Evaluation of Postoperative Quality of Life After Pancreatic Surgery and Determination of Influencing Risk Factors

Which technical difficulty score can best predict postoperative outcomes after minimally invasive liver resections?

BACKGROUND

To assess technical difficulty scores for laparoscopic liver resections (LLR) in a large well-characterized cohort of low to high difficulty LLR.

METHODS

Patients undergoing LLR and open liver resection (OLS) (2007-2022) at Massachusetts General Hospital were included. Patients were classified according to the technical difficulty scores Ban difficulty score, IWATE criteria, Hasegawa score, IMM score, and Southhampton score (SHH) and calibration of these scores in predicting postoperative outcome parameters was assessed.

RESULTS

301 patients underwent LLR. Median age was 59 years and 58.5% of the patients were female. Median lesion size was 42.2 mm, median operative time was 197.7 min, and median estimated blood loss was 400.5 ml. According to the different scoring systems, 18.9% (SHH) to 52.2% (IWATE) of the LLR were high difficulty. Overall intraoperative events according to the modified Satava classification grade II (6.6%) and grade III (2.7%) were low as was postoperative 90 days major morbidity (5.3%) and mortality (1.0%). The respective scores' calibration for predicting non-textbook outcomes, intraoperative events, operative time, major postoperative morbidity, blood transfusion rates, and length of hospital stay was moderate to good for the respective scores and best for the IWATE criteria.

DISCUSSION

Even high technical difficulty LLR can be performed with low postoperative morbidity and mortality rates. The scores evaluated performed well in predicting major liver surgery outome parameters. Among the different difficulty scoring systems, the IWATE criteria performed best.

Clinical significance of resection and adjuvant chemotherapy for pancreatic ductal adenocarcinoma with occult para-aortic lymph node metastasis

BACKGROUND

This study aimed to determine the clinical significance of resection of pancreatic ductal adenocarcinoma diagnosed with occult para-aortic lymph node metastasis using intraoperative para-aortic lymph node sampling.

METHODS

Between January 2005 and May 2021, a total of 606 patients who underwent surgery for pancreatic ductal adenocarcinoma with intraoperative para-aortic lymph node sampling were retrospectively investigated and divided into the resected para-aortic lymph node-negative (n = 543), resected para-aortic lymph node-positive (n = 44), and unresected para-aortic lymph node-positive (n = 19) groups. Overall survival, clinicopathologic characteristics, and prognostic factors were analyzed.

RESULTS

The overall survival in the resected para-aortic lymph node-positive group was significantly worse than that in the resected para-aortic lymph node-negative group (3-year overall survival, 29.8% vs 48.4%, P < .001) and significantly better than that in the unresected para-aortic lymph node-positive group (3-year overall survival, 29.8% vs 0.0%, P = .008). In the resected para-aortic lymph node-positive group, adjuvant chemotherapy was an independent prognostic factor (hazard ratio = 2.689, P = .033). The overall survival of patients in the resected para-aortic lymph node-positive group who received adjuvant chemotherapy was comparable to that of patients in the resected para-aortic lymph node-negative group who had 4 or more regional lymph node metastases and received adjuvant chemotherapy (3-year overall survival, 33.9% vs 34.1%, P = .343). A logistic regression analysis showed that neoadjuvant therapy, age <65 years, creatinine clearance >60 mL/min, pancreatic body or tail tumor, and serum albumin level >3.5 g/dL were significant predictive factors for induction of adjuvant chemotherapy in 587 resected patients.

CONCLUSIONS

Resection may be acceptable for patients with para-aortic lymph node-positive pancreatic ductal adenocarcinoma who are likely to tolerate adjuvant chemotherapy.

The Impact of Postoperative Complications on Recovery of Health-Related Quality of Life and Functional Capacity After Pancreatectomy: Findings From a Prospective Observational Study

OBJECTIVE

To evaluate the extent to which postoperative complications impact patient health-related quality of life (HRQoL) and survival after pancreatic surgery.

BACKGROUND

Pancreatectomy is frequently associated with severe postoperative morbidity, which can affect patient recovery. Few and conflicting data are available regarding the effect of post-pancreatectomy complications on patient-reported HRQoL.

