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Hughes DLL, Hughes A, Gordon-Weeks AN, Silva MA. Continuous drain irrigation as a risk mitigation strategy for postoperative pancreatic fistula: a meta-analysis. Surgery 2024; 176:180-188. [PMID: 38734504 DOI: 10.1016/j.surg.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 01/21/2024] [Accepted: 03/18/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula serves as the principle cause for the morbidity and mortality observed after pancreatectomy. Continuous drain irrigation as a treatment strategy for infected pancreatic necrosis has previously been described; however, its role adter pancreatectomy has yet to be determined. The aim of this study was to determine whether continuous drain irrigation reduces postoperative pancreatic fistula. METHODS A meta-analysis of the pre-existing literature was performed. The primary end point was whether continuous drain irrigation reduced postoperative pancreatic fistula after pancreatectomy. The secondary end point evaluated its impact on postoperative morbidity, mortality, and length of stay. RESULTS Nine articles involving 782 patients were included. Continuous drain irrigation use was associated with a statistically significant reduction in postoperative pancreatic fistula rates (odds ratio [95% confidence interval] 0.40 [0.19-0.82], P = .01). Upon subgroup analysis, a significant reduction in clinically relevant postoperative pancreatic fistula was also noted (odds ratio 0.37 [0.20-0.66], P = .0008). A reduction in postoperative complications was also observed-delayed gastric emptying (0.45 [0.24-0.84], P = .01) and the need for re-operation (0.33 [0.11-0.96], P = .04). This reduction in postoperative complications translated into a reduced length of stay (mean difference -2.62 [-4.97 to -0.26], P = .03). CONCLUSION Continuous drain irrigation after pancreatectomy is a novel treatment strategy with a limited body of published evidence. After acknowledging the limitations of the data, initial analysis would suggest that it may serve as an effective risk mitigation strategy against postoperative pancreatic fistula. Further research in a prospective context utilizing patient risk stratification for fistula development is, however, required to define its role within clinical practice.
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Affiliation(s)
- Daniel L L Hughes
- Department of Hepatopancreaticobiliary surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
| | - Aron Hughes
- Department of Acute Medicine, University Hospital of Wales, Cardiff, United Kingdom
| | - Alex N Gordon-Weeks
- Department of Hepatopancreaticobiliary surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Michael A Silva
- Department of Hepatopancreaticobiliary surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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2
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Davis CH, Augustinus S, de Graaf N, Wellner UF, Johansen K, Andersson B, Beane JD, Björnsson B, Busch OR, Gleeson EM, van Santvoort HC, Tingstedt B, Williamsson C, Keck T, Besselink MG, Koerkamp BG, Pitt HA. Impact of Neoadjuvant Therapy for Pancreatic Cancer: Transatlantic Trend and Postoperative Outcomes Analysis. J Am Coll Surg 2024; 238:613-621. [PMID: 38224148 DOI: 10.1097/xcs.0000000000000971] [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: 01/16/2024]
Abstract
BACKGROUND The introduction of modern chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). A recent North American study demonstrated increased use of NAT and improved operative outcomes in patients with PDAC. The aims of this study were to compare the use of NAT and short-term outcomes in patients with PDAC undergoing pancreatoduodenectomy (PD) among registries from the US and Canada, Germany, the Netherlands, and Sweden. STUDY DESIGN Databases from 2 multicenter (voluntary) and 2 nationwide (mandatory) registries were queried from 2018 to 2020. Patients undergoing PD for PDAC were compared based on the use of upfront surgery vs NAT. Adoption of NAT was measured in each country over time. Thirty-day outcomes, including the composite measure (ideal outcomes), were compared by multivariable analyses. Sensitivity analyses of patients undergoing vascular resection were performed. RESULTS Overall, 11,402 patients underwent PD for PDAC with 33.7% of patients receiving NAT. The use of NAT increased steadily from 28.3% in 2018 to 38.5% in 2020 (p < 0.0001). However, use of NAT varied widely by country: the US (46.8%), the Netherlands (44.9%), Sweden (11.0%), and Germany (7.8%). On multivariable analysis, NAT was significantly (p < 0.01) associated with reduced rates of serious morbidity, clinically relevant pancreatic fistulae, reoperations, and increased ideal outcomes. These associations remained on sensitivity analysis of patients undergoing vascular resection. CONCLUSIONS NAT before PD for pancreatic cancer varied widely among 4 Western audits yet increased by 26% during 3 years. NAT was associated with improved short-term outcomes.
