba A, Kawakatsu S, Ono Y, Sato T, Mise Y, Ishizawa T, Takahashi Y, Ito H. Optimal Extent of Superior Mesenteric Artery Dissection during Pancreaticoduodenectomy for Pancreatic Cancer: Balancing Surgical and Oncological Safety. J Gastrointest Surg 2019; 23:1373-1383. [PMID: 30306451 DOI: 10.1007/s11605-018-3995-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/23/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND We describe the short- and long-term outcomes for PDAC patients after tailored mesopancreas dissection using supracolic artery-first approach followed by adjuvant therapy. METHODS This study analyzed 233 consecutive patients who underwent artery-first pancreaticoduodenectomy for PDAC. Dissection extent for the superior mesenteric artery (SMA) was categorized into three levels: level 2 (LV2) including regional lymph nodes, level 3 (LV3) with hemicircumferential nerve plexus dissection, and extended-level 3 (E-LV3) including borderline resectable cases for the SMA. All clinical, pathological, and survival outcomes were reviewed. RESULTS LV2/3/E-LV3 dissection was performed in 77/115/41 patients. The short-term outcomes were similar among groups without mortality. Although postoperative diarrhea requiring opioids was significantly more frequent in the E-LV3 group (76%) than other groups (vs. LV2 (21%), P < .0001; vs. LV3 (34%), P < .0001; LV2 vs. LV3, P = 0.20), most cases of diarrhea were well controlled. Adjuvant chemotherapy was introduced similarly among groups (LV2, 76%; LV3, 81%; E-LV3, 88%, P = 0.29). The 3- and 5-year overall survival rates in the LV2/3/E-LV3 groups were 42/33/42% and 27/22/26%, respectively, showing no significant difference among groups. DISCUSSION Our tailored dissection and preemptive use of opioid antidiarrheal effectively prevents intractable diarrhea, increasing the success of adjuvant chemotherapy.
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Affiliation(s)
- Yosuke Inoue
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Atsushi Oba
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Shoji Kawakatsu
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Ono
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takafumi Sato
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Mise
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takeaki Ishizawa
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Takahashi
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Thogari K, Tewari M, Shukla SK, Mishra SP, Shukla HS. Assessment of Exocrine Function of Pancreas Following Pancreaticoduodenectomy. Indian J Surg Oncol 2019; 10:258-267. [PMID: 31168245 PMCID: PMC6527627 DOI: 10.1007/s13193-019-00901-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 01/07/2019] [Accepted: 03/03/2019] [Indexed: 12/31/2022] Open
Abstract
Pancreatic exocrine insufficiency (PEI) is a common long-term complication after pancreaticoduodenectomy (PD) and is observed in 23-80% of patients. As the postoperative mortality after PD has substantially decreased, it warrants more attention on the diagnosis and treatment of functional long-term consequences after PD. These include PEI and endocrine insufficiency that can result in significant nutritional impairment and often adversely impacts quality of life (QOL) of the patient. A PubMed search was performed for articles using key words "pancreatic exocrine insufficiency"; "pancreaticoduodenectomy"; "quality of life after pancreaticoduodenectomy"; "stool elastase"; "direct, indirect tests for pancreatic exocrine insufficiency"; "pancreatic enzyme replacement therapy." Relevant studies were shortlisted and analyzed. This review summarizes relevant studies addressing PEI following PD. We also discuss functional changes after PD, risk factors and predictive factors for postoperative PEI, clinical symptoms, direct and indirect tests for estimation of PEI, pancreatic enzyme replacement therapy (PERT), and QOL after pancreatic resection for malignancy. It was found that significant PEI occurs in most patients following PD. Fecal elastase 1 is an easy indirect test and should be performed routinely in both symptomatic and asymptomatic patients after PD. PERT should be considered in every patient after PD with the aim to improve the QOL and perhaps even their long time survival.
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Affiliation(s)
- Kiran Thogari
- Division of Hepatopancreatobiliary and GastroIntestinal Oncology, Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005 India
| | - Mallika Tewari
- Division of Hepatopancreatobiliary and GastroIntestinal Oncology, Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005 India
| | - S. K. Shukla
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005 India
| | - S. P. Mishra
- Department of Biochemistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005 India
| | - H. S. Shukla
- Division of Hepatopancreatobiliary and GastroIntestinal Oncology, Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005 India
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Systematic review on the impact of pancreatoduodenectomy on quality of life in patients with pancreatic cancer. HPB (Oxford) 2018; 20:204-215. [PMID: 29249649 DOI: 10.1016/j.hpb.2017.11.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/11/2017] [Accepted: 11/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients undergoing pancreatoduodenectomy for pancreatic cancer have a high risk of major postoperative complications and a low survival rate. Insight in the impact of pancreatoduodenectomy on quality of life (QoL) is therefore of great importance. The aim of this systematic review was to assess QoL after pancreatoduodenectomy for pancreatic cancer. METHODS A systematic review of the literature was performed according to the PRISMA guidelines. A systematic search of all the English literature available in PubMed and Medline was performed. All studies assessing QoL with validated questionnaires in pancreatic cancer patients undergoing pancreatoduodenectomy were included. RESULTS After screening a total of 788 articles, the full texts of 36 articles were assessed, and 17 articles were included. QoL of physical and social functioning domains decreased in the first 3 months after surgery. Recovery of physical and social functioning towards baseline values took place after 3-6 months. Pain, fatigue and diarrhoea scores deteriorated postoperatively, but eventually resolved after 3-6 months. CONCLUSION Pancreatoduodenectomy for malignant disease negatively influences QoL in the physical and social domains at short term. It will eventually recover to baseline values after 3-6 months. This information is valuable for counselling and expectation management of patients undergoing pancreatoduodenectomy.
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Contreras CM, Lin CP, Oster RA, Reddy S, Wang T, Vickers S, Heslin M. Increased pancreatic cancer survival with greater lymph node retrieval in the National Cancer Data Base. Am J Surg 2017; 214:442-449. [PMID: 28687101 DOI: 10.1016/j.amjsurg.2017.06.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/23/2017] [Accepted: 06/14/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND We evaluated the role of lymph node (LN) retrieval in pancreatic adenocarcinoma (PA) patients undergoing pancreaticoduodenectomy (PD). METHODS We utilized the National Cancer Data Base; Cox regression models and logistic regression models were used for statistical evaluation. RESULTS We evaluated 26,792 patients with PA who underwent PD. The mean LN retrieved in LN(-) patients was 10.8 vs 14.4 for LN(+) patients (P < 0.0001). Greater LN retrieval is an independent predictor of a negative microscopic margin and decreased length of stay. The median survival of LN(-) patients exceeded that of LN(+) patients (24.5 vs 15.1 months, P < 0.0001). Increasing LN retrieval is a significant predictor of survival in all patients, and in LN(-) patients. The relationship of increased LN retrieval and enhanced survival is a nearly linear trend. CONCLUSIONS Rather than demonstrating an inflection point that defines the extent of adequate lymphadenectomy, this dataset demonstrates an incremental relationship between LN retrieval and survival.
