Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units

Developments in pancreatic cancer surgery

Pancreatic cancer surgery, with one of the worst prognoses in oncology, is a challenge to the surgical community. Centralization of pancreatic surgery has led to the foundation of high-volume centers, thereby greatly facilitating the successful performance of more radical approaches. This review spotlights on recent advances in surgical approaches to pancreatic cancer and the risks and benefits of vascular reconstruction to improve resectability. Surgery being the only modality to achieve cure, multivisceral and vascular resections are being incorporated to improve dismal operability rates of < 10%. Great leaps have been made in neoadjuvant and adjuvant treatment, as targeted and specific chemotherapeutic agents are being continually added. The concept of borderline and locally advanced pancreatic tumors and the use of neoadjuvant chemorad has extended the indications of oncological resection in such tumors. Venous resections are being routinely performed so as to facilitate en bloc removal of tumors, while arterial resections, owing to the increased morbidity and mortality, are offered to highly selective cases. New techniques like the triangle operation and periarterial divestment have opened new viable surgical options. Although laparoscopic approach is time consuming, it offers reduced operative blood loss and a shortened hospital stay at specialized centers. Robotic surgery may produce better results in patients needing vascular resection and reconstruction, but the expenses involved and limited availability are major deterrents. Advanced techniques of surgical resection and vessel reconstruction provide a repository for curative-intent surgery in borderline resectable and locally advanced pancreatic cancer.

Transitioning to a high volume centre for Whipple pancreaticoduodenectomy in Western Australia: a single centre experience

BACKGROUND

Pancreaticoduodenectomy (PD) is a curative resection for peri-ampullary tumours associated with high rates of peri-operative mortality and morbidity. The global trend is towards the establishment of high volume centres to reduce this. Australia faces geographical and population distribution challenges. Western Australia has centralized PD to two centres and we present the results of our institution in transitioning to a high volume centre.

METHODS

This was a prospective database of all PDs performed at our institution from 1 January 2005 to 2 April 2020. Mortality outcomes included peri-operative, 30 day and 90 day mortality. Complications, readmission and reinterventions at 90 days were recorded. The annual volume exceeded 20 from 2015. Outcomes prior to this were compared to characterize the transition to a high volume centre.

RESULTS

One hundred and twenty eight PDs were performed in Period 1 (1 January 2005-31 December 2014) and 170 in the high volume Period 2 (1 January 2015-2 April 2020). There was a non-statistically significant reduction in 90 day mortality in Period 2 (4.69% versus 1.18%, p = 0.06). There was a reduction in clinically significant post-operative pancreatic fistulas (31.25% versus 11.76%, p < 0.05), delayed gastric emptying (39.84% versus 22.35%, p < 0.05) and transfusion requirements (56.25% versus 17.65%, p < 0.05). Severe complications (Clavien-Dindo III or greater) were reduced (30.47% versus 18.24%, p < 0.05).

CONCLUSION

Since establishing a high volume service, there was a reduction in post-operative complications and 90 day mortality. This is in line with outcomes from international centres and demonstrates the improvements that can be made.

Short-term outcomes after vascular resection for pancreatic tumors: Lessons learned from 72 cases from a single Brazilian Cancer Center

INTRODUCTION

Pancreatic malignant tumors are resectable at diagnosis in only 15% to 20% of cases and invasion of vascular structures is commonly present. Therefore, extended resections are needed for adequate local control and negative margins. However, morbidity and mortality associated with these enlarged resections are limiting factors. The aim of this study was to correlate demographic and technical aspects that influenced early and late outcomes.

MATERIALS AND METHODS

Between October 2007 and May 2019, 523 pancreatic surgeries were performed, of which 72 required vascular resections. Clinical and histopathological data, surgical techniques, and perioperative parameters were analyzed in a prospectively collected database.