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Affiliation(s)
- Catherine H Davis
- From the Department of Surgery, Baylor Scott & White Health, Dallas, TX (Davis)
| | - Simone Augustinus
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands (Augustinus, de Graaf, Busch, Besselink)
| | - Nine de Graaf
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands (Augustinus, de Graaf, Busch, Besselink)
| | - Ulrich F Wellner
- DGAV StuDoQ/Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany (Wellner, Keck)
| | - Karin Johansen
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Bodil Andersson
- Departments of Surgery and Clinical Sciences Lund, Lund University, Lund, Sweden (Andersson)
- Skåne University Hospital, Lund, Sweden (Andersson)
| | - Joal D Beane
- Department of Surgery, The Ohio State University, Columbus, OH (Beane)
| | - Bergthor Björnsson
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Olivier R Busch
- From the Department of Surgery, Baylor Scott & White Health, Dallas, TX (Davis)
| | - Elizabeth M Gleeson
- Department of Surgery, University of North Carolina, Chapel Hill, NC (Gleeson)
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands (van Santvoort)
| | - Bobby Tingstedt
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Caroline Williamsson
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Tobias Keck
- DGAV StuDoQ/Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany (Wellner, Keck)
| | - Marc G Besselink
- From the Department of Surgery, Baylor Scott & White Health, Dallas, TX (Davis)
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands (Koerkamp)
| | - Henry A Pitt
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (Pitt)
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3
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Non-Surgical Interventions for the Prevention of Clinically Relevant Postoperative Pancreatic Fistula-A Narrative Review. Cancers (Basel) 2023; 15:5865. [PMID: 38136409 PMCID: PMC10741911 DOI: 10.3390/cancers15245865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is the leading cause of morbidity and mortality after pancreatic surgery. Post-pancreatectomy acute pancreatitis (PPAP) has been increasingly understood as a precursor and exacerbator of CR-POPF. No longer believed to be the consequence of surgical technique, the solution to preventing CR-POPF may lie instead in non-surgical, mainly pharmacological interventions. Five databases were searched, identifying eight pharmacological preventative strategies, including neoadjuvant therapy, somatostatin and its analogues, antibiotics, analgesia, corticosteroids, protease inhibitors, miscellaneous interventions with few reports, and combination strategies. Two further non-surgical interventions studied were nutrition and fluids. New potential interventions were also identified from related surgical and experimental contexts. Given the varied efficacy reported for these interventions, numerous opportunities for clarifying this heterogeneity remain. By reducing CR-POPF, patients may avoid morbid sequelae, experience shorter hospital stays, and ensure timely delivery of adjuvant therapy, overall aiding survival where prognosis, particularly in pancreatic cancer patients, is poor.
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Affiliation(s)
- Nadya Rykina-Tameeva
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
| | - Jaswinder S. Samra
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Sumit Sahni
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Anubhav Mittal
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
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Wu HY, Liu T, Zhong T, Zheng SY, Zhai QL, Du CJ, Wu TZ, Li JZ. Research trends and hotspots of neoadjuvant therapy in pancreatic cancer: a bibliometric analysis based on the Web of Science Core Collection. Clin Exp Med 2023; 23:2473-2485. [PMID: 36773211 DOI: 10.1007/s10238-023-01013-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/26/2023] [Indexed: 02/12/2023]
Abstract
Neoadjuvant therapy (NAT) for pancreatic cancer (PC) has achieved certain results. This article was aimed to analyze the trends in NAT in PC over the past 20 years using bibliometric analysis and visualization tools to guide researchers in exploring future research hotspots. Articles related to NAT for PC were retrieved from the Web of Science Core Collection for the period 2002-2021. The information was analyzed and visualized using VOSviewer, Citespace, Microsoft Excel and R software. The number of articles per year has continued to increase over the past 20 years. Of the 1,598 eligible articles, the highest number was from the United States (760), and an analysis of institutions indicated that the University of Texas System (150) had the highest number of articles. Matthew H. G. Katz had the highest number of citations and the highest H-index. "Pancreatic cancer" (981), "Resection" (623), "Cancer" (553), "Neoadjuvant therapy" (509) and "Survival" (484) were the top five ranked keywords. Combined with the keywords-cluster analysis and citation burst analysis, current research hotspots were the optimal NAT regimen, NAT response assessment, NAT for resectable PC and management of complications. NAT has received increasing attention in the field of PC over the past 20 years, but greater collaboration between countries and additional multicenter randomized clinical trials are needed. Overall, we have revealed current research hotspots and provided valuable information for the choice of future research directions.
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Affiliation(s)
- Hong-Yu Wu
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Tao Liu
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Tao Zhong
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Si-Yuan Zheng
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Qi-Long Zhai
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Chang-Jie Du
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Tian-Zhu Wu
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Jin-Zheng Li
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China.