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Affiliation(s)
- Carlo M Contreras
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA.
| | - Chee Paul Lin
- University of Alabama at Birmingham, Center for Clinical and Translational Science, Birmingham, AL, USA
| | - Robert A Oster
- University of Alabama at Birmingham, Department of Preventive Medicine, Birmingham, AL, USA
| | - Sushanth Reddy
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
| | - Thomas Wang
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
| | - Selwyn Vickers
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
| | - Martin Heslin
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
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Mizutani S, Suzuki H, Aimoto T, Yamagishi S, Mishima K, Watanabe M, Kitayama Y, Motoda N, Isshiki S, Uchida E. Usefulness of Color Coding Resected Samples from a Pancreaticoduodenectomy with Tissue Marking Dyes for a Detailed Examination of Surgical Margin Surrounding the Uncinate Process of the Pancreas. J NIPPON MED SCH 2017; 84:32-40. [DOI: 10.1272/jnms.84.32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Satoshi Mizutani
- Institute of Gastroenterology, Nippon Medical School Musashi Kosugi Hospital
| | - Hideyuki Suzuki
- Institute of Gastroenterology, Nippon Medical School Musashi Kosugi Hospital
| | - Takayuki Aimoto
- Institute of Gastroenterology, Nippon Medical School Musashi Kosugi Hospital
| | - Seiji Yamagishi
- Institute of Gastroenterology, Nippon Medical School Musashi Kosugi Hospital
| | - Keisuke Mishima
- Institute of Gastroenterology, Nippon Medical School Musashi Kosugi Hospital
| | - Masanori Watanabe
- Institute of Gastroenterology, Nippon Medical School Musashi Kosugi Hospital
| | - Yasuhiko Kitayama
- Department of Pathology, Nippon Medical School Musashi Kosugi Hospital
| | - Norio Motoda
- Department of Pathology, Nippon Medical School Musashi Kosugi Hospital
| | - Saiko Isshiki
- Department of Radiology, Nippon Medical School Musashi Kosugi Hospital
| | - Eiji Uchida
- Department of Surgery, Nippon Medical School
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17
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Sabater L, Ausania F, Bakker OJ, Boadas J, Domínguez-Muñoz JE, Falconi M, Fernández-Cruz L, Frulloni L, González-Sánchez V, Lariño-Noia J, Lindkvist B, Lluís F, Morera-Ocón F, Martín-Pérez E, Marra-López C, Moya-Herraiz Á, Neoptolemos JP, Pascual I, Pérez-Aisa Á, Pezzilli R, Ramia JM, Sánchez B, Molero X, Ruiz-Montesinos I, Vaquero EC, de-Madaria E. Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery. Ann Surg 2016; 264:949-958. [PMID: 27045859 DOI: 10.1097/sla.0000000000001732] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery. BACKGROUND EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients. METHODS Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement. RESULTS These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement. CONCLUSIONS EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.
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Affiliation(s)
- Luis Sabater
- *Department of Surgery, Hospital Clinico, University of Valencia, Valencia, Spain †Department of Surgery, Complejo Hospitalario Universitario de Vigo, Vigo, Spain ‡Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands §Department of Gastroenterology, Consorci Sanitari de Terrassa, Terrassa, Spain ¶Department of Gastroenterology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain ||Department of Surgery, Università Vita e Salute, Ospedale San Raffaele IRCCS, Milano, Italy **Department of Surgery, Institut de Malalties Digestives I Metabòliques, Hospital Clínic, IDIBAPS, Barcelona, Spain ††Department of Medicine, Pancreas Center, University of Verona, Verona, Italy ‡‡Department of Endocrinology and Nutrition, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. §§Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ¶¶Department of Surgery, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. ||||Department of Surgery, Hospital Universitario de La Princesa, Madrid, Spain ***Department of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain †††Unidad de Cirugía Hepato-bilio-pancreática y Trasplante, Hospital Universitari i Politecnic. La Fe, Valencia, Spain ‡‡‡NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK §§§Department of Gastroenterology, Hospital Clinico, University of Valencia, Valencia, Spain ¶¶¶Unit of Digestive Disease, Agencia Sanitaria Costa del Sol, Marbella, Málaga ||||||Department Digestive System, Sant'Orsola-Malpighi Hospital, Bologna, Italy ****Department of Surgery, Hospital Universitario de Guadalajara, Guadalajara, Spain ††††Department of HPB Surgery and Liver Transplantation, Hospital Carlos Haya, Malaga, Spain ‡‡‡‡Exocrine Pancreas Research Unit, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, CIBEREHD, Barcelona, Spain §§§§Department of Digestive Surgery- Division of HBP Surgery, Hospital Universitario Donostia, San Sebastián, Spain ¶¶¶¶Department of Gastroenterology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, IDIBAPS, CiberEHD, Barcelona, Spain ||||||||Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
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18
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Younan G, Tsai S, Evans DB, Christians KK. Techniques of Vascular Resection and Reconstruction in Pancreatic Cancer. Surg Clin North Am 2016; 96:1351-1370. [PMID: 27865282 DOI: 10.1016/j.suc.2016.07.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Multimodality therapy has become the standard approach for the treatment of pancreatic cancer. With improved response rates to newer chemotherapeutic agents, tumors that used to be considered unresectable are now being considered for operation. Neoadjuvant therapy for borderline resectable pancreatic cancer is considered standard of care and venous resection/reconstruction is no longer controversial. Arterial resection and reconstruction in select patients has also proven to be safe when done in highly specialized centers by high-volume surgeons. This article reviews indications for, and technical aspects of, vascular resection/reconstruction and shunting procedures during pancreatectomy, including critical elements of perioperative care.
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Affiliation(s)
- George Younan
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Susan Tsai
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Douglas B Evans
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Kathleen K Christians
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA.
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Abstract
Pancreaticoduodenectomy (PD) represents an important challenge for surgeons due to the complexity of the operation, requirement for technical skills and experience, and postoperative management involving important and life-threatening complications. Despite efforts to reduce mortality in high-volume centers, the morbidity rate is still high (approximately 40-50%). The PD standardization process of surgical aspects and preoperative and postoperative settings is essential to permit pancreatic surgeons to communicate in the same language, compare experiences and results, and to improve the short- and long-term outcomes. The aim of this article is to assess the state of the art practices for important matters of debate for PD (the role of mini invasive approach, the definition and the role of mesopancreas, the extent of lymphadenectomy, the different methods of reconstructions, the prophylactic drainage of the abdominal cavity), and to suggest possible future studies.
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Hüttner FJ, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Büchler MW, Diener MK. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2016; 2:CD006053. [PMID: 26905229 PMCID: PMC8255094 DOI: 10.1002/14651858.cd006053.pub6] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic cancer is the fourth-leading cause of cancer death for both, men and women. The standard treatment for resectable tumours consists of a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of these procedures is more favourable in terms of survival, postoperative mortality, complications, and quality of life. OBJECTIVES The objective of this systematic review was to compare the effectiveness of CW and PPW techniques for surgical treatment of cancer of the pancreatic head and the periampullary region. SEARCH METHODS We conducted searches on 28 March 2006, 11 January 2011, 9 January 2014, and 18 August 2015 to identify all randomised controlled trials (RCTs), while applying no language restrictions. We searched the following electronic databases on 18 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) from the Cochrane Library (2015, Issue 8); MEDLINE (1946 to August 2015); and EMBASE (1980 to August 2015). We also searched abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010); we did not update this part of the search for the 2014 and 2015 updates because the prior searches did not contribute any additional information. We identified two additional trials through the updated search in 2015. SELECTION CRITERIA RCTs comparing CW versus PPW including participants with periampullary or pancreatic carcinoma. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included trials. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (ORs), pooled continuous outcomes using mean differences (MDs), and used hazard ratios (HRs) for meta-analysis of survival. Two review authors independently evaluated the methodological quality and risk of bias of included trials according to the standards of The Cochrane Collaboration. MAIN RESULTS We included eight RCTs with a total of 512 participants. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. Postoperative mortality (OR 0.64, 95% confidence interval (CI) 0.26 to 1.54; P = 0.32), overall survival (HR 0.84, 95% CI 0.61 to 1.16; P = 0.29), and morbidity showed no significant differences, except of delayed gastric emptying, which significantly favoured CW (OR 3.03, 95% CI 1.05 to 8.70; P = 0.04). Furthermore, we noted that operating time (MD -45.22 minutes, 95% CI -74.67 to -15.78; P = 0.003), intraoperative blood loss (MD -0.32 L, 95% CI -0.62 to -0.03; P = 0.03), and red blood cell transfusion (MD -0.47 units, 95% CI -0.86 to -0.07; P = 0.02) were significantly reduced in the PPW group. All significant results were associated with low-quality evidence based on GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. AUTHORS' CONCLUSIONS Current evidence suggests no relevant differences in mortality, morbidity, and survival between the two operations. However, some perioperative outcome measures significantly favour the PPW procedure. Given obvious clinical and methodological heterogeneity, future high-quality RCTs of complex surgical interventions based on well-defined outcome parameters are required.
