1
|
Zhang C, Zironda A, Vierkant RA, Starlinger P, Warner S, Smoot R, Kendrick M, Cleary S, Truty M, Thiels C. Quality of Life and Gastrointestinal Symptoms in Long-term Survivors of Pancreatic Cancer Following Pancreatoduodenectomy. Ann Surg 2024; 279:842-849. [PMID: 37497660 DOI: 10.1097/sla.0000000000006053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To describe long-term quality of life (QOL) and gastrointestinal (GI) symptoms in patients who underwent pancreatoduodenectomy for pancreatic cancer in the modern era. BACKGROUND As advances in pancreatic cancer management improve outcomes, it is essential to assess long-term patient-reported outcomes after surgery. METHODS Patients who underwent curative intent pancreatoduodenectomy for pancreatic cancer between January 2011 and June 2019 from a single center were identified. Patients alive ≥3 years after surgery were considered long-term survivors (LTS). LTS who were alive in June 2022 received a 55-question survey to assess their QOL (EORTC-QLQ-C30) and GI symptoms (EORTC-PAN26 and Problem Areas in Diabetes Questionnaire). Responses were compared against population norms. Clinicodemographic characteristics in LTS versus non-LTS and survey completion were compared. RESULTS Six hundred seventy-two patients underwent pancreatoduodenectomy for pancreatic cancer; 340 were LTS. One hundred thirty-seven patients of the 238 eligible to complete the survey responded (response rate: 58%). Compared to the US general population, LTS reported significantly higher QOL (75 vs 64; P <0.001), less nausea/vomiting, pain, dyspnea, insomnia, appetite loss, and constipation, but more diarrhea (all P <0.001). Most patients (n=136/137, 99%) reported experiencing postoperative GI symptoms related to pancreatic insufficiency (n=71/135, 53%), reflux (n=61/135, 45%), and delayed gastric emptying (n=31/136, 23%). Most patients (n=113/136, 83%) reported that digestive symptoms overall had little to no impact on QOL, and 91% (n=124/136) would undergo surgery again. CONCLUSIONS Despite known long-term complications following pancreatoduodenectomy, cancer survivors appear to have excellent QOL. Specific long-term gastrointestinal symptoms data should be utilized for preoperative education and follow-up planning.
Collapse
Affiliation(s)
- Chi Zhang
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester, MN
| | - Andrea Zironda
- Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, MN
| | - Robert A Vierkant
- Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, MN
| | | | - Susanne Warner
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Rory Smoot
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | | | - Sean Cleary
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Mark Truty
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | | |
Collapse
|
2
|
Schleimer LE, Chabot JA, Kluger MD. Innovation in the Surgical Management of Pancreatic Cystic Neoplasms: Same Operations, Narrower Indications, and an Individualized Approach to Decision-Making. Gastrointest Endosc Clin N Am 2023; 33:655-677. [PMID: 37245941 DOI: 10.1016/j.giec.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Historically, the management of pancreatic cystic neoplasms (PCN) has been operative. Early intervention for premalignant lesions, including intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN), offers an opportunity to prevent pancreatic cancer-with potential decrement to patients' short-term and long-term health. The operations performed have remained fundamentally the same, with most patients undergoing pancreatoduodenectomy or distal pancreatectomy using oncologic principles. The role of parenchymal-sparing resection and total pancreatectomy remains controversial. We review innovations in the surgical management of PCN, focusing on the evolution of evidence-based guidelines, short-term and long-term outcomes, and individualized risk-benefit assessment.
Collapse
Affiliation(s)
- Lauren E Schleimer
- Department of Surgery, Columbia University Irving Medical Center, 177 Fort Washington Avenue, 8 Garden South, New York, NY 10032, USA. https://twitter.com/lschleim
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 819, New York, NY 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 823, New York, NY 10032, USA.