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Rykina-Tameeva N, MacCulloch D, Hipperson L, Ulyannikova Y, Samra JS, Mittal A, Sahni S. Drain fluid biomarkers for the diagnosis of clinically relevant postoperative pancreatic fistula: a diagnostic accuracy systematic review and meta-analysis. Int J Surg 2023; 109:2486-2499. [PMID: 37216227 PMCID: PMC10442108 DOI: 10.1097/js9.0000000000000482] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 05/08/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Pancreatectomy is the only curative treatment available for pancreatic cancer and a necessity for patients with challenging pancreatic pathology. To optimize outcomes, postsurgical complications such as clinically relevant postoperative pancreatic fistula (CR-POPF) should be minimized. Central to this is the ability to predict and diagnose CR-POPF, potentially through drain fluid biomarkers. This study aimed to assess the utility of drain fluid biomarkers for predicting CR-POPF by conducting a diagnostic test accuracy systematic review and meta-analysis. METHODS Five databases were searched for relevant and original papers published from January 2000 to December 2021, with citation chaining capturing additional studies. The QUADAS-2 tool was used to assess the risk of bias and concerns regarding applicability of the selected studies. RESULTS Seventy-eight papers were included in the meta-analysis, encompassing six drain biomarkers and 30 758 patients with a CR-POPF prevalence of 17.42%. The pooled sensitivity and specificity for 15 cut-offs were determined. Potential triage tests (negative predictive value >90%) were identified for the ruling out of CR-POPF and included postoperative day 1 (POD1) drain amylase in pancreatoduodenectomy (PD) patients (300 U/l) and in mixed surgical cohorts (2500 U/l), POD3 drain amylase in PD patients (1000-1010 U/l) and drain lipase in mixed surgery groups (180 U/l). Notably, drain POD3 lipase had a higher sensitivity than POD3 amylase, while POD3 amylase had a higher specificity than POD1. CONCLUSIONS The current findings using the pooled cut-offs will offer options for clinicians seeking to identify patients for quicker recovery. Improving the reporting of future diagnostic test studies will further clarify the diagnostic utility of drain fluid biomarkers, facilitating their inclusion in multivariable risk-stratification models and the improvement of pancreatectomy outcomes.
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Affiliation(s)
- Nadya Rykina-Tameeva
- Faculty of Medicine and Health, University of Sydney
- Kolling Institute of Medical Research, University of Sydney, St Leonards
| | | | - Luke Hipperson
- Faculty of Medicine and Health, University of Sydney
- Kolling Institute of Medical Research, University of Sydney, St Leonards
| | | | - Jaswinder S. Samra
- Faculty of Medicine and Health, University of Sydney
- Upper GI Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital
- Australian Pancreatic Centre, St Leonards
| | - Anubhav Mittal
- Faculty of Medicine and Health, University of Sydney
- Upper GI Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital
- Australian Pancreatic Centre, St Leonards
- The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Sumit Sahni
- Faculty of Medicine and Health, University of Sydney
- Kolling Institute of Medical Research, University of Sydney, St Leonards
- Australian Pancreatic Centre, St Leonards
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6
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Marcinak CT, Parker WF, Parikh AA, Datta J, Maithel SK, Kooby DA, Burkard ME, Kim HJ, LeCompte MT, Afshar M, Churpek MM, Zafar SN. Accuracy of models to prognosticate survival after surgery for pancreatic cancer in the era of neoadjuvant therapy. J Surg Oncol 2023; 128:280-288. [PMID: 37073788 PMCID: PMC10330210 DOI: 10.1002/jso.27287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/10/2023] [Accepted: 04/09/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Outcomes for pancreatic adenocarcinoma (PDAC) remain difficult to prognosticate. Multiple models attempt to predict survival following the resection of PDAC, but their utility in the neoadjuvant population is unknown. We aimed to assess their accuracy among patients that received neoadjuvant chemotherapy (NAC). METHODS We performed a multi-institutional retrospective analysis of patients who received NAC and underwent resection of PDAC. Two prognostic systems were evaluated: the Memorial Sloan Kettering Cancer Center Pancreatic Adenocarcinoma Nomogram (MSKCCPAN) and the American Joint Committee on Cancer (AJCC) staging system. Discrimination between predicted and actual disease-specific survival was assessed using the Uno C-statistic and Kaplan-Meier method. Calibration of the MSKCCPAN was assessed using the Brier score. RESULTS A total of 448 patients were included. There were 232 (51.8%) females, and the mean age was 64.1 years (±9.5). Most had AJCC Stage I or II disease (77.7%). For the MSKCCPAN, the Uno C-statistic at 12-, 24-, and 36-month time points was 0.62, 0.63, and 0.62, respectively. The AJCC system demonstrated similarly mediocre discrimination. The Brier score for the MSKCCPAN was 0.15 at 12 months, 0.26 at 24 months, and 0.30 at 36 months, demonstrating modest calibration. CONCLUSIONS Current survival prediction models and staging systems for patients with PDAC undergoing resection after NAC have limited accuracy.