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Affiliation(s)
- Felix J Hüttner
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermany69120
| | - Christina Fitzmaurice
- University of Washington/Fred Hutchinson Cancer Research CenterHematology‐Oncology1100 Fairview Ave N – D5‐100PO Box 19024SeattleWashington StateUSA98109‐1024
| | - Guido Schwarzer
- Medical Center ‐ University of FreiburgCenter for Medical Biometry and Medical InformaticsStefan‐Meier‐Str. 26FreiburgGermanyD‐79104
| | - Christoph M Seiler
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermany69120
| | - Gerd Antes
- Medical Center ‐ University of FreiburgCochrane GermanyBerliner Allee 29FreiburgGermany79110
| | - Markus W Büchler
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermany69120
| | - Markus K Diener
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermany69120
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Fink DM, Steele MM, Hollingsworth MA. The lymphatic system and pancreatic cancer. Cancer Lett 2015; 381:217-36. [PMID: 26742462 DOI: 10.1016/j.canlet.2015.11.048] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/16/2015] [Accepted: 11/30/2015] [Indexed: 02/06/2023]
Abstract
This review summarizes current knowledge of the biology, pathology and clinical understanding of lymphatic invasion and metastasis in pancreatic cancer. We discuss the clinical and biological consequences of lymphatic invasion and metastasis, including paraneoplastic effects on immune responses and consider the possible benefit of therapies to treat tumors that are localized to lymphatics. A review of current techniques and methods to study interactions between tumors and lymphatics is presented.
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Affiliation(s)
- Darci M Fink
- Eppley Institute, University of Nebraska Medical Center, Omaha, NE 68198-5950, USA
| | - Maria M Steele
- Eppley Institute, University of Nebraska Medical Center, Omaha, NE 68198-5950, USA
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22
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Marmor S, Burke EE, Portschy PR, Virnig BA, Jensen EH, Tuttle TM. Lymph node evaluation for treatment of adenocarcinoma of the pancreas. Surg Oncol 2015; 24:284-91. [PMID: 26303825 DOI: 10.1016/j.suronc.2015.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 04/15/2015] [Accepted: 06/07/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Increased lymph node evaluation has been associated with improved survival rates in patients with pancreatic cancer. We sought to evaluate the trends and factors associated with lymph node examination over time and the effects on survival. METHODS Using the Surveillance, Epidemiology and End Results database, we conducted an analysis of adults with adenocarcinoma of the pancreas who underwent surgical resection. Using the Cochrane Armitage test for trend and logistic regression we identified factors associated with lymph node evaluation. Kaplan-Meier and Cox proportional hazards modeling were used to examine survival. RESULTS We identified 4831 patients who underwent surgical resection from 1990 to 2010. The proportion of patients with 15 or more lymph nodes evaluated increased from 16% to 42% (p < 0.05) and the median number of lymph nodes examined increased from 7 to 15 nodes (p < 0.05) during the study period. Overall, 56% of patients had lymph node metastases; this proportion significantly increased during the study period. Factors that were independently associated with less than 15 lymph nodes evaluated included male gender, receipt of pre-operative radiation therapy, early year of diagnosis, older age, and missing information on tumor grade and size (p < 0.05). Survival rates significantly improved when 15 or more lymph nodes were examined. CONCLUSION We observed a significant increase in the number of lymph nodes evaluated with pancreas cancer resection over time. Lymph node evaluation was significantly associated with patient, tumor, and treatment characteristics. Our results suggest that adequate lymph node evaluation is associated with improved survival.
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Affiliation(s)
- Schelomo Marmor
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Erin E Burke
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Pamela R Portschy
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Beth A Virnig
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Eric H Jensen
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Todd M Tuttle
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
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Orci LA, Meyer J, Combescure C, Bühler L, Berney T, Morel P, Toso C. A meta-analysis of extended versus standard lymphadenectomy in patients undergoing pancreatoduodenectomy for pancreatic adenocarcinoma. HPB (Oxford) 2015; 17:565-72. [PMID: 25913578 PMCID: PMC4474502 DOI: 10.1111/hpb.12407] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 01/24/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lymph node involvement in pancreatic adenocarcinoma is a key prognostic factor. Therefore, extending the number of lymph node stations excised in pancreatoduodenectomy may be beneficial to patients with pancreatic adenocarcinoma. This systematic review and meta-analysis examines the outcomes of extended versus standard lymphadenectomy in the published literature. METHODS A meta-analysis of randomized controlled trials (RCTs) comparing extended with standard lymphadenectomy in patients undergoing pancreatoduodenectomy for pancreatic adenocarcinoma was performed. Perioperative outcomes were assessed as pooled odds ratios (ORs) and weighted mean differences. Overall survival was analysed for patients with positive and negative lymph nodes. Results were reported according to the PRISMA statement. RESULTS Five RCTs were included, accounting for 724 patients. Extended lymphadenectomy was associated with greater operative time [mean difference: 63 min, 95% confidence interval (CI) 29-96; P < 0.001], increased need for blood transfusions (mean difference: 0.20, 95% CI 0.01-0.30; P = 0.030) and greater postoperative morbidity (OR 1.5, 95% CI 1.25-2.00; P = 0.030), as well as with prolonged diarrhoea after circumferential autonomic nerve dissection around major vessels (OR 12.2, 95% CI 5.3-28.5; P < 0.001). Median survival was similar across the groups in the whole cohort, as well as in subgroups of patients with, respectively, positive and negative lymph nodes. CONCLUSIONS Extended lymphadenectomy has a harmful impact on patients undergoing oncological pancreatoduodenectomy compared with standard lymphadenectomy.
