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Nanashima A, Hiyoshi M, Imamura N, Yano K, Hamada T, Kai K, Nishida T, Uchise Y, Sakamoto R, Inomata M. Preoperative Prognostic Nutritional Index is a significant predictive factor for posthepatectomy bile leakage. Ann Hepatobiliary Pancreat Surg 2021; 25:477-484. [PMID: 34845119 PMCID: PMC8639299 DOI: 10.14701/ahbps.2021.25.4.477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/19/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims It is known that preoperative nutritional status can influence patient outcomes after hepatectomy. Prognostic Nutritional Index (PNI) is a useful parameter to reflect patient outcomes undergoing gastro-intestinal surgery. The aim of this study was to retrospectively evaluate relationships of nutritional parameters, demographics, and surgical records with postoperative outcomes in a cohort study. Methods Curative hepatectomy was performed for 182 patients at the University of Miyazaki between 2015 and 2018. Each preoperative level of albumin, prealbumin, lymphocyte, total cholesterol, or the comprehensively calculated Onodera's PNI was examined as a nutritional parameter. Results The mean PNI was 39.6 ± 5.1, with PNI below 40 observed in 91 (50.0%) patients. Nutritional parameters were not different among patients with various liver diseases. Serum albumin or prealbumin level was significantly correlated with each hepatic parameter (p < 0.01). Prealbumin and total cholesterol levels were significantly correlated with postoperative prothrombin activity (p < 0.05). Albumin or prealbumin levels and PNI were significantly lower in patients with posthepatectomy complications, particularly bile leakage in comparison those without such complications (p < 0.05). Multiple logistic analysis showed that albumin level was an independent risk factor for complications after hepatectomy (risk ratio [RR]: 1.33) and that lymphocyte count was an independent risk factor for bile leakage (RR: 1.28) (p < 0.05). The cut-off level of albumin was approximately 3.8 mg/dL and that of lymphocyte count was 1,320/mm3. Conclusions Preoperative PNI reflected perioperative liver functional status. It was a predictive parameter for postoperative complications, particularly biliary leakage.
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Affiliation(s)
- Atsushi Nanashima
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Masahide Hiyoshi
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Naoya Imamura
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Koichi Yano
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Takeomi Hamada
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Kengo Kai
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Takahiro Nishida
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Yukako Uchise
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Risa Sakamoto
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Mayu Inomata
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
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Wu L, Nahm CB, Jamieson NB, Samra J, Clifton-Bligh R, Mittal A, Tsang V. Risk factors for development of diabetes mellitus (Type 3c) after partial pancreatectomy: A systematic review. Clin Endocrinol (Oxf) 2020; 92:396-406. [PMID: 32017157 DOI: 10.1111/cen.14168] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 02/02/2020] [Accepted: 02/02/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Type 3c diabetes mellitus (T3cDM) occurring post pancreatectomy can be challenging to treat due to the frequent combination of decreased circulating levels of insulin and glucagon and concurrent exocrine insufficiency. Relatively, little is known regarding the risk factors for development of T3cDM post pancreatectomy. Our aim was to review the literature and assess what is known of the risk factors for the development of new-onset DM following partial pancreatic resection and where possible determines the incidence, time of onset and the management approach to hyperglycaemia in this context. DESIGN Medline and Embase databases were reviewed using specific keyword criteria. Original manuscripts published in 1990 or later included. Articles with study population <20, lacking information on new-onset DM, follow-up duration or specifically targeting rare procedures/pathology were excluded. The Newcastle Ottawa Quality Assessment form was applied. Results reported according to PRISMA guidelines. Pooled effect size calculated using random effects model. PATIENTS Thirty six articles were identified that described a total of 5636 patients undergoing pancreaticoduodenectomy, 3922 patients having distal pancreatectomy and 315 with central pancreatectomy. RESULTS The incidence of new-onset DM was significantly different between different types of resection from 9% to 24% after pancreaticoduodenectomy (pooled estimate 16%; 95% CI: 14%-17%), 3%-40% after distal pancreatectomy (pooled estimate 21%; 95% CI: 16%-25%) and 0%-14% after central pancreatectomy (pooled estimate 6%; 95% CI: 3%-9%). Surgical site, higher preoperative HbA1c, fasting plasma glucose and lower remnant pancreatic volume had strongest associations with new-onset DM. CONCLUSIONS This systematic review supports that risk of development of T3cDM is associated with type of pancreatic resection, lower remnant pancreatic volume and higher preoperative HbA1c.