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Affiliation(s)
- Clayton T. Marcinak
- Division of Surgical Oncology, Department of Surgery, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - William F. Parker
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Alexander A. Parikh
- Division of Surgical Oncology and Endocrine Surgery, UT Health San Antonio MD Anderson – Mays Cancer Center, San Antonio, TX, USA
| | - Jashodeep Datta
- Division of Surgical Oncology, Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - David A. Kooby
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mark E. Burkard
- Division of Hematology, Oncology, and Palliative Care, Department of Medicine, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Hong Jin Kim
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| | - Michael T. LeCompte
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| | - Majid Afshar
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Matthew M. Churpek
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Syed Nabeel Zafar
- Division of Surgical Oncology, Department of Surgery, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
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Maman Y, Goykhman Y, Yakir O, Barenboim A, Geva R, Peles-Avraham S, Wolf I, Klausner JM, Lahat G, Lubezky N. Adjuvant FOLFIRINOX in Patients with Resectable Pancreatic Cancer Is Effective but Rarely Feasible in Real Life: Is Neoadjuvant FOLFIRINOX a Better Option? Cancers (Basel) 2023; 15:cancers15113049. [PMID: 37297011 DOI: 10.3390/cancers15113049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND The recommended treatment for resectable pancreatic cancer (PC) is resection followed by adjuvant FOLFIRINOX. We assessed the proportion of patients that managed to complete the 12 courses of adjuvant FOLFIRINOX and compared their outcome with that of patients with borderline resectable pancreatic cancer (BRPC) who underwent resection after neoadjuvant FOLFIRINOX. METHODS A retrospective analysis was performed on a prospectively maintained database of all PC patients who underwent resection with (2/2015-12/2021) or without (1/2018-12/2021) neoadjuvant therapy. RESULTS A total of 100 patients underwent upfront resection, and 51 patients with BRPC received neoadjuvant treatment. Only 46 resection patients started adjuvant FOLFIRINOX, and only 23 completed 12 courses. The main reasons for not starting/completing adjuvant therapy were poor tolerance and rapid recurrence. Significantly more patients in the neoadjuvant group received at least six FOLFIRINOX courses (80.4% vs. 31%, p < 0.001). Patients who completed at least 6 courses, either pre- or postoperatively, had better overall survival (p = 0.025) than those who did not. In spite of having more advanced disease, the neoadjuvant group had comparable overall survival (p = 0.062) regardless of the number of treatment courses. CONCLUSION Only a minority of patients (23%) undergoing upfront pancreatic resection completed the planned 12 courses of FOLFIRINOX. Patients who received neoadjuvant treatment were significantly more likely to receive at least six treatment courses. Patients receiving at least six courses had better overall survival than those who received fewer than six courses, regardless of the timing of treatment relative to surgery. Potential ways to increase chemotherapy adherence, such as administering treatment before surgery, should be considered.
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Affiliation(s)
- Yossi Maman
- Departments of Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Yaacov Goykhman
- Departments of HPB and Transplant Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Oz Yakir
- Departments of HPB and Transplant Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Alex Barenboim
- Departments of Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Ravit Geva
- Institute of Oncology, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Sharon Peles-Avraham
- Institute of Oncology, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Ido Wolf
- Institute of Oncology, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Joseph M Klausner
- Departments of Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Guy Lahat
- Departments of Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel-Aviv University, Tel-Aviv 69978, Israel
| | - Nir Lubezky
- Departments of HPB and Transplant Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel-Aviv University, Tel-Aviv 69978, Israel
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8
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de Jesus VHF, Riechelmann RP. Current Treatment of Potentially Resectable Pancreatic Ductal Adenocarcinoma: A Medical Oncologist's Perspective. Cancer Control 2023; 30:10732748231173212. [PMID: 37115533 PMCID: PMC10155028 DOI: 10.1177/10732748231173212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/01/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
Pancreatic cancer has traditionally been associated with a dismal prognosis, even in early stages of the disease. In recent years, the introduction of newer generation chemotherapy regimens in the adjuvant setting has improved the survival of patients treated with upfront resection. However, there are multiple theoretical advantages to deliver early systemic therapy in patients with localized pancreatic cancer. So far, the evidence supports the use of neoadjuvant therapy for patients with borderline resectable pancreatic cancer. The benefit of this treatment sequence for patients with resectable disease remains elusive. In this review, we summarize the data on adjuvant therapy for pancreatic cancer and describe which evidence backs the use of neoadjuvant therapy. Additionally, we address important issues faced in clinical practice when treating patients with localized pancreatic cancer.
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9
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Sternby H, Andersson B. Nationwide trends and outcomes of neoadjuvant chemotherapy in pancreatic cancer - an analysis of the Swedish national pancreatic cancer registry. Scand J Gastroenterol 2022; 57:1361-1366. [PMID: 35635264 DOI: 10.1080/00365521.2022.2078668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES During the last decade, neoadjuvant therapy (NAT) for pancreatic cancer has become more frequent. Pathological response and overall survival are promising; however, various post-operative complications have been reported. Our primary aim was to compare the complication scenario of patients receiving NAT in borderline resectable and locally advanced disease with those who had upfront pancreatic surgery (UFS) for primarily resectable cancer. METHODS From the Swedish National Pancreatic and Periampullary Cancer Registry, patients resected for pancreatic ductal adenocarcinoma (PDAC) between 2010 and 2018 were identified. Data on patient characteristics, neoadjuvant therapy, post-operative complications and survival were obtained. Comparisons between groups as well as survival analysis were performed. RESULTS Within the total cohort of 13,948 patients, 1894 (median age 69 years, 51% men) were resected for PDAC. Among these, 112 (5.9%) patients received NAT followed by surgery. The patients who received NAT were younger (67 vs 70 years, p < .001), had a lower level of CA19-9 (47 vs 108, p = .001) and had to a larger extent vascular resection (58.9 vs 26.9%, p < .001) and total pancreatectomy performed (23.2 vs 9.1%, p < .001). No difference was found for major post-operative complications and there was no significant change in survival rate between the NAT and UFS groups (median 28 vs 26 months, p = .122). CONCLUSIONS When analyzing data from a national registry, no difference in post-operative complications was found between resected patients receiving UFS and NAT for PDAC. Also, the survival was equal between groups. NAT is a feasible treatment option for patients with potentially curable pancreatic cancer.