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Affiliation(s)
- Lorenzo A Orci
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Hepato-Pancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Jeremy Meyer
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Hepato-Pancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Christophe Combescure
- Division of Clinical Epidemiology, Department of Health and Community Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Centre de Recherche Clinique, Geneva University Hospitals, Geneva, Switzerland
| | - Leo Bühler
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Hepato-Pancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Thierry Berney
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Hepato-Pancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Morel
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Hepato-Pancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Christian Toso
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Hepato-Pancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
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Diener MK, Fitzmaurice C, Schwarzer G, Seiler CM, Hüttner FJ, Antes G, Knaebel HP, Büchler MW. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2014; 11:CD006053. [PMID: 25387229 PMCID: PMC4356182 DOI: 10.1002/14651858.cd006053.pub5] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours consists of a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of these procedures is more favourable in terms of survival, mortality, complications and quality of life.Objectives The objective of this systematic review is to compare the effectiveness of CW and PPW techniques for surgical treatment of cancer of the pancreatic head and the periampullary region.Search methods We conducted searches on 28 March 2006, 11 January 2011 and 9 January 2014 to identify all randomised controlled trials (RCTs),while applying no language restrictions. We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects(DARE) from The Cochrane Library (2013, Issue 4); MEDLINE (1946 to January 2014); and EMBASE (1980 to January 2014). We also searched abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010). We identified no additional studies upon updating the systematic review in 2014.Selection criteria We considered RCTs comparing CW versus PPW to be eligible if they included study participants with periampullary or pancreatic carcinoma. Data collection and analysis Two review authors independently extracted data from the included studies. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (ORs), pooled continuous outcomes using mean differences (MDs) and used hazard ratios (HRs) for meta-analysis of survival. Two review authors independently evaluated the methodological quality and risk of bias of included studies according to the standards of The Cochrane Collaboration.Main results We included six RCTs with a total of 465 participants. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. In-hospital mortality (OR 0.49, 95% confidence interval (CI) 0.17 to 1.40; P value 0.18), overall survival (HR 0.84, 95% CI 0.61 to 1.16; P value 0.29) and morbidity showed no significant differences. However, we noted that operating time (MD -68.26 minutes, 95% CI -105.70 to -30.83; P value 0.0004) and intraoperative blood loss (MD -0.76 mL, 95%CI -0.96 to -0.56; P value < 0.00001) were significantly reduced in the PPW group. All significant results are associated with low quality of evidence as determined on the basis of GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria.Authors' conclusions No evidence suggests relevant differences in mortality, morbidity and survival between the two operations. Given obvious clinical and methodological heterogeneity, future research must be undertaken to perform high-quality randomised controlled trials of complex surgical interventions on the basis of well-defined outcome parameters.
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Affiliation(s)
- Markus K Diener
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany. markuschar "A8penalty z@
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25
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Tamandl D, Sahora K, Prucker J, Schmid R, Holst JJ, Miholic J, Goetzinger P, Gnant M. Impact of the reconstruction method on delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: a prospective randomized study. World J Surg 2014; 38:465-75. [PMID: 24121364 DOI: 10.1007/s00268-013-2274-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is of considerable concern in patients undergoing pylorus-preserving pancreaticoduodenectomy (PPPD). Prolonged hospital stay, increased cost, and decreased quality of life add on to interventions needed to treat DGE. This study was conducted to determine if performing duodenojejunostomy via the antecolic rather than the retrocolic route improved incidence of DGE. METHODS Patients undergoing PPPD between April 2007 and November 2009 were randomized for either antecolic or retrocolic reconstruction of the duodenojejunostomy. DGE was then assessed by clinical criteria on postoperative day (POD) 10. A paracetamol absorption test was also administered with a liquid meal, and serial plasma levels of intestinal peptides were measured. RESULTS Overall, 64 patients were amenable for analysis: 36 in the antecolic group and 28 in the retrocolic group. The incidences of DGE on POD 10 were 17.6 and 23.1 % (antecolic vs. retrocolic, respectively) (p = 0.628). The two groups did not differ in regard to their median (interquartile range) postoperative hospital length of stay [13.0 (10.0–17.5) vs. 12.5 (11.0–17.0) days; p = 0.446], time to regular diet [5 (5–7) vs. 5 (4–6) days; p = 0.353], or morbidity (52.9 vs. 50.0 %; p = 0.777). The median length of nasogastric tube decompression was similar in the two groups [4 (3–7) vs. 3 (3–5) days; p = 0.600]. Levels of paracetamol and glucagon-like peptide-1 were markedly decreased in patients with DGE. CONCLUSIONS Antecolic reconstruction after PPPD does not improve the occurrence/the incidence of DGE and is similar to retrocolic reconstruction with regard to secondary outcome parameters.
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Abstract
OBJECTIVES The objectives of this study were to assess the long-term quality of life (QOL) after the resection of a primary pancreatic cyst and to determine predictors of outcome. Secondary outcomes were pancreatic function and survival. METHODS One hundred eight consecutive patients, who underwent resection between 1992 and 2007 and had nearly 60 months follow-up, were reviewed. Questionnaires and function tests were collected during scheduled outpatient clinic visits. RESULTS At follow-up, 20 patients had died. Five-year overall survival was 94% for benign and 62% for malignant neoplasia. Of 88 living patients, 65 (74%) returned questionnaires. Generic physical and mental QOL scores were equal or better compared with healthy references. None of the disease-specific symptom scales were above mean 50, implicating none to mild complaints. Independent predictors for good generic QOL were young age (P < 0.05) and resected malignancy (P < 0.05); predictors for good gastrointestinal QOL were male sex (P < 0.1), limited resection (P < 0.05), endocrine insufficiency (P < 0.05), and employment (P < 0.05). Endocrine insufficiency prevalence was 40%, and 59% for exocrine insufficiency. CONCLUSIONS After cyst resection, long-term QOL is equal to healthy references, pancreatic insufficiency is prevalent but does not impair QOL, and survival relates positive compared with solid pancreatic adenocarcinoma. The excellent long-term outcome justifies proceeding with surgery once a medical indication for resection has been established.
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27
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Chen YJ, Lai ECH, Lau WY, Chen XP. Enteric reconstruction of pancreatic stump following pancreaticoduodenectomy: a review of the literature. Int J Surg 2014; 12:706-11. [PMID: 24851718 DOI: 10.1016/j.ijsu.2014.05.060] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/11/2014] [Accepted: 05/14/2014] [Indexed: 01/15/2023]
Abstract
Techniques for reconstruction of pancreatic stump with gastrointestinal tract following pancreaticoduodenectomy are closely related to postoperative complications, mortality and quality of life. In order to reduce postoperative complications, particularly pancreatic fistula, many modifications and new surgical techniques have been proposed to replace the traditional pancreaticojejunostomy and pancreaticogastrostomy. The objective of this review, based on large prospective randomized trials and meta-analyses, is to evaluate the different techniques of enteric reconstruction of pancreatic stump following pancreaticoduodenectomy, including: invagination pancreaticojejunostomy, binding pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy, Roux-en-Y pancreaticojejunostomy, and pancreaticogastrostomy, so as to provide a comprehensive comparison of these techniques and to assess of their roles and effectiveness.
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Affiliation(s)
- Yong-jun Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
| | - Eric C H Lai
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chaiwan, Hong Kong, China.
| | - Wan-Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
| | - Xiao-ping Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
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A prospective randomized controlled study comparing outcomes of standard resection and extended resection, including dissection of the nerve plexus and various lymph nodes, in patients with pancreatic head cancer. Ann Surg 2014; 259:656-64. [PMID: 24368638 DOI: 10.1097/sla.0000000000000384] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To prospectively evaluate the survival benefit of dissection of the nerve plexus and lymphadenectomy in patients with pancreatic head cancer. BACKGROUND Despite randomized controlled trials on the extent of surgery in pancreatic cancer, attempts have been made to perform more extended resections. METHODS A total of 244 patients were enrolled; of these, 200 were randomized to undergo standard resection or extended resection, with the latter including the dissection of additional lymph nodes and the right half of the nerve plexus around the superior mesenteric artery and celiac axis. We evaluated 167 patients from 7 centers who fulfilled all of the required criteria. RESULT Operation time was longer and estimated blood loss was higher in the extended resection group than in the standard resection group, but the R0 resection rate was comparable. The mean number of lymph nodes retrieved per patient was higher in the extended resection group than in the standard resection group (33.7 vs 17.3; P < 0.001). The morbidity rate was slightly higher in the extended resection group than in the standard resection group. Two patients in the extended resection group died in hospital. Median survival after R0 resection was similar in the extended resection and standard resection groups (18.0 vs 19.0 months; P = 0.239) regardless of lymph node metastasis. Adjuvant chemoradiation had a positive impact on overall survival. CONCLUSIONS This study suggests that extended lymphadenectomy with dissection of the nerve plexus does not provide a significant survival benefit compared with standard resection in pancreatic head cancer. Standard resection can be performed safely and efficiently, without negatively affecting oncologic efficacy or long-term survival, when compared with extended pancreaticoduodenal resection. (NCT00679913)?