RESULTS

Of the 72 cases of vascular resection, 31 were male and 41 females with a mean age of 60.9 years (34-81). The most commonly affected vascular structure was the portal vein (in 40.3%). Free margins were obtained in 77.8% of cases. Postoperative mortality rate at 60 days was 13.9%. American Society of Anesthesiologists (ASA) and age were the most important predictors of major complications.

CONCLUSION

Extended resections with vascular involvement in pancreatic surgeries are feasible and safe; furthermore, patient selection plays are key. ASA and age were the most important factors in the decision-making process for extended resections.

Pancreatic cancer--low survival rates

INTRODUCTION

Cancers of the pancreas are identified in 11 800 to 13 500 patients each year in Germany. Epidemiological studies prove smoking and chronic alcohol consumption as causes of about 30% of pancreatic cancers.

METHODS

Selective literature review.

RESULTS

Only patients within TNM stage I and II have after oncologic tumor extirpation a chance for long term survival. Controlled prospective clinical trials demonstrated adjuvant chemotherapy yielding an additional significant survival benefit. The 3- and 5-year-survival after R0-resection and adjuvant chemotherapy are about 30% and below 15% respectively. Using the criteria of observed 5-year-survival less than 2% of all pancreatic cancer patients are alive. After R0-resection the median survival time is between 17 and 28 months, after R1/2-resection between 8 and 22 months.

DISCUSSION

Pancreatic cancer is even today for more than 95% of the patients incurable. Strategies to prevent pancreatic cancer are intended to stop smoking and chronic alcohol consumption and early surgical extirpation of cystic neoplastic lesions. For patients with established pancreatic cancer risk a follow-up protocol is discussed.

Sub-specialization in general surgery: the problem of providing a safe emergency general surgical service

BACKGROUND

The increasing subspecialization of general surgeons in their elective work may result in deskilling and create problems in providing expert care for emergency cases. To evaluate the size of the problem this study determined how often complex emergency surgical cases are treated by general surgeons working outside their own elective subspecialty.

METHOD

In a district general hospital in the south of the UK serving a population of 550 000 where there is almost complete subspecialization within general surgery, 1554 patients having emergency general surgical operations were studied in a one-year review. The time an operation occurred, the seniority of the operating surgeon, the subspecialty interest of the consultant responsible for the case compared with the specialist nature of the operation was determined.

RESULTS

Of 1554 patients having emergency general surgical operations, 23% (352/1554) were of a high category of complexity. Ninety were vascular procedures and were dealt with by specialist vascular surgeons on a separate rota. Of the remaining 262 operations, 78 (30%) did not match the subspecialty of the consultant surgeon responsible for their care; 56 (72%) of these occurred out of hours of which 14 (18%) had a consultant surgeon present and scrubbed in the theatre; one per month of the study. Seventy-three percent (57/78) of these were complex colorectal operations.

CONCLUSION

The mismatch between the subspecialist elective interests of the consultant general surgeon and out of hours specialist major surgery needing consultant involvement occurred infrequently, and was mainly due to major lower gastrointestinal cases managed by upper gastrointestinal and breast surgeons. This has important implications for the future training of general surgeons and the provision of an emergency nonvascular general surgical service.

Exocrine pancreatic function following pancreatectomy

Pancreatic exocrine insufficiency can follow major pancreatic resection and result in the malabsorption of fat, causing symptoms of steatorrhea, abdominal pain and weight loss. The extent of malabsorption will depend on the original disease process and the type and extent of surgical resection. The steatorrhea can be severe and difficult to control, and patients may require high doses of pancreatic enzyme supplements. There have been few studies that have looked at the treatment of steatorrhea postpancreatectomy, and very few randomized studies. Results of the latter have demonstrated that after treatment with oral pancreatic supplements over a third of postpancreatectomy patients still have significant levels of steatorrhea. These results show that even using the best available agents the complete elimination of steatorrhea following major pancreatic resection is not possible at the present time. This indicates a need for further effective therapies.