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Affiliation(s)
- Hanna Sternby
- Department of Surgery, Institute of Clinical Sciences-Malmö, Lund University, Lund, Sweden
- Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Surgery, Institute of Clinical Sciences-Malmö, Lund University, Lund, Sweden
- Skåne University Hospital, Lund, Sweden
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Ciprani D, Bannone E, Marchegiani G, Nessi C, Salvia R, Bassi C. Progression from biochemical leak to pancreatic fistula after distal pancreatectomy. Don't cry over spilt amylase. Pancreatology 2022; 22:817-822. [PMID: 35773177 DOI: 10.1016/j.pan.2022.06.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/22/2022] [Accepted: 06/19/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a frequent complication after distal pancreatectomy (DP), but its upgrading from biochemical leak (BL) still represents an unexplored phenomenon. This study aims at identifying risk factors of the clinical evolution from BL to grade-B POPF after DP. METHODS Patients who underwent DP between 2015 and 2019 and who developed either BL (n = 89,56%) or BL upgraded to late B fistula (LB) after postoperative day 5 (n = 71,44%) were included. Preoperative, surgical, postoperative predictors were compared between the two groups. RESULTS Patients with LB were significantly older (61 vs 56 years, P < 0.025) and received neoadjuvant chemotherapy more frequently (22.5% vs 8.5%,P = 0.017). Extended lymphadenectomy (52.8% vs 31.0%,P = 0.006), longer operative times (OT) (307 vs 250 min,P = 0.002), greater estimated blood loss (250 vs 150 ml, P = 0.021), and the appearance of purulent fluid in surgical drains (58.4% vs 21.1%; P < 0.001) were more frequently observed in LB group. Only purulent fluid in surgical drains and longer OT were confirmed as independent predictors of BL clinical progression. CONCLUSIONS Purulent fluid from surgical drains should be suspicious of BL upgrading. Frail patients undergoing longer interventions may represent key targets of mitigation strategies to minimize the magnitude of an incipient fistula and its increase in morbidity.
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Affiliation(s)
- D Ciprani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - E Bannone
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Nessi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
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11
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Davis CH, Beane JD, Gazivoda VP, Grandhi MS, Greenbaum AA, Kennedy TJ, Langan RC, August DA, Alexander HR, Pitt HA. Neoadjuvant Therapy for Pancreatic Cancer: Increased Use and Improved Optimal Outcomes. J Am Coll Surg 2022; 234:436-443. [PMID: 35290262 DOI: 10.1097/xcs.0000000000000095] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The introduction of more effective chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to assess the evolving use of NAT in individuals with PDAC undergoing pancreatoduodenectomy (PD) and to compare their outcomes with patients undergoing upfront operation. STUDY DESIGN The American College of Surgeons NSQIP Procedure Targeted Pancreatectomy database was queried from 2014 to 2019. Patients undergoing pancreatoduodenectomy were evaluated based on the use of NAT versus upfront operation. Multivariable analysis was performed to determine the effect of NAT on postoperative outcomes, including the composite measure optimal pancreatic surgery (OPS). Mann-Kendall trend tests were performed to assess the use of NAT and associated outcomes over time. RESULTS A total of 13,257 patients were identified who underwent PD for PDAC between 2014 and 2019. Overall, 33.6% of patients received NAT. The use of NAT increased steadily from 24.2% in 2014 to 42.7% in 2019 (p < 0.0001). On multivariable analysis, NAT was associated with reduced serious morbidity (odds ratio [OR] 0.83, p < 0.001), clinically relevant pancreatic fistulas (OR 0.52, p < 0.001), organ space infections (OR 0.74, p < 0.001), percutaneous drainage (OR 0.73, p < 0.001), reoperation (OR 0.76, p = 0.005), and prolonged length of stay (OR 0.63, p < 0.001). OPS was achieved more frequently in patients undergoing NAT (OR 1.433, p < 0.001) and improved over time in patients receiving NAT (50.7% to 56.6%, p < 0.001). CONCLUSION NAT before pancreatoduodenectomy increased more than 3-fold over the past decade and was associated with improved optimal operative outcomes.