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Ke K, Chen W, Chen Y. Standard and extended lymphadenectomy for adenocarcinoma of the pancreatic head: a meta-analysis and systematic review. J Gastroenterol Hepatol 2014; 29:453-62. [PMID: 24164704 DOI: 10.1111/jgh.12393] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Although some retrospective studies have recommended that pancreaticoduodenectomy with extended lymphadenectomy might improve the survival of patients with adenocarcinoma of the head of the pancreas, the procedure remains controversial. METHODS Using PubMed, EMBASE, and The Cochrane Library databases, a systematic literature review was performed to identify randomized, controlled trials comparing standard and extended lymphadenectomy in pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas. RESULTS Four trials including 423 patients satisfied the inclusion criteria. Extended lymphadenectomy failed to improve the overall survival of patients with adenocarcinoma of the head of the pancreas (hazard ratio 1.09; 95% confidence interval 0.84-1.41; P = 0.51). Additionally, postoperative mortality and morbidity were comparable between the standard and extended groups, while extended lymphadenectomy was associated with poor quality of life within 1 year after the operation. CONCLUSIONS Extended lymphadenectomy do not benefit overall survival. Considering the poor quality of life associated with extended lymphadenectomy, pancreaticoduodenectomy with standard lymphadenectomy is suitable for patients with adenocarcinoma of the head of the pancreas.
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Affiliation(s)
- Kun Ke
- Department of Hepatobiliary Surgery, Union Hospital, Fujian Medical University, Fuzhou, China; Fujian Institute of Hepatobiliary Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
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Gerstenhaber F, Grossman J, Lubezky N, Itzkowitz E, Nachmany I, Sever R, Ben-Haim M, Nakache R, Klausner JM, Lahat G. Pancreaticoduodenectomy in elderly adults: is it justified in terms of mortality, long-term morbidity, and quality of life? J Am Geriatr Soc 2013; 61:1351-7. [PMID: 23865843 DOI: 10.1111/jgs.12360] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate long-term morbidity, mortality, and quality of life (QoL) after pancreaticoduodenectomy (PD) in elderly adults. DESIGN Retrospective cohort study. SETTING Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel. PARTICIPANTS One hundred and sixty-eight individuals aged 70 and older who underwent PD between 1995 and 2010. MEASUREMENTS A prospective pancreatic surgery database was analyzed for postoperative morbidity; mortality; intensive care unit (ICU), hospital, and rehabilitation facility stay; and readmissions after surgery. QoL was assessed using a validated questionnaire completed 3, 6, and 12 months after surgery. RESULTS Seventy-two percent of the participants had an American Society of Anesthesiologists score of 3 or greater. There was no intraoperative death. Thirty- and 60-day postoperative mortality rates were 5.9% and 6.5%, respectively. Median ICU stay was 2 days, and median hospital stay was 22 days. Sixty-four participants (37.5%) were discharged to a rehabilitation facility. The first-year readmission rate was 31%. One- and 2-year overall survival rates were 58% and 36%, respectively. Global QoL scores 3 and 12 months after surgery were 68% and 73%, respectively. Scores were lower yet comparable with those of matched individuals undergoing laparoscopic cholecystectomy. CONCLUSION Most elderly adults with pancreatic cancer survive longer than 1 year after PD; 36% survive longer than 2 years. These individuals are likely to have acceptable long-term morbidity and overall good QoL, corresponding with their age.
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Calvo F, Guillen Ponce C, Muñoz Beltran M, Sanjuanbenito Dehesa A. Multidisciplinary management of locally advanced–borderline resectable adenocarcinoma of the head of the pancreas. Clin Transl Oncol 2012. [DOI: 10.1007/s12094-012-0962-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, Miyagawa S, Yamaguchi A, Ishiyama S, Takeda Y, Sakoda K, Kinoshita T, Yasui K, Shimada H, Katoh H. Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 19:230-41. [PMID: 22038501 DOI: 10.1007/s00534-011-0466-6] [Citation(s) in RCA: 185] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The value of pancreatoduodenectomy (PD) with extended lymphadenectomy for pancreatic cancer has been evaluated by many retrospective studies and 3 randomized controlled trials (RCT). However, the protocols used and the results found in the 3 RCTs were diverse. Therefore, a multicenter RCT was proposed in 1998 to evaluate the primary end point of long-term survival and the secondary end points of morbidity, mortality and quality of life of patients undergoing standard versus extended lymphadenectomy in radical PD for pancreatic cancer. METHODS From March 2000 to May 2003, 112 patients with potentially curable pancreatic head cancer were enrolled and intraoperatively randomized to a standard or extended lymphadenectomy group. No resected patients received any adjuvant treatments. RESULTS A hundred and one eligible patients were analyzed. Demographic and histopathological characteristics of the two groups were similar. The mean operating time, intraoperative blood loss and number of retrieved lymph nodes were greater in the extended group, but the other operative results were comparable. CONCLUSIONS Although this multicenter RCT was conducted in a strict setting, extended lymphadenectomy in radical PD did not benefit long-term survival in patients with resectable pancreatic head cancer and led to levels of morbidity, mortality and quality of life comparable to those found after standard lymphadenectomy.
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Affiliation(s)
- Yuji Nimura
- The First Department of Surgery, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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Boyd CA, Branch DW, Sheffield KM, Han Y, Kuo YF, Goodwin JS, Riall TS. Hospital and medical care days in pancreatic cancer. Ann Surg Oncol 2012; 19:2435-42. [PMID: 22451235 PMCID: PMC3407309 DOI: 10.1245/s10434-012-2326-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little is known about resource utilization (number of days in the hospital or medical care) between diagnosis and death in patients with pancreatic cancer. METHODS Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, we identified 25,476 patients with pancreatic cancer (1992-2005). Hospital and medical care days per person-month from the time of diagnosis were described, stratified by stage, treatment, and survival duration. RESULTS Hospital/medical care days vary by length of survival and treatment strategy in patients with pancreatic cancer. For all stages, patients were in the hospital a mean of 6.4 days and received medical care a total of 9.0 days in the first month after diagnosis, decreasing to 1.7 and 3.7 days per month, respectively, by the end of the first year. Hospital/medical care days per month of life were higher in patients with shorter survival but increased sharply at the end of life in all patients, regardless of duration of survival. In patients with locoregional disease, resection was associated with a higher number of hospital/medical care days during the first 4 months after diagnosis, but fewer at the end of the first year. For distant disease, hospital days were similar but days in medical care were higher for patients receiving chemotherapy, increasing especially at the end of life. CONCLUSIONS This study is the first to quantify hospital/medical care days in patients with pancreatic cancer by stage, treatment, and survival. This information will provide realistic expectations and allow for treatment decisions based on patient preferences.
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Affiliation(s)
- Casey A Boyd
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA.