| |
Collapse
|
3
|
Papaefthymiou A, Johnson GJ, Maida M, Gkolfakis P, Ramai D, Facciorusso A, Arvanitakis M, Ney A, Fusai GK, Saftoiu A, Tabacelia D, Phillpotts S, Chapman MH, Webster GJ, Pereira SP. Performance and Safety of EUS Ablation Techniques for Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15092627. [PMID: 37174092 PMCID: PMC10177078 DOI: 10.3390/cancers15092627] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Pancreatic cystic lesions (PCL) represent an increasingly diagnosed condition with significant burden to patients' lives and medical resources. Endoscopic ultrasound (EUS) ablation techniques have been utilized to treat focal pancreatic lesions. This systematic review with meta-analysis aims to assess the efficacy of EUS ablation on PCL in terms of complete or partial response and safety. METHODS A systematic search in Medline, Cochrane and Scopus databases was performed in April 2023 for studies assessing the performance of the various EUS ablation techniques. The primary outcome was complete cyst resolution, defined as cyst disappearance in follow-up imaging. Secondary outcomes included partial resolution (reduction in PCL size), and adverse events rate. A subgroup analysis was planned to evaluate the impact of the available ablation techniques (ethanol, ethanol/paclitaxel, radiofrequency ablation (RFA), and lauromacrogol) on the results. Meta-analyses using a random effects model were conducted and the results were reported as percentages with 95% confidence intervals (95%CI). RESULTS Fifteen studies (840 patients) were eligible for analysis. Complete cyst resolution after EUS ablation was achieved in 44% of cases (95%CI: 31-57; 352/767; I2 = 93.7%), and the respective partial response rate was 30% (95%CI: 20-39; 206/767; I2 = 86.1%). Adverse events were recorded in 14% (95%CI: 8-20; 164/840; I2 = 87.2%) of cases, rated as mild in 10% (95%CI: 5-15; 128/840; I2 = 86.7%), and severe in 4% (95%CI: 3-5; 36/840; I2 = 0%). The subgroup analysis for the primary outcome revealed rates of 70% (95%CI: 64-76; I2 = 42.3%) for ethanol/paclitaxel, 44% (95%CI: 33-54; I2= 0%) for lauromacrogol, 32% (95%CI: 27-36; I2 = 88.4%) for ethanol, and 13% (95%CI: 4-22; I2 = 95.8%) for RFA. Considering adverse events, the ethanol-based subgroup rated the highest percentage (16%; 95%CI: 13-20; I2 = 91.0%). CONCLUSION EUS ablation of pancreatic cysts provides acceptable rates of complete resolution and a low incidence of severe adverse events, with chemoablative agents yielding higher performance rates.
Collapse
Affiliation(s)
- Apostolis Papaefthymiou
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
| | - Gavin J Johnson
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, General Hospital of Nea Ionia "Konstantopoulio-Patision", 14233 Athens, Greece
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, 37920 Foggia, Italy
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Alexander Ney
- Institute for Liver and Digestive Health, University College London, London NW3 2PF, UK
| | - Giuseppe K Fusai
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London NW3 2QG, UK
| | - Adrian Saftoiu
- Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy "Carol Davila", 4192910 Bucharest, Romania
| | - Daniela Tabacelia
- Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy "Carol Davila", 4192910 Bucharest, Romania
| | - Simon Phillpotts
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
| | - Michael H Chapman
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
| | - George J Webster
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
| | - Stephen P Pereira
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
- Institute for Liver and Digestive Health, University College London, London NW3 2PF, UK
| |
Collapse
|
4
|
Pollini T, Marchegiani G, Facciorusso A, Balduzzi A, Biancotto M, Bassi C, Maker AV, Salvia R. It is not necessary to resect all mucinous cystic neoplasms of the pancreas: current guidelines do not reflect the actual risk of malignancy. HPB (Oxford) 2023:S1365-182X(23)00074-6. [PMID: 37003852 DOI: 10.1016/j.hpb.2023.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 02/06/2023] [Accepted: 03/03/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Mucinous Cystic Neoplasms (MCN) of the pancreas are premalignant cysts for which current guidelines support pancreatic resection. The primary aim of this systematic review and meta-analysis is to define the pooled rate of malignancy for MCN. METHODS A systematic review of eligible studies published between 2000 and 2021 was performed on PubMed and Embase. Primary outcome was rate of malignancy. Data regarding high-risk features, including cyst size and mural nodules, were collected and analyzed. RESULTS A total of 40 studies and 3292 patients with resected MCN were included in the final analysis. The pooled rate of malignancy was 16.1% (95%CI 13.1-19.0). The rate of malignant MCN in studies published before 2012 was significantly higher than that of studies published after recent guidelines were published (21.0% vs 14.9%, p < 0.001). Malignant MCN were larger than benign (mean difference 25.9 mm 95%CI 14.50-37.43, p < 0.001) with a direct correlation between size and presence of malignant MCN (R2 = 0.28, p = 0.020). A SROC identified a threshold of 65 mm to be associated with the diagnosis of malignant MCN. Presence of mural nodules was associated with the diagnosis of a malignant MCN (OR = 4.34, 95%CI 3.00-6.29, p < 0.001). CONCLUSION Whereas guidelines recommend resection of all MCN, the rate of malignancy in resected MCN is 16%, implying that surveillance has a role in most cases, and that surgical selection criteria are warranted. Size and presence of mural nodules are significantly associated with an increased risk of malignant degeneration, small MCN and without mural nodules can be considered for surveillance.