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Affiliation(s)
- Catherine H Davis
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Joal D Beane
- Division of Surgical Oncology, The Ohio State University, Columbus, OH (Beane)
| | - Victor P Gazivoda
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Miral S Grandhi
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Alissa A Greenbaum
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Timothy J Kennedy
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Russell C Langan
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- the Department of Surgery, Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, NJ (Langan)
| | - David A August
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - H Richard Alexander
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Henry A Pitt
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
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12
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Potter KC, Sutton TL, O'Grady J, Gilbert EW, Pommier R, Mayo SC, Sheppard BC. Risk factors for postoperative pancreatic fistula in the Era of pasireotide. Am J Surg 2022; 224:733-736. [DOI: 10.1016/j.amjsurg.2022.02.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/12/2022] [Accepted: 02/16/2022] [Indexed: 11/01/2022]
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13
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van Dongen JC, Wismans LV, Suurmeijer JA, Besselink MG, de Wilde RF, Groot Koerkamp B, van Eijck CHJ. The effect of preoperative chemotherapy and chemoradiotherapy on pancreatic fistula and other surgical complications after pancreatic resection: a systematic review and meta-analysis of comparative studies. HPB (Oxford) 2021; 23:1321-1331. [PMID: 34099372 DOI: 10.1016/j.hpb.2021.04.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative chemo- or chemoradiotherapy is recommended for borderline-resectable pancreatic cancer. The aim of this study was to determine the impact of preoperative therapy on surgical complications in patients with resected pancreatic cancer. METHODS This systematic review and meta-analysis included studies reporting on the rate of surgical complications after preoperative chemo- or chemoradiotherapy versus immediate surgery in pancreatic cancer patients. The primary endpoint was the rate of grade B/C POPF. Pooled odds ratios were calculated using random-effects models. RESULTS Forty-one comparative studies including 25,389 patients were included. Vascular resections were more often performed after preoperative therapy (29.4% vs. 15.7%, p < 0.001). Preoperative therapy was associated with a lower rate of grade B/C POPF as compared to immediate surgery (pooled OR 0.47, 95%CI 0.38-0.58). This reduction was mostly obtained by preoperative chemoradiotherapy (OR 0.46, 95%CI 0.29-0.73), but not by preoperative chemotherapy alone (OR 0.83, 95%CI 0.59-1.16). No difference was demonstrated for major morbidity, mortality, postpancreatectomy haemorrhage, delayed gastric emptying and overall morbidity. CONCLUSION Preoperative chemo- and chemoradiotherapy in patients with pancreatic cancer appears to be safe with respect to POPF and other surgical complications as compared to immediate surgery. The reduced rate of POPF appears to be attributable to preoperative chemoradiation.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Leonoor V Wismans
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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14
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Ielpo B, Pueyo-Périz EM, Radosevic A, Andaluz A, Berjano E, Grande L, Sánchez-Velázquez P, Burdío F. Clinical case report: endoluminal thermal ablation of main pancreatic duct for patients at high risk of postoperative pancreatic fistula after pancreaticoduodenectomy. Int J Hyperthermia 2021; 38:755-759. [PMID: 33941013 DOI: 10.1080/02656736.2021.1917703] [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: 10/21/2022] Open
Abstract
PURPOSE Multiple attempts have been made to manage the pancreatic stump and the pancreatic duct in order to reduce the rate of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), however radiofrequency-based technologies could help to achieve this goal. Previous encouraging clinical and experimental results support the use of endoluminal thermal ablation (ETHA) of the main pancreatic duct to reduce pancreatic exocrine secretion and hence POPF. We here describe our initial clinical experience with ETHA of the main pancreatic duct in two cases at high risk of POPF. METHODS Two cases underwent PD for malignancy with a high risk of POPF (adenocarcinoma, obese patients, surgical difficulties with heavy intraoperative blood loss, soft pancreas or walled-off pancreatitis and a tight small pancreatic main duct). In both cases, ETHA of the main pancreatic duct was conducted intraoperatively just before Blumgart-type pancreatic-jejunal anastomosis using a ClosureFast catheter (Medtronic, Mansfield, MA, USA) normally used for varicose vein treatment (therefore an off-label use). RESULTS Although a clear radiological POPF was detected in the second case, the clinical postoperative course in both cases was uneventful. Little pancreatic fluid collected in the abdominal drainage with low levels of amylase enzyme, confirming low exocrine pancreatic function. No other procedure-related complications were detected. CONCLUSION Endoluminal thermal ablation of the main pancreatic duct may be a feasible and safe technique to reduce the adverse effects of POPF after PD.