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Orfanidis NT, Loren DE, Santos C, Kennedy EP, Siddiqui AA, Lavu H, Yeo CJ, Kowalski TE. Extended follow-up and outcomes of patients undergoing pancreaticoduodenectomy for nonmalignant disease. J Gastrointest Surg 2012; 16:80-7; discussion 87-8. [PMID: 22058043 DOI: 10.1007/s11605-011-1751-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 10/13/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Due to improved surgical outcomes and increased detection of pancreatic lesions, the resection of nonmalignant and indeterminate lesions of the pancreas has increased. AIMS This study aims to assess the outcomes over an extended period of time and the clinical consequences of pancreaticoduodenectomy (PD) performed for nonmalignant indications. METHODS Patients undergoing a PD between 2006 and 2010 were retrospectively identified and asked to complete a symptom survey. Charts were reviewed for hospital admissions, emergency room visits, complications, and procedures performed. RESULTS A total of 132 patients were identified through database review with a median follow-up of 2.8 years. Forty-two patients (31.1%) completed the phone survey. Pain and diarrhea were the most common symptoms reported, negatively impacting the patient's daily life in 4.9% and 7.3% of patients, respectively. Diabetes developed or worsened in 19.5%, with new insulin required in 12.2%. Complications were rare, with abdominal abscess (7.6%) occurring most commonly. CONCLUSIONS Although some patients experienced symptoms that negatively impacted their daily life or had diabetic issues following surgery, the outcome of patients undergoing PD for nonmalignant indications was generally favorable. Further prospective study is warranted.
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Affiliation(s)
- Nicholas Thomas Orfanidis
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, 132 South 10th Street, Main Building, Suite 480, Philadelphia, PA 19107, USA
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Diener MK, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Knaebel HP, Büchler MW. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2011:CD006053. [PMID: 21563148 DOI: 10.1002/14651858.cd006053.pub4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours is either a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of the procedures is more favourable in terms of survival, mortality, complications and quality of life. OBJECTIVES The objective of this systematic review is to compare the effectiveness of each operation. SEARCH STRATEGY We conducted searches on 28 March 2006 and 11 January 2011 to identify all randomised controlled trials (RCTs), applying no language restrictions. We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), CDSR and DARE from The Cochrane Library (2010, Issue 4), MEDLINE (1966 to January 2011), and EMBASE (1980 to January 2011). Abstracts from Digestive Disease Week and U nited European Gastroenterology Week (1995 to 2010). No additional studies were indentified upon updating the systematic review in 2011. SELECTION CRITERIA We considered RCTs comparing the CW with PPW to be eligible if they included patients with periampullary or pancreatic carcinoma. DATA COLLECTION AND ANALYSIS Two authors independently extracted data from the included studies. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (OR), pooled continuous outcomes using mean differences (MD) and used hazard ratios (HR) for meta-analysis of survival. Two authors independently evaluated the methodological quality and risk of bias of the included studies according to Cochrane standards. MAIN RESULTS We included six randomised controlled trials with a total of 465 patients. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. In-hospital mortality (OR 0.49; 95% confidence interval (CI) 0.17 to 1.40; P = 0.18), overall survival (HR 0.84; 95% CI 0.61 to 1.16; P = 0.29) and morbidity showed no significant differences. However, we noted that operating time (MD -68.26 minutes; 95% CI -105.70 to -30.83; P = 0.0004) and intra-operative blood loss (MD -0.76 millilitres; 95% CI -0.96 to -0.56; P < 0.00001) were significantly reduced in the PPW group. All significant results have low quality of evidence based on GRADE criteria. AUTHORS' CONCLUSIONS There is no evidence of relevant differences in mortality, morbidity and survival between the two operations. Given obvious clinical and methodological heterogeneity, future research must be undertaken to perform high-quality randomised controlled trials of complex surgical interventions on the basis of well-defined outcome parameters.
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Affiliation(s)
- Markus K Diener
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 10, Heidelberg, Germany, 69120
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Development of pancreatoduodenectomy in North America. Surg Today 2011; 41:377-81. [DOI: 10.1007/s00595-010-4277-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Accepted: 02/03/2010] [Indexed: 01/04/2023]
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[Surgical treatment of pancreatic adenocarcinoma by cephalic duodenopancreatectomy (Part 1). Post-surgical complications in 204 cases in a reference hospital]. Cir Esp 2011; 88:299-307. [PMID: 20663494 DOI: 10.1016/j.ciresp.2010.05.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 04/22/2010] [Accepted: 05/09/2010] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Cephalic duodenopancreatectomy (CDP) is the treatment of choice in cancer of the head of the pancreas. However, it continues to have a high post-surgical morbidity and mortality. The aim of this article is to define variables that influence post-surgical morbidity and mortality after cephalic duodenopancreatectomy due to pancreatic adenocarcinoma (PA) cancer of the head of the pancreas (CHP). MATERIAL AND METHODS The variables were prospectively collected form patients operated on between 1991 and 2007, in order to investigate the factors of higher morbidity. RESULTS A total of 204 patients had been intervened due to PA, of whom 57 were older than 70 years. Of these patients, 119 had a CPD, 11 extended lymphadenectomy, 66 with pyloric conservation, and 8 with extension to total pancreatectomy due to involvement of the section margin. Portal or mesenteric vein resection was included in 35 cases. Post-surgical complications were detected in 45% of cases, the most frequent being: slow gastric emptying (20%), surgical wound infection (17%), pancreatic fistula (10%), and serious medical complications (8%). Further surgery was required in 13%, and the over post-surgical mortality was 7%. A patient age greater than 70 years, post-surgical haemoperitoneum, gastroenteric dehiscence, and the presence of medical complications were post-surgical mortality risk factors in the multivariate analysis. Pancreatic fistula was not a factor associated with post-surgical mortality. CONCLUSIONS Cephalic duodenopancreatectomy is a safe technique but with a considerable morbidity. Patients over 70 years of age must be carefully selected before considering surgery. Serious medical complications must be treated aggressively to avoid an unfavourable progression.
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Diener MK, Heukaeufer C, Schwarzer G, Seiler CM, Antes G, Knaebel HP, Büchler MW. WITHDRAWN: Pancreaticoduodenectomy (classic Whipple) versus pylorus-preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2011:CD006053. [PMID: 21328281 DOI: 10.1002/14651858.cd006053.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours is either a classic Whipple operation or a pylorus-preserving pancreaticoduodenectomy. It is unclear which of the procedures is more favourable in terms of survival, mortality, complications and quality of life. OBJECTIVES Several publications have highlighted advantages and disadvantages of the two techniques and the current basis of evidence remains unclear. The objective of this systematic review is to compare the effectiveness of each operation. SEARCH STRATEGY We conducted a search on 28/03/2006 to identify all RCTs, applying no language restriction.We searched the following electronic databases: CENTRAL, CDSR and DARE from The Cochrane Library (2006, issue 2), MEDLINE (1966 to 2006) and EMBASE (1980 to 2006). We handsearched abstracts from 1995 to 2006 from the American Digestive Disease Week (DDW), published in Gastroenterology, and the United European Gastroenterology Week (UEGW), published in Gut. SELECTION CRITERIA We considered randomised controlled trials comparing the classic Whipple operation with pylorus-preserving pancreaticoduodenectomy to be eligible if they included patients with periampullary or pancreatic carcinoma. DATA COLLECTION AND ANALYSIS Two authors independently extracted data from the included studies. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (OR), pooled continuous outcomes using weighted mean differences (WMD), and used hazard ratios (HR) for meta-analysis of survival. Two authors independently evaluated the methodological quality of included studies according to quality standards and by using a questionnaire. MAIN RESULTS We retrieved 1235 abstracts and checked these for eligibility, including seven randomised controlled trials. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. Our comparisons of in-hospital mortality (OR 0.49; 95% confidence interval (CI) 0.17 to 1.40; P = 0.18), overall survival (HR 0.84; 95% CI 0.61 to 1.16; P = 0.29) and morbidity showed no significant differences. However, we noted that operating time (WMD -68.26 minutes; 95% CI -105.70 to -30.83; P = 0.0004) and intra-operative blood loss (WMD -0.76 millilitres; 95% CI -0.96 to -0.56; P < 0.00001) were significantly reduced in the pylorus-preserving pancreaticoduodenectomy group. AUTHORS' CONCLUSIONS There is no evidence of relevant differences in mortality, morbidity and survival between the two operations. Given obvious clinical and methodological heterogeneity, future research must be undertaken to perform high-quality randomised controlled trials of complex surgical interventions on the basis of well-defined outcome parameters.