Collapse
Affiliation(s)
- Tommaso Pollini
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, USA; The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Giovanni Marchegiani
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Alberto Balduzzi
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Marco Biancotto
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Claudio Bassi
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, USA
| | - Roberto Salvia
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy.
| |
Collapse
|
5
|
Faccioli N, Santi E, Foti G, D’Onofrio M. Cost-effectiveness analysis of including contrast-enhanced ultrasound in management of pancreatic cystic neoplasms. LA RADIOLOGIA MEDICA 2022; 127:349-359. [PMID: 35230618 PMCID: PMC8989810 DOI: 10.1007/s11547-022-01459-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 01/21/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Pancreatic cystic neoplasms (PCN) management consists of non-invasive imaging studies (CT, MRI), with a high resource burden. We aimed to determine the cost-effectiveness of including contrast-enhanced ultrasound (CEUS) in the management of PCN without risk features. MATERIALS AND METHODS By using a decision-tree model in a hypothetical cohort of patients, we compared management strategy including CEUS with the latest Fukuoka consensus, European and Italian guidelines. Our strategy for BD-IPMN/MCN < 1 cm includes 1 CEUS annually. For those between 1 and 2 cm, it includes CEUS 4 times/year during the first year, then 3 times/year for 4 years and then annually. For those between 2 and 3 cm, it comprises MRI twice/year during the first one, then alternating 2 CEUS and 1 MRI yearly. RESULTS CEUS surveillance is the dominant strategy in all scenarios. CEUS surveillance average cost is 1,984.72 €, mean QALY 11.79 and mean ICER 181.99 €. If willingness to pay is 30,000 €, 45% of patients undergone CEUS surveillance of BDIPMN/MCN < 1 cm would be within budget. CONCLUSION Guidelines strategies are very effective, but costs are relatively high from a policy perspective. CEUS surveillance may be a cost-effective strategy yielding a nearly high QALYs, an acceptable ICER, and a lower cost.
Collapse
Affiliation(s)
- Niccolo’ Faccioli
- Present Address: Department of Radiology, G.B. Rossi Hospital, Università di Verona, Piazzale L.A.Scuro 10, 37134 Verona, Italy
| | - Elena Santi
- Present Address: Department of Radiology, G.B. Rossi Hospital, Università di Verona, Piazzale L.A.Scuro 10, 37134 Verona, Italy
| | - Giovanni Foti
- IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Mirko D’Onofrio
- Present Address: Department of Radiology, G.B. Rossi Hospital, Università di Verona, Piazzale L.A.Scuro 10, 37134 Verona, Italy
| |
Collapse
|
6
|
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.
Collapse
Affiliation(s)
- Clare Toms
- From the Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney Local Health District
| | | | | | | | | |
Collapse
|
7
|
[Quality of indications in cystic lesions of the pancreas]. Chirurg 2020; 91:736-742. [PMID: 32642818 DOI: 10.1007/s00104-020-01217-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cystic tumors of the pancreas (PCN) have increasingly gained importance in the clinical routine as they are frequently diagnosed as an incidental finding due to the continuous improvement in cross-sectional imaging. A differentiation is made between non-neoplastic and neoplastic cysts, whereby the latter has a tendency to malignant transformation to a varying extent. Therefore, they can be considered as precursor lesions of pancreatic cancer (PDAC). In addition to a detailed patient history and examination, imaging modalities, such as computed tomography (CT), magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) with fine needle aspiration (FNA) are used for the differential diagnosis. The indications for surgical resection of these lesions are based on the current European guidelines from 2018; however, the content is not evidence-based but relies on knowledge and recommendations from experts. According to these consensus recommendations asymptomatic serous cystic neoplasms (SCN) are serous lesions with a low tendency for malignant transformation and can be monitored. In contrast resection is warranted for all mucinous cystic neoplasms (MCN) >4 cm and all solid pseudopapillary neoplasms (SPN). Intraductal papillary mucinous neoplasms (IPMN), which are differentiated into main duct (MD-IPMN) and branch duct type (BD-IPMN) IPMN based on the position in the pancreatic duct system, should be resected as MD-IPMN and mixed type (MT)-IPMN. The risk of malignant transformation in BD-IPMN is variable and depends on risk factors, which are defined clinically and by imaging morphology. The treatment management is therefore carried out on an individual basis following risk estimation. In order to quantify the quality of indications in PCN and thereby also contributing to optimized medical care, prospective long-term studies are urgently needed.