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Affiliation(s)
- Benedetto Ielpo
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Eva M Pueyo-Périz
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | | | - Anna Andaluz
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Enrique Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Luis Grande
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Patricia Sánchez-Velázquez
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Fernando Burdío
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
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15
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Nappo G, Donisi G, Zerbi A. Borderline resectable pancreatic cancer: Certainties and controversies. World J Gastrointest Surg 2021; 13:516-528. [PMID: 34194610 PMCID: PMC8223708 DOI: 10.4240/wjgs.v13.i6.516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/09/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC) is currently a well-recognized entity, characterized by some specific anatomic, biological and conditional features: It includes patients with a stage of disease intermediate between the resectable and the locally advanced ones. The term BR identifies a tumour with an aggressive biological behaviour, on which a neoadjuvant approach instead of an upfront surgery one should be preferred, in order to obtain a radical resection (R0) and to avoid an early recurrence after surgery. Even if during the last decades several studies on this topic have been published, some aspects of BR-PDAC still represent a matter of debate. The aim of this review is to critically analyse the available literature on this topic, particularly focusing on: The problem of the heterogeneity of definition of BR-PDAC adopted, leading to a misinterpretation of published data; its current management (neoadjuvant vs upfront surgery); which neoadjuvant regimen should be preferably adopted; the problem of radiological restaging and the determination of resectability after neoadjuvant therapy; the post-operative outcomes after surgery; and the role and efficacy of adjuvant treatment for resected patients that already underwent neoadjuvant therapy.
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Affiliation(s)
- Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| | - Greta Donisi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
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16
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Zhou Y, Liao S, You J, Wu H. Conversion surgery for initially unresectable pancreatic ductal adenocarcinoma following induction therapy: a systematic review of the published literature. Updates Surg 2021; 74:43-53. [PMID: 34021484 DOI: 10.1007/s13304-021-01089-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022]
Abstract
Patients with unresectable pancreatic ductal adenocarcinoma (UR-PDAC) are traditionally treated with palliative chemotherapy. The aim of this study was to evaluate the safety and efficacy of conversion surgery for initially UR-PDAC following induction therapy. The PubMed and Embase databases were systematically searched for eligible studies published between January 2000 and October 2020. Thirty-two series involving 1270 patients with 1056 locally advanced (LA) disease and 214 distant metastases were reviewed. The median mortality and morbidity was 0% (range 0-10%) and 47.1% (range 8.6-93.3%), respectively. Lymph-node negativity, negative resection margin and pathological complete response were observed in a median of 62.9% (38.5-90.9%), 84.4% (32.8-100%) and 6.7% (0-45.8%) of the specimens. The median survival was 32 (16.4-63.9) months with a 3-year survival rate of 47% (22-80%). Meta-analysis demonstrated that conversion surgery of initially UR-PDAC was associated with a significantly improved survival (hazard ratio [HR] = 0.55; 95% confidence intervals (CI) 0.45-0.66, P < 0.001). There was no significant difference in survival between the group with LA disease and that with distant metastases after conversion surgery (HR = 0.96; 95% CI 0.72-1.28, P = 0.790). Conversion surgery improved long-term survival of patients with initially UR-PDAC who had favorable response to induction therapy.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China.
| | - Shan Liao
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
| | - Jun You
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
| | - Huaxing Wu
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
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17
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Rieser CJ, Zenati M, Narayanan S, Bahary N, Lee KK, Paniccia A, Bartlett DL, Zureikat AH. Optimal Management of Resectable Pancreatic Head Cancer in the Elderly Patient: Does Neoadjuvant Therapy Offer a Survival Benefit? Ann Surg Oncol 2021; 28:6264-6272. [PMID: 33748894 DOI: 10.1245/s10434-021-09822-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/22/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Neoadjuvant therapy (NAT) is a growing strategy for patients with resectable pancreatic ductal adenocarcinoma (PDAC). Elderly patients are at increased risk of treatment withdrawal due to functional decline, and the benefit of NAT in this cohort remains to be studied. OBJECTIVE The objective of this study was to compare outcomes of elderly patients with resectable head PDAC who underwent NAT or a surgery-first (SF) approach. METHODS All patients 75 years of age and older with radiographically resectable (National Comprehensive Cancer Network criteria) PDAC who underwent pancreaticoduodenectomy at a single institution from 2008 to 2017 were analyzed. Baseline characteristics and perioperative outcomes were compared between the SF and NAT cohorts. Recurrence-free survival and overall survival (OS) were analyzed by treatment strategy. RESULTS Overall, 158 patients were identified: SF cohort = 90 (57%) and NAT cohort = 68 (43%). Patients in the SF cohort were older (80 vs. 78 years; p = 0.01) but there were no differences in preoperative comorbidities or frailty indices. SF patients had a trend toward higher rates of major complications (38% vs. 24%; p = 0.06) with higher Comprehensive Complication Index totals (20.9 vs. 20; p = 0.03). There were similar rates of adjuvant therapy. NAT was associated with significantly longer OS (24.6 vs. 17.6 months; p = 0.01) in both the intent-to-treat and resected cohorts. On multivariable analysis (MVA), NAT remained an independent predictor of OS (hazard ratio 0.60; p = 0.02). CONCLUSION NAT is safe and effective for elderly patients with PDAC. This study suggests NAT is associated with fewer complications after surgery, equal rates of adjuvant therapy receipt, and increased OS over a surgery-first approach.
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Affiliation(s)
- Caroline J Rieser
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mazen Zenati
- Department of Surgery and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sowmya Narayanan
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alessandro Paniccia
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - David L Bartlett
- AHN Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA.