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Affiliation(s)
- Markus K Diener
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, Germany, 69120
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Tratamiento quirúrgico del adenocarcinoma pancreático mediante duodenopancreatectomía cefálica (parte 2). Seguimiento a largo plazo tras 204 casos. Cir Esp 2010; 88:374-82. [DOI: 10.1016/j.ciresp.2010.09.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 08/09/2010] [Accepted: 09/07/2010] [Indexed: 01/02/2023]
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Kawai M, Yamaue H. Analysis of clinical trials evaluating complications after pancreaticoduodenectomy: a new era of pancreatic surgery. Surg Today 2010; 40:1011-7. [PMID: 21046497 DOI: 10.1007/s00595-009-4245-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Accepted: 09/16/2009] [Indexed: 12/18/2022]
Abstract
Pancreatic fistula and delayed gastric emptying (DGE) are the major postoperative complications of pancreaticoduodenectomy (PD). Pancreatic fistula is life-threatening and DGE, while not life-threatening, prolongs the hospital stay, increasing costs and compromising quality of life. To establish the current consensus of pancreatic fistula and DGE after PD, we analyzed the results of randomized controlled trials (RCTs) designed to prevent these postoperative complications. Five RCTs comparing PD with pylorus-preserving pancreaticoduodenectomy (PpPD) performed for periampullary tumors showed that the two procedures were equally effective with respect to morbidity, mortality, and survival. We reviewed 15 RCTs, 2 prospective nonrandomized studies, and 2 meta-analyses of operative techniques and postoperative management designed to prevent pancreatic fistula. The results of the RCTs designed to prevent pancreatic fistula recommended duct-to-mucosa pancreaticojejunostomy or one-layer end-to-side pancreaticojejunostomy, equally. We also reviewed five RCTs of operative techniques and postoperative management designed to prevent DGE, which revealed that the antecolic route for duodenojejunostomy significantly reduced the incidence of DGE. Further RCTs to study innovative approaches to prevent postoperative complications after PD are warranted.
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Affiliation(s)
- Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama, 641-8510, Japan
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Pancreatoduodenectomy for ductal adenocarcinoma in the very elderly; is it safe and justified? J Gastrointest Surg 2010; 14:1826-31. [PMID: 20714937 DOI: 10.1007/s11605-010-1294-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 08/05/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND The outcomes of complex major surgery in the elderly are being scrutinized because of the demands on surgical services by an aging population and the concern whether such endeavors are justified. Pancreatoduodenectomy (PD) for pancreatic adenocarcinoma presents special challenges because of the high morbidity of the procedure, dismal prognosis of the disease, and the increasing incidence of pancreatic cancer with age. METHODS All patients who underwent PD for pancreatic adenocarcinoma from 1981 to 2007 were analyzed for perioperative outcomes, tumor-related parameters, use of adjuvant therapy, and long-term survival. Specifically those aged ≥80 years were compared with a control group aged ≤80 years. Continuous variables are displayed as median and interquartile range (IQR); log-rank test and Cox's proportional hazards were used to determine survival and effect of age as an independent marker against other covariates. RESULTS Fifty-three patients aged ≥80 years underwent PD. Twenty-six (51%) developed complications, including delayed gastric emptying (nine, 17%), pancreatic leak (six, 11%), and postoperative bleeding (five, 9%). There was one in-hospital death (2%). The hospital stay was 13.5 days (IQR 9-19). Forty-one (79%) patients were discharged home; of the 11 (21%) patients who went to an outside health care facility (pancreatic leak/drains and feeding issues--five, delayed gastric emptying/nutritional--four, no home support--one), one died in a nursing home at 5 months while the other ten patients returned to their previous abode (median 4 weeks). The median disease-free and overall survivals were 11.8 (IQR 7.8-18.4) and 13.5 months (IQR 12-21.3). Compared to the non-octogenarians (n = 567), the older population had more poor risk patients with respect to ASA status (P < 0.0004), stayed longer as in-patients (P < 0.04), were more likely to develop complications (P < 0.001), and were less likely to receive adjuvant therapy (P < 0.0001). There was no difference in long-term disease-free or overall survival (log-rank P < 0.30 and P < 0.14), and age did not appear to be an independent marker of prognosis when analyzed (Cox's proportional hazards P < 0.26; chi-square, 1.25). CONCLUSIONS In experienced institutions, PD for ductal adenocarcinoma is a viable option in the ambulatory octogenarian population who are deemed operative candidates for a PD. The trade off is a greater complication rate and the prospect of discharge (one in five) to a chronic care facility. The majority, however, can be discharged home with a reasonable functional status, and those discharged to temporary health care rehabilitation facilities are likely to make a recovery over a few weeks.
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[Survival, mortality and quality of life after pylorus-preserving or classical Whipple operation. A systematic review with meta-analysis]. Chirurg 2010; 81:454-71. [PMID: 20020091 DOI: 10.1007/s00104-009-1829-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Two surgical procedures are mainly performed for the treatment of pancreatic head cancer and periampullary carcinoma: the classical Whipple operation and the pylorus-preserving Whipple operation. METHODS This manuscript represents an extension of a systematic review and meta-analysis previously published in the Annals of Surgery. A systematic literature search was performed in MEDLINE, EMBASE and the Cochrane Library (central) to identify randomized controlled trials (RCTs) and observational studies. A meta-analysis based on a random-effects model was performed for the hazard ratios (HR) of survival and the odds ratios (OR) of postoperative mortality. The results of the different studies on quality of life (QoL) could not be summarized quantitatively in a meta-analysis and were therefore summarized qualitatively. Subgroup analyses were performed by study type, RCTs, prospective cohort studies (PSs), retrospective cohort studies (RSs), study quality and tumor localization (pancreatic head cancer versus periampullary carcinoma). RESULTS The systematic literature search retrieved 4,503 studies of which 4,460 did not fulfill the inclusion criteria. The remaining 43 studies (6 RCTs, 12 PSs and 25 RSs) representing 3,893 patients were finally included in the review. There was neither a significant survival difference for patients with pancreatic head cancer in the pooled estimate of the RCTs (HR 0.80; 95% CI 0.53-1.22; p=0.16) nor in the pooled estimate of the PSs (HR 0.84; 95% CI 0.7-1.0; p=0.95) or the RSs (HR 0.84; 95% CI 0.7-1.01; p=0.21). Survival of patients with periampullary carcinoma was not significantly different in the RCTs (HR 1.02; 95% CI 0.49-2.13; p=0.3), the PSs (HR 1.26; 95% CI 0.46-3.42; p=0.65) or the RSs (HR 0.86; 95% CI 0.6-1.24; p=0.33). Postoperative mortality was not significantly different after both types of operations (RCTs: HR 0.49; 95% CI 0.17-1.4; p=0.18; PSs: HR 0.63; 95% CI 0.34-1.18; p=0.15; RSs: HR 0.7; 95% CI 0.37-1.31; p=0.27). QoL was reported as either the same in both groups or in favor of the pylorus-preserving Whipple operation. CONCLUSIONS Mortality, survival and QoL were not significantly different between the classical Whipple and the pylorus-preserving Whipple operations. Given the poor quality of the underlying trials a pragmatic RCT is recommended to prove the findings of this systematic review.