Collapse
|
8
|
Pathanki AM, Attard JA, Bradley E, Powell-Brett S, Dasari BVM, Isaac JR, Roberts KJ, Chatzizacharias NA. Pancreatic exocrine insufficiency after pancreaticoduodenectomy: Current evidence and management. World J Gastrointest Pathophysiol 2020; 11:20-31. [PMID: 32318312 PMCID: PMC7156847 DOI: 10.4291/wjgp.v11.i2.20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/13/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is the commonest procedure performed for pancreatic cancer. Pancreatic exocrine insufficiency (PEI) may be caused or exacerbated by surgery and remains underdiagnosed and undertreated. The aim of this review was to ascertain the incidence of PEI, its consequences and management in the setting of PD for indications other than chronic pancreatitis. A literature search of databases (MEDLINE, EMBASE, Cochrane and Scopus) was carried out with the MeSH terms “pancreatic exocrine insufficiency” and “Pancreaticoduodenectomy”. Studies that analysed PEI and its complications in the setting of PD for malignant and benign disease were included. Studies reporting PEI in the setting of PD for chronic pancreatitis, conference abstracts and reviews were excluded. The incidence of PEI approached 100% following PD in some series. The pre-operative incidence varied depending on the characteristics of the patient cohort and it was higher (46%-93%) in series where pancreatic cancer was the predominant indication for surgery. Variability was also recorded with regards to the method used for the diagnosis and evaluation of pancreatic function and malabsorption. Pancreatic enzyme replacement therapy is the mainstay of the management. PEI is common and remains undertreated after PD. Future studies are required for the identification of a well-tolerated, reliable and reproducible diagnostic test in this setting.
Collapse
Affiliation(s)
- Adithya M Pathanki
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Joseph A Attard
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Elizabeth Bradley
- Department of Nutrition and Dietetics, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Sarah Powell-Brett
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Bobby V M Dasari
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - John R Isaac
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Keith J Roberts
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Nikolaos A Chatzizacharias
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| |
Collapse
|
9
|
Shah KP, Baugh KA, Brubaker LS, Van Buren G, Villafane-Ferriol N, McElhany AL, Mohamed S, Silberfein EJ, Hsu C, Massarweh NN, Tran Cao HS, Mendez-Reyes JE, Fisher WE. Long-Term Assessment of Pancreatic Function After Pancreatectomy for Cystic Neoplasms. J Surg Res 2019; 247:547-555. [PMID: 31740011 DOI: 10.1016/j.jss.2019.09.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/20/2019] [Accepted: 09/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND With advances in cross-sectional imaging, pancreatic cysts are more frequently diagnosed and have become a common indication for pancreatectomy. The impact of pancreatectomy in these patients is important. The purpose of this study was to assess short-term outcomes, long-term nutritional status, quality of life (QOL), and pancreas function after pancreatectomy for cystic neoplasms. MATERIALS AND METHODS At a single institution, patients at least 3 y post-pancreatectomy for benign cystic neoplasms were identified. Using a validated questionnaire, short-term outcomes, long-term outcomes including endocrine and exocrine insufficiency, long-term nutritional status, and preoperative and postoperative QOL were compared based on operation and indication for resection. RESULTS Among 102 eligible patients, 70 had valid contact information and 51 (72.9%) agreed to participate. Median follow-up was 6 (4-8) y. Patients undergoing pancreatoduodenectomy for benign cysts had higher morbidity than a similar cohort resected for pancreatic adenocarcinoma (patients with at least 1 ≥ grade 2 complication [49.0% versus 31.6%, P = 0.038]). After long-term follow-up, pancreatectomy did not significantly affect perceived QOL. Half of patients had mild-moderate or severe malnourishment, but pancreatic enzyme replacement was reported by only 4 (7.8%) patients. New-onset diabetes was present in 15 (29.4%) patients with median time-to-diagnosis of 6 (1-12) mo after resection. CONCLUSIONS Pancreatectomy for benign cysts did not negatively impact patients' perceived QOL. However, after long-term follow-up, malnutrition and pancreatic insufficiency occurred in a significant percentage and may be greater than previously estimated. Consideration of short- and long-term outcomes should factor into preoperative counseling, especially in cysts with minimal risk of progression to malignancy.