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18
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Garnier J, Robin F, Ewald J, Marchese U, Bergeat D, Boudjema K, Delpero JR, Sulpice L, Turrini O. Pancreatectomy with Vascular Resection After Neoadjuvant FOLFIRINOX: Who Survives More Than a Year After Surgery? Ann Surg Oncol 2021; 28:4625-4634. [PMID: 33462718 DOI: 10.1245/s10434-020-09520-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Experienced pancreatic surgeons, for whom complexity is not an issue, must decide at the end of neoadjuvant therapy whether to continue or discontinue surgery, when pancreatectomy with vascular resection is planned in patients with pancreatic ductal adenocarcinoma (PDAC). OBJECTIVE Our study aimed to determine preoperative factors that can predict short postoperative survival in such situations. METHODS Overall, 105 patients with borderline or locally advanced PDAC received neoadjuvant FOLFIRINOX (followed by chemoradiation in 22% of patients) and underwent pancreatectomy with segmental venous and/or arterial resection at two high-volume centers. The primary endpoint was overall survival (OS) of < 1 year after surgery for patients who did not die from the surgery. RESULTS Tumors were classified as borderline in 78% of cases and locally advanced in 22% of cases. Mean CA19-9 at diagnosis was 934 U/mL, which significantly decreased to 213 U/mL (p < 0.01) after a median of six cycles of FOLFIRINOX. Pancreaticoduodenectomy was performed most often (76%). The vast majority of patients underwent venous resection (92%), and a simultaneous arterial resection was performed in 16 patients (15%). The severe morbidity rate and 30- and 90-day mortality rates were 21%, 8.5%, and 10.4%, respectively. The median OS after surgery was 23 months. In the multivariate analysis, preoperative CA19-9 ≥ 450 U/mL was the only preoperative factor independently associated with OS of < 1 year (p = 0.044). CONCLUSION The preoperative CA19-9 value should be considered in the clinical decision-making process when complex vascular resection is required.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France.
| | - Fabien Robin
- Department of Hepato-Biliary and Digestive Surgery, CHU Rennes, Université Rennes 1, Rennes, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Damien Bergeat
- Department of Hepato-Biliary and Digestive Surgery, CHU Rennes, Université Rennes 1, Rennes, France
| | - Karim Boudjema
- Department of Hepato-Biliary and Digestive Surgery, CHU Rennes, Université Rennes 1, Rennes, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Laurent Sulpice
- Department of Hepato-Biliary and Digestive Surgery, CHU Rennes, Université Rennes 1, Rennes, France
| | - Olivier Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes, Aix-Marseille University, CRCM, Marseille, France
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19
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Kamarajah SK, Naffouje SA, Salti GI, Dahdaleh FS. Neoadjuvant Chemotherapy for Pancreatic Ductal Adenocarcinoma is Associated with Lower Post-Pancreatectomy Readmission Rates: A Population-Based Cohort Study. Ann Surg Oncol 2021; 28:1896-1905. [PMID: 33398644 DOI: 10.1245/s10434-020-09470-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/20/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Despite neoadjuvant chemotherapy (NAC) being increasingly utilized and possibly associated with improved oncological outcomes, the impact of NAC on textbook outcomes following pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) remains debated. METHODS A retrospective review of the National Cancer Database of patients undergoing resection of non-metastatic PDAC from 2004 to 2016 was performed. Propensity score matching was used to account for treatment selection bias in patients with and without NAC (noNAC). A multivariable binary logistic regression model was used to analyze the association of NAC with length of stay (LOS), 30-day readmission, and 30- and 90-day mortality. RESULTS Of 7975 (11%) NAC patients and 65,338 (89%) noNAC patients, 2911 NAC and 2911 noNAC patients remained in the cohort after matching. Clinicopathologic and demographic variables were well-balanced after matching. After matching, NAC was associated with significantly lower rates of 30-day readmission (5.5% vs. 7.4%; p = 0.006), which remained after multivariable adjustment (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.60-0.92; p = 0.006). There were no significant differences in LOS and 30- and 90-day mortality in patients receiving NAC and noNAC. Stratified analyses by surgery type (i.e. pancreaticoduodenectomy [PD] and distal pancreatectomy [DP]) demonstrated consistent results. CONCLUSION Receipt of NAC in PDAC patients undergoing DP or PD is associated with lower readmission rates and does not otherwise compromise short-term outcomes. These data reaffirm the safety of strategies incorporating NAC and is important to consider when devising policies aimed at quality improvement in achieving textbook outcomes.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, Newcastle, UK
| | - Samer A Naffouje
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - George I Salti
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA.,Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - Fadi S Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA.
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20
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Dhir M, Are C. Another Potential Benefit of Neoadjuvant Therapy in Pancreatic Cancer: Reduction in Postoperative Readmission Rates. Ann Surg Oncol 2021; 28:1871-1873. [PMID: 33389295 DOI: 10.1245/s10434-020-09474-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Mashaal Dhir
- Section of Hepatobiliary and Pancreatic Surgery, Division of Surgical Oncology, Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA.
| | - Chandrakanth Are
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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