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Weinberg BM, Spiegel BM, Tomlinson JS, Farrell JJ. Asymptomatic pancreatic cystic neoplasms: maximizing survival and quality of life using Markov-based clinical nomograms. Gastroenterology 2010; 138:531-40. [PMID: 19818780 PMCID: PMC2949077 DOI: 10.1053/j.gastro.2009.10.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2008] [Revised: 09/19/2009] [Accepted: 10/01/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The natural history and management of pancreatic cysts, especially for branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), remain uncertain. We developed evidence-based nomograms to assist with clinical decision making. METHODS We used decision analysis with Markov modeling to compare competing management strategies in a patient with a pancreatic head cyst radiographically suggestive of BD-IPMN, including the following: (1) initial pancreaticoduodenectomy (PD), (2) yearly noninvasive radiographic surveillance, (3) yearly invasive surveillance with endoscopic ultrasound, and (4) "do nothing." We derived probability estimates from a systematic literature review. The primary outcomes were overall and quality-adjusted survival. We depicted the results in a series of nomograms accounting for age, comorbidities, and cyst size. RESULTS Initial PD was the dominant strategy to maximize overall survival for any cyst greater than 2 cm, regardless of age or comorbidities. In contrast, surveillance was the dominant strategy for any lesion less than 1 cm. However, when measuring quality-adjusted survival, the do-nothing approach maximized quality of life for all cysts less than 3 cm in patients younger than age 75. Once age exceeded 85 years, noninvasive surveillance dominated. Initial PD did not maximize quality of life in any age group or cyst size. CONCLUSIONS Management of pancreatic cysts can be guided using novel Markov-based clinical nomograms, and depends on age, cyst size, comorbidities, and whether patients value overall survival vs quality-adjusted survival. For patients focused on overall survival, regardless of quality of life, surgery is optimal for lesions greater than 2 cm. For patients focused on quality-adjusted survival, a 3-cm threshold is more appropriate for surgery except for the extreme elderly.
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Affiliation(s)
- Benjamin M. Weinberg
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System,Division of Digestive Diseases, David Geffen School of Medicine at UCLA
| | - Brennan M.R. Spiegel
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System,Division of Digestive Diseases, David Geffen School of Medicine at UCLA,Department of Health Services, UCLA School of Public Health,UCLA/VA Center for Outcomes Research and Education
| | - James S. Tomlinson
- Department of Surgery, David Geffen School of Medicine at UCLA,Department of Surgery, VA Greater Los Angeles Healthcare System
| | - James J. Farrell
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System,Division of Digestive Diseases, David Geffen School of Medicine at UCLA
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Tran TCK, van Lanschot JJB, Bruno MJ, van Eijck CHJ. Functional changes after pancreatoduodenectomy: diagnosis and treatment. Pancreatology 2010; 9:729-37. [PMID: 20090394 DOI: 10.1159/000264638] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Relatively little is known about the gastrointestinal function after recovery of a pancreatoduodenectomy. This review focuses on the functional changes of the stomach, duodenum and pancreas that occur after pancreatoduodenectomy. Although the mortality in relation to pancreatoduodenectomy has decreased over the years, it remains associated with considerable morbidity, which occurs in 40-60% of patients. Physical complaints early after the operation are often caused by motility disorders, in particular delayed gastric emptying, which occurs in up to 40% of patients. During longer follow-up of these patients the occurrence of endocrine and exocrine pancreatic insufficiency becomes more predominant. Diabetes mellitus develops in 20-50% of patients after a pancreatic resection (pancreatogenic diabetes). The main presenting symptoms of exocrine insufficiency are weight loss and steatorrhea. Its presence is suspected on clinical ground and can be supported by fecal elastase-1 measurement. Exocrine insufficiency can be compensated with oral enteric-coated enzyme supplements. The quality of life issue will be addressed as an important outcome measurement after pancreaticoduodenectomy. Furthermore, the functional changes after pancreatoduodenectomy are described in detail with suggestions for diagnosis and treatment.
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Affiliation(s)
- T C Khe Tran
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.
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Rudloff U, Maker AV, Brennan MF, Allen PJ. Randomized Clinical Trials in Pancreatic Adenocarcinoma. Surg Oncol Clin N Am 2010; 19:115-50. [DOI: 10.1016/j.soc.2009.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Evans DB, Farnell MB, Lillemoe KD, Vollmer C, Strasberg SM, Schulick RD. Surgical Treatment of Resectable and Borderline Resectable Pancreas Cancer: Expert Consensus Statement. Ann Surg Oncol 2009; 16:1736-44. [DOI: 10.1245/s10434-009-0416-6] [Citation(s) in RCA: 173] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Revised: 01/31/2009] [Accepted: 02/01/2009] [Indexed: 12/15/2022]
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The effect of adjuvant and neoadjuvant chemo(radio)therapy on survival in 1,679 resected pancreatic carcinoma cases in Japan: report of the national survey in the 34th annual meeting of Japanese Society of Pancreatic Surgery. ACTA ACUST UNITED AC 2009; 16:485-92. [DOI: 10.1007/s00534-009-0077-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2008] [Accepted: 09/21/2008] [Indexed: 01/13/2023]
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Iqbal N, Lovegrove R, Tilney H, Abraham A, Bhattacharya S, Tekkis P, Kocher H. A comparison of pancreaticoduodenectomy with extended pancreaticoduodenectomy: A meta-analysis of 1909 patients. Eur J Surg Oncol 2009; 35:79-86. [DOI: 10.1016/j.ejso.2008.01.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 01/08/2008] [Indexed: 12/21/2022] Open
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Rupp CC, Linehan DC. Extended lymphadenectomy in the surgery of pancreatic adenocarcinoma and its relation to quality improvement issues. J Surg Oncol 2008; 99:207-14. [DOI: 10.1002/jso.21210] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Sauvanet A. [Not Available]. JOURNAL DE CHIRURGIE 2008; 145:12S31-12S35. [PMID: 22794069 DOI: 10.1016/s0021-7697(08)45006-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
A. Sauvanet Several factors argue for extended lymphadenectomy in surgery for pancreatic adenocarcinoma: 1) lymph node extension is an adverse prognostic factor; 2) some tumor recurrences are only loco-regional suggesting that initial resection was insufficient; 3) some retrospective studies suggest that extension of lymphadenectomy improves post-resection survival. Extended lymphadenectomy, including circumferential dissection of both the celiac axis and the superior mesenteric artery and resection of para-aortic nodes, was evaluated by 4 randomized trials; globally there was no survival benefit. Extended lymphadenectomy increases, at least transiently, the risk of post-operative diarrhea. Its influence on the rate of loco-regional recurrences has not been evaluated. However, this technique should not be definitively and globally precluded since a more radical resection was associated with a trend toward better long-term survival in the trial with the largest number of patients.
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