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Affiliation(s)
- Linda Wu
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nigel B Jamieson
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Jaswinder Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
- Faculty of Medical and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Venessa Tsang
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Nanashima A, Hiyoshi M, Imamura N, Yano K, Hamada T, Hamada R, Nagatomo K, Ikenoue M, Tobinaga S, Nagayasu T. Clinical significance of preoperative nutritional parameter and patient outcomes after pancreatectomy: A retrospective study at two academic institute. Ann Hepatobiliary Pancreat Surg 2019; 23:168-173. [PMID: 31225419 PMCID: PMC6558137 DOI: 10.14701/ahbps.2019.23.2.168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 01/09/2023] Open
Abstract
Backgrounds/Aims Preoperative nutritional status has been reported to influence patient outcomes after pancreatectomy. The Prognostic Nutritional Index (PNI) is a useful parameter to reflect the outcomes of patients undergoing gastrointestinal surgery. Therefore, the relationship between the PNI and clinicopathological factors, surgical data, and postoperative morbidity were retrospectively evaluated at two academic institutes in a cohort study. Methods Curative pancreatectomy was performed on 222 patients at the University of Nagasaki between 1995 and March 2015, and 101 at the University of Miyazaki between April 2015and March 2018. The PNI was calculated using preoperative albumin and total cholesterol levels. Results The mean PNI in our series was 39.2±5.4 and the prevalence of PNIs less than 40 was observed in 134 patients (44%). The PNI was not significantly different between normal, hard, and fatty architecture of the pancreatic parenchyma. The PNIs were significantly negatively correlated with higher age (p<0.01), but not with gender, co-morbidity, or habits. The PNI was significantly correlated with levels of hemoglobin, prothrombin activity, choline esterase, total protein, albumin and cholesterol (p<0.01), and with postoperative total protein and albumin levels (p<0.05). Although the preoperative PNI tended to be lower in patients with total postoperative complications, no significant differences for each complication were observed. Conclusions Although the preoperative PNIs reflect the perioperative nutritional status, its predictive usefulness for postoperative complications could not be significantly confirmed.
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Affiliation(s)
- Atsushi Nanashima
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan.,Department of Surgical Oncology, Nagasaki University School of Biomedical Sciences, Nagasaki, Japan
| | - Masahide Hiyoshi
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Naoya Imamura
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Koichi Yano
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Takeomi Hamada
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Rouko Hamada
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Kenzo Nagatomo
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Makoto Ikenoue
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Shuichi Tobinaga
- Department of Surgical Oncology, Nagasaki University School of Biomedical Sciences, Nagasaki, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University School of Biomedical Sciences, Nagasaki, Japan
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Yüksel A, Bostancı EB, Çolakoğlu MK, Ulaş M, Özer İ, Karaman K, Akoğlu M. Pancreatic stump closure using only stapler is associated with high postoperative fistula rate after minimal invasive surgery. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 29:XXXX. [PMID: 29749326 DOI: 10.5152/tjg.2018.17567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND/AIMS Postoperative pancreatic fistula (POPF) is the most common cause of morbidity and mortality after distal pancreatectomy (DP). The aim of the present study is to determine the risk factors that can lead to POPF. MATERIALS AND METHODS The study was conducted between January 2008 and December 2012. A total of 96 patients who underwent DP were retrospectively analyzed. RESULTS Overall, 24 patients (25%) underwent laparoscopic distal pancreatectomy (LDP) and 72 patients (75%) open surgery. The overall morbidity rate was 51% (49/96). POPF (32/96, 33.3%) was the most common postoperative complication. Grade B fistula (18/32, 56.2%) was the most common fistula type according to the International Study Group on Pancreatic Fistula definition. POPF rate was significantly higher in the minimally invasive surgery group (50%, p=0.046). POPF rate was 58.6% (17/29) in patients whose pancreatic stump closure was performed with only stapler, whereas POPF rate was 3.6% (1/28) in the group where the stump was closed with stapler plus oversewing sutures. Both minimally invasive surgery (OR: 0.286, 95% CI: 0.106-0.776, p=0.014) and intraoperative blood transfusion (OR: 4.210, 95% CI: 1.155-15.354, p=0.029) were detected as independent risk factors for POPF in multi-variety analysis. CONCLUSION LDP is associated with a higher risk of POPF when stump closure is performed with only staplers. Intraoperative blood transfusion is another risk factor for POPF. On the other hand, oversewing sutures to the stapler line reduces the risk of POPF.