METHODS

This is an observational cohort study including consecutive patients enrolled in a prospective clinical trial (NCT04431076) who underwent elective pancreatectomy (2020-2022). Before surgery and on postoperative days 15, 30, 90, and 180, patients completed the PROMIS-29 profile and Duke Activity Status Index questionnaires to assess their HRQoL and functional capacity. Mean differences in HRQoL scores were obtained using multivariable linear regression adjusting for preoperative scores and confounders.

RESULTS

Of 528 patients, 370 (70%) experienced morbidity within 90 days, and 154 (29%) had severe complications (Clavien-Dindo grade >2). Delayed gastric emptying had the greatest impact on HRQoL, showing decreased mental health up to POD90 and physical health up to POD180 compared with uncomplicated patients. An inverse relationship between complication severity grade and HRQoL was evident for most domains, with Clavien-Dindo grade 3b to 4 patients showing worse HRQoL and functional capacity scores up to 6 months after surgery. In 235 pancreatic cancer patients, grade 3b and 4 complications were associated with reduced disease-specific survival (median 25 vs 41 mo, P <0.001).

CONCLUSIONS

In patients undergoing pancreatic resection, postoperative complications significantly impact all domains of patient quality of life with a dose-effect relationship between complication severity and impairment of HRQoL and functional capacity.

Do Complications After Pancreatoduodenectomy Have an Impact on Long-Term Quality of Life and Functional Outcomes?

Objective

Our aim was to assess whether complications after pancreatoduodenectomy (PD) impact long-term quality of life (QoL) and functional outcomes.

Background

There is an increasing number of long-term post-PD survivors, but few studies have evaluated long-term QoL outcomes.

Methods

The EORTC QLQ-C30 and QLQ-PAN26 questionnaires were administered to patients who survived >5 years post-PD. Clinical relevance (CR) was scored as small (5-10), moderate (10-20), or large (>20). Patients were stratified based on whether they experienced a complication during the index hospitalization.

Results

Of 305 patients >5 years post-PD survivors, with valid contact information, 248 completed the questionnaires, and 231 had complication data available. Twenty-nine percent of patients experienced a complication, of which 17 (7.4%) were grade 1, 27 (11.7%) were grade 2, and 25 (10.8%) were grade 3. Global health status and functional domain scores were similar between both groups. Patients experiencing complications reported lower fatigue (21.4 vs 28.1, P < 0.05, CR small) and diarrhea (15.9 vs 23.1, P < 0.05, CR small) symptom scores when compared to patients without complications. Patients experiencing complications also reported lower pancreatic pain (38.2 vs 43.4, P < 0.05, CR small) and altered bowel habits (30.1 vs 40.7, P < 0.01, CR moderate) symptom scores. There was a lower prevalence of worrying (36.2% vs 60.5%, P < 0.05) and bloating (42.0% vs 56.2%, P < 0.05) among PD survivors with complications.

Conclusions

Post-PD complication rates were not associated with long-term global QoL or functionality, and may be associated with less severe pancreas-specific symptoms.

It is not necessary to resect all mucinous cystic neoplasms of the pancreas: current guidelines do not reflect the actual risk of malignancy

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.

Tailored surgery in chronic pancreatitis after implementation of a multidisciplinary team assessment; a prospective observational study

INTRODUCTION

Optimal management of chronic pancreatitis involves several specialties. Selection of patients for surgery may benefit from evaluation by a multidisciplinary team (MDT), similar to cancer care. The aim of this study was to evaluate outcomes in patients selected for surgery after MDT decision.

METHODS

A prospective, observational study of consecutive patients operated for pain due to chronic pancreatitis after implementation of a MDT. The main outcome was Quality of life (QoL) assessed by EORTC-QLQ C30 and pain relief in patients followed >3 months. Complications were registered and predictive factors for pain relief analyzed.

RESULTS

Of 269 patients evaluated by the MDT, 60 (22%) underwent surgery. Postoperative surgical complications occurred in five patients (8.3%) and reoperation within 30 days in two. There was no 90-days mortality. Complete or partial pain relief was achieved in 44 of 50 patients followed >3 months (88%). Preoperative duration of pain predicted lower probability of success. Postoperative improvement in QoL was most prominent for pain, appetite and nausea.

CONCLUSIONS

After MDT evaluation, one in five patients was selected for surgery. Pain relief was obtained in a majority of patients with improved QoL. A tailored approach through a MDT seems warranted and efficient.