Collapse
Affiliation(s)
- Kevin P Shah
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Katherine A Baugh
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Lisa S Brubaker
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - George Van Buren
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Amy L McElhany
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sadde Mohamed
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Eric J Silberfein
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Cary Hsu
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nader N Massarweh
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Hop S Tran Cao
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Jose E Mendez-Reyes
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - William E Fisher
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
| |
Collapse
|
10
|
Decision-Making for the Management of Cystic Lesions of the Pancreas: How Satisfied Are Patients with Surgery? J Gastrointest Surg 2018; 22:88-97. [PMID: 28875275 DOI: 10.1007/s11605-017-3564-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/24/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION This study aims to understand patients' perspectives and satisfaction with choosing surgery for the treatment of pancreatic cystic lesions (PCLs). METHODS A 62-question survey was administered to 113 patients who had a resection for a PCL by 12 surgeons at two pancreatic specialty centers (2004-2016). Patients' final diagnoses and perioperative outcomes were correlated to the survey's results using univariate analysis. RESULTS Fear of cancer was quite or extremely important in most respondents' decision to have surgery (95.4%). Respondents were quite or fully satisfied with the outcomes of surgery (91.1%) and with the decision-making process (89.3%). Distress from anxiety about the cyst before surgery (58.6%) largely outweighed that from postsurgical lifestyle changes (14.4%). Furthermore, 88.7% of patients with pathologically non-malignant disease were quite or fully satisfied with their decision to have surgery, and patients with mucinous neoplasms reported high satisfaction rates independent of grade of dysplasia or malignancy (p = 0.641). CONCLUSION Patients with a resected PCL are highly satisfied with their decision to have surgery, regardless of the final diagnosis or clinical outcome. Fear of cancer is the main driver in the decision-making process, and the anxiety of harboring a cyst is a greater cause of distress than are postsurgical lifestyle changes.
Collapse
|
11
|
Moris M, Wallace MB. Intraductal papillary mucinous neoplasms and mucinous cystadenomas: current status and recommendations. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:358-367. [PMID: 28112959 DOI: 10.17235/reed.2017.4630/2016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The real prevalence of pancreatic cystic lesions remains unknown. The malignant potential of some of these lesions remains a cause for significant concern. Thus, it is mandatory to develop a strategy to clearly discriminate those cysts with a potential for malignant transformation from those that do not carry any significant risk. Intraductal papillary mucinous neoplasms and mucinous cystadenomas are mucinous cystic neoplasms with a known malignant potential that have gained greater recognition in recent years. However, despite the numerous studies that have been carried out, their differential diagnosis among other cysts subtypes and their therapeutic approach continue to be a challenge for clinicians. This review contains a critical approach of the current recommendations and management strategies regarding intraductal papillary mucinous neoplasms and mucinous cystadenomas, as well as highlighting the limitations exposed in current guidelines.
Collapse
|
12
|
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.
Collapse
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
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Scavini M, Dugnani E, Pasquale V, Liberati D, Aleotti F, Di Terlizzi G, Petrella G, Balzano G, Piemonti L. Diabetes after pancreatic surgery: novel issues. Curr Diab Rep 2015; 15:16. [PMID: 25702096 DOI: 10.1007/s11892-015-0589-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In the developed world, pancreatic surgery is becoming more common, with an increasing number of patients developing diabetes because of either partial or total pancreatectomy, with a significant impact on quality of life and survival. Although these patients are expected to consume increasing health care resources in the near future, many aspects of diabetes after pancreatectomy are still not well defined. The treatment of diabetes in these patients takes advantage of the therapies used in type 1 and 2 diabetes; however, no specific guidelines for its management, both immediately after pancreatic surgery or in the long term, have been developed. In this article, on the basis of both the literature and our clinical experience, we address the open issues and discuss the most appropriate therapeutic options for patients with diabetes after pancreatectomy.
Collapse
Affiliation(s)
- Marina Scavini
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|