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Affiliation(s)
- Adem Yüksel
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - Erdal Birol Bostancı
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - Muhammet Kadri Çolakoğlu
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - Murat Ulaş
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - İlter Özer
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - Kerem Karaman
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - Musa Akoğlu
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
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Farkas G, Leindler L, Márton J, Lázár G, Farkas Jr G. Polysorb R (an absorbable lactomer) staples, a safe closure technique for distal pancreatic resection. World J Gastroenterol 2014; 20:17185-17189. [PMID: 25493034 PMCID: PMC4258590 DOI: 10.3748/wjg.v20.i45.17185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/28/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate twenty-year experience evaluated the use of the PolysorbR (an absorbable lactomer) staples for distal pancreatic resection.
METHODS: The data on 150 patients [92 men, 58 women, mean age 52 (24-72) years] who underwent distal pancreatectomy (DP) in the last 20 years were collected prospectively from an electronic database. The diagnosis was confirmed by endoscopic retrograde cholangiopancreatography, sonography, computed tomography and/or magnetic resonance imaging. The indications for DP were focal pancreatic necrosis, spontaneous pancreatic fistulas, abscesses, pseudocysts, segmental chronic obstructive pancreatitis in the tail, traumatic disruption, and benign (cystadenomas, insulinomas, or glucagonomas) or malignant tumours. The distal resections were performed without splenectomy in 29 of the 150 patients (19%). In the event of splenectomy, the splenic artery and vein were individually ligated, the TA-55 Auto Suture stapler, loaded with Premium PolysorbR 55 staples (5.5 mm), was placed across the gland, and the trigger was pulled, the action of which produced two staggered absorbable suture lines. The gland distal to the stapler was then amputated with a scalpel on the TA-55 stapler and the two rows of staples were left in the proximal pancreatic stump. After the distal resection, a drainage tube was inserted into the pancreatic bed.
RESULTS: The average duration of the operation was 150 min (range: 90-210 min) and no transfusion was indicated during the operation. After DP in one patient a type B fistula was diagnosed, which was treated successfully by conservative treatment comprising of 12-d octreotide medication (3 × 0.1 mg/d) and jejunal feeding. The incidence of postoperative pancreatic fistula was therefore 0.6%. Another 2 patients suffered postoperative pancreatitis, which was also conservatively treated. Reoperations were performed in 2 patients on the first or second postoperative day, necessitated by bleeding from the retroperitoneal region. The morbidity was 3.3% (5 patients), but no mortality occurred in the postoperative period. Overall, the postoperative period was uneventful without any complications (pancreatic fistula, abscess, bleeding or wound infection) in 145 patients. The length of the postoperative stay ranged between 8 and 16 d. For the 145 patients who had no any postoperative complications, the hospital stay was 8 or 9 d. No mortality occurred in the follow-up period (6 or 12 mo postoperatively); but 6 mo after surgery one patient suffered a pseudocyst following recurrent pancreatitis and was treated with cystojejunostomy.
CONCLUSION: Our clinical results demonstrated that the application of absorbable lactomer staples for distal pancreatic resection is a safe alternative to the standard closure technique.