Quality of Life Associated with Open vs Minimally Invasive Pancreaticoduodenectomy: A Prospective Pilot Study

BACKGROUND

This prospective study was designed to compare quality of life (QoL) among patients who underwent open (O-PD) vs minimally invasive pancreaticoduodenectomy (MI-PD), using a combination of validated qualitative and quantitative methodologies.

STUDY DESIGN

From 2017 to 2019, patients scheduled for pancreaticoduodenectomy (PD) were enrolled and presented with Functional Assessment of Cancer Therapy-Hepatobiliary surveys preoperatively, before discharge, at first postoperative visit and approximately 3 to 4 months after operation ("3 months"). Longitudinal plots of median QoL scores were used to illustrate change in each score over time. In a subset of patients, content analysis of semistructured interviews at postoperative time points (1.5 to 6 months after operation) was conducted.

RESULTS

Among 56 patients who underwent PD, 33 had an O-PD (58.9%). Physical and functional scores decreased in the postoperative period but returned to baseline by 3 months. No significant differences were found in any domains of QoL at baseline and in the postoperative period between patients who underwent O-PD and MI-PD. Qualitative findings were concordant with quantitative data (n = 14). Patients with O-PD and MI-PD reported similar experiences with complications, pain, and wound healing in the postoperative period. Approximately half the patients in both groups reported "returning to normal" in the 6-month postoperative period. A total of 4 patients reported significant long-term issues with physical and functional well-being.

CONCLUSIONS

Using a novel combination of qualitative and quantitative analyses in patients undergoing PD, we found no association between operative approach and QoL in patients who underwent O-PD vs MI-PD. Given the increasing use of minimally invasive techniques for PD and the steep learning curve associated with these techniques, continued assessment of patient benefit is critical.

Robotische Pankreaschirurgie – Lernkurve und Etablierung

Minimalinvasive Resektionstechniken zur Behandlung verschiedener Pathologien des Pankreas sind potenziell vorteilhaft für die behandelten Patienten in Bezug auf Rekonvaleszenzzeit und postoperative Morbidität, stellen jedoch eine besondere technische Herausforderung für den behandelnden Chirurgen dar. Der Einzug der robotischen Technik in die Viszeralchirurgie bietet eine prinzipielle Möglichkeit zur weitreichenden Verbreitung minimalinvasiver Verfahren in der Pankreaschirurgie.

Ziel dieser Arbeit war es, die Entwicklungsmöglichkeiten der robotischen Pankreaschirurgie in Deutschland zu überprüfen. Datengrundlage sind die Qualitätsberichte der Krankenhäuser der Jahre 2015–2019 kombiniert mit einer selektiven Literaturrecherche.

Die Anzahl der vorliegenden Qualitätsberichte reduzierte sich von 2015 bis 2019 von 1635 auf 1594. Im Median führten 96 Kliniken 11–20, 56 Kliniken 21–50 und 15 Kliniken mehr als 50 Pankreaskopfresektionen jährlich durch. Bei den Linksresektionen waren es 35 Kliniken mit 11–20, 14 Kliniken mit 21–50 und 2 Kliniken mit mehr als 50 Eingriffen. Unter Berücksichtigung aller Kliniken, die 5 oder mehr Linksresektionen pro Jahr durchführen, wurden an nur 29 Kliniken minimalinvasive Verfahren eingesetzt. Der Anteil an laparoskopischen Linksresektionen über 50% wurde an nur 7 Kliniken beschrieben.

Nach Datenlage in der Literatur divergieren die Lernkurven für die robotische Pankreaslinks- und Pankreaskopfresektion. Während die Lernkurve für die robotische Pankreaslinksresektion nach etwa 20 Eingriffen durchlaufen ist, hat die Lernkurve für die robotische Pankreaskopfresektion mehrere Plateaus, die etwa nach 30, 100 und 250 Eingriffen erreicht werden.

Aufgrund der dezentralen Struktur der Pankreaschirurgie in Deutschland scheint ein flächendeckendes Angebot robotischer Verfahren aktuell in weiter Ferne. Insbesondere die Etablierung der robotischen Pankreaskopfresektion wird zunächst Zentren mit entsprechend hoher Fallzahl vorbehalten bleiben.