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Dominguez-Comesaña E, Gonzalez-Rodriguez FJ, Ulla-Rocha JL, Lede-Fernandez Á, Portela-Serra JL, Piñon-Cimadevila MÁ. Morbimortalidad de la resección pancreática. Cir Esp 2013; 91:651-8. [DOI: 10.1016/j.ciresp.2012.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Revised: 12/11/2012] [Accepted: 12/16/2012] [Indexed: 12/19/2022]
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Das SK, Sarkar S, Dash R, Dent P, Wang XY, Sarkar D, Fisher PB. Chapter One---Cancer terminator viruses and approaches for enhancing therapeutic outcomes. Adv Cancer Res 2013; 115:1-38. [PMID: 23021240 DOI: 10.1016/b978-0-12-398342-8.00001-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
No single or combinatorial therapeutic approach has proven effective in decreasing morbidity or engendering a cure of metastatic cancer. In principle, conditionally replication-competent adenoviruses that induce tumor oncolysis through cancer-specific replication hold promise for cancer therapy. However, a single-agent approach may not be adequate to completely eradicate cancer in a patient because most cancers arise from abnormalities in multiple genetic and signal transduction pathways and targeting disseminated metastases is difficult to achieve. Based on these considerations, a novel class of cancer destroying adenoviruses have been produced, cancer terminator viruses (CTVs), in which cancer-specific replication is controlled by the progression-elevated gene-3 promoter and replicating viruses produce a second transgene encoding an apoptosis-inducing and immunomodulatory cytokine, either melanoma differentiation-associated gene-7/interleukin-24 (mda-7/IL-24) or interferon-γ. This review focuses on these viruses and ways to improve their delivery systemically and enhance their therapeutic efficacy.
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Affiliation(s)
- Swadesh K Das
- Department of Human and Molecular Genetics, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
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Hackert T, Büchler MW. Remnant closure after distal pancreatectomy: current state and future perspectives. Surgeon 2011; 10:95-101. [PMID: 22113052 DOI: 10.1016/j.surge.2011.10.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 09/02/2011] [Accepted: 10/18/2011] [Indexed: 02/06/2023]
Abstract
Remnant closure after distal pancreatectomy remains a surgical challenge and is still associated with a fistula rate of about 30%. Despite numerous technical modifications including the use of stapling devices, artificial patches and glue components, no important progress has been made concerning this topic within the last decade. Although tissue texture, co-morbidities and the type of resection may influence fistula rate, substantial improvement can probably be reached by further technical modifications. In addition to the avoidance of fistula development, the recognition and management of this complication is essential to achieve good postoperative outcome. The present review summarizes the currently available data on technical approaches, incidence and risk factors for failure of remnant closure, fistula-associated complications and management as well as the future perspectives in this field of surgery.
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Affiliation(s)
- Thilo Hackert
- Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Hall MA. Chronic pancreatitis: an update for home care and hospice clinicians. HOME HEALTHCARE NURSE 2011; 29:562-570. [PMID: 21956011 DOI: 10.1097/nhh.0b013e31822eb6e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Chronic pancreatitis is a relentlessly painful condition associated most commonly with alcoholism. Patients suffer wasting and depression as a result of chronic pain. It is important for home care clinicians to recognize the signs of pancreatitis and understand the current evidence-based treatment strategies to control the symptoms. Although alcoholism and depression are frequent comorbidities of pancreatitis, a full discussion of alcoholism and depression is outside the scope of this article.
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Affiliation(s)
- Mellisa A Hall
- University of Southern Indiana, Evansville, Indiana, USA.
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Transcriptional control of gene expression in pancreatic cancer: from sequence-specific transcription factors to nuclear architecture. J Gastrointest Cancer 2011; 42:73-5. [PMID: 21279553 DOI: 10.1007/s12029-011-9254-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Transcription plays a central role in the regulation of gene expression during neoplastic transformation in different tissues. Using this nuclear process as a common topic in this special issue of the Journal of Gastrointestinal Cancer we have covered with five review articles key aspects of gene transcription and its impact in pancreatic carcinogenesis. We are confident that the knowledge included in these review articles will help understand the contribution of this molecular event to the pathogenesis of this devastating disease and serve as foundation for the development of new therapeutic tools.
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Hackert T, Werner J, Büchler MW. Postoperative pancreatic fistula. Surgeon 2010; 9:211-7. [PMID: 21672661 DOI: 10.1016/j.surge.2010.10.011] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2010] [Revised: 10/10/2010] [Accepted: 10/14/2010] [Indexed: 12/16/2022]
Abstract
Postoperative pancreatic fistula is an important complication after pancreatic resection. The frequency of its incidence varies between 3% after pancreatic head resections and up to 30% following distal pancreatectomy. In recent years, the international definition of pancreatic fistula has been standardised according to the approach of the International Study Group on Pancreatic Fistula (ISGPF). Consequently, results from different studies have become comparable and the historically reported fistula rates can be evaluated more critically. The present review summarises the currently available data on incidence, risk factors, fistula-associated complications and management of postoperative pancreatic fistula.
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Affiliation(s)
- Thilo Hackert
- Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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