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Yang J, Zhang J, Tan M, Gu J, Tang L, Zheng Y, Zhou Q, Wang X, Xia R, Zhang T, Yang Y, Guo S, Wang H. Identifying suitable candidates for pancreaticoduodenectomy with extended lymphadenectomy for pancreatic ductal adenocarcinoma. HPB (Oxford) 2024:S1365-182X(24)02217-2. [PMID: 39054211 DOI: 10.1016/j.hpb.2024.07.405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 04/24/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND To evaluate long-term quality of life and survival in pancreatic ductal adenocarcinoma (PDAC) patients after pancreatoduodenectomy with extended lymphadenectomy (PDEL) and identify candidates. METHODS Patients with resectable PDAC with ≥1 examined lymph node (LN) during pancreatoduodenectomy (PD), and were divided into the PD with standard lymphadenectomy (PDSL) and PDEL groups. Perioperative data, long-term quality of life and survival were compared, and the prognostic effect of LNs ± in every peripancreatic station were analysed. RESULTS Screening 446 PDAC patients, 237 and 126 were included in the PDSL and PDEL groups, respectively. The PDEL group showed a longer operation time, greater intraoperative blood loss, severe diarrhoea, a higher incidence of grade III complications. Notably, the PDEL patients experienced significant relief from low back pain and diarrhoea, with an obvious survival advantage (p = 0.037), especially in patients with preoperative tumor contact with vascular and pathological N0; however, LNs+ in any station (No. 8p, 12, 14, or 16) were associated with a poorer prognosis. The vascular reconstruction, T and N stage were independent risk factors for survival. CONCLUSION PDEL can relieve symptoms and prolong the survival of PDAC patients with acceptable complications, and EL should be performed regardless of preoperative LN enlargement.
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Affiliation(s)
- Jiali Yang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Junfeng Zhang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Mingda Tan
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Jianyou Gu
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Li Tang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Yao Zheng
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Qiang Zhou
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Xianxing Wang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Renpei Xia
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Tao Zhang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Yongjun Yang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Shixiang Guo
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China.
| | - Huaizhi Wang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China.
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Meng L, Li J, Ouyang G, Li Y, Cai Y, Wu Z, Peng B. Delayed gastric emptying after laparoscopic pancreaticoduodenectomy: a single-center experience of 827 cases. BMC Surg 2024; 24:145. [PMID: 38734631 PMCID: PMC11088113 DOI: 10.1186/s12893-024-02447-7] [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: 01/31/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) commonly occurs after pancreaticoduodenectomy (PD). Risk factors for DGE have been reported in open PD but are rarely reported in laparoscopic PD (LPD). This study was designed to evaluate the perioperative risk factors for DGE and secondary DGE after LPD in a single center. METHODS This retrospective cohort study included patients who underwent LPD between October 2014 and April 2023. Demographic data, preoperative, intraoperative, and postoperative data were collected. The risk factors for DGE and secondary DGE were analyzed. RESULTS A total of 827 consecutive patients underwent LPD. One hundred and forty-two patients (17.2%) developed DGE of any type. Sixty-five patients (7.9%) had type A, 62 (7.5%) had type B, and the remaining 15 (1.8%) had type C DGE. Preoperative biliary drainage (p = 0.032), blood loss (p = 0.014), and 90-day any major complication with Dindo-Clavien score ≥ III (p < 0.001) were independent significant risk factors for DGE. Seventy-six (53.5%) patients were diagnosed with primary DGE, whereas 66 (46.5%) patients had DGE secondary to concomitant complications. Higher body mass index, soft pancreatic texture, and perioperative transfusion were independent risk factors for secondary DGE. Hospital stay and drainage tube removal time were significantly longer in the DGE and secondary DGE groups. CONCLUSION Identifying patients at an increased risk of DGE and secondary DGE can be used to intervene earlier, avoid potential risk factors, and make more informed clinical decisions to shorten the duration of perioperative management.
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Affiliation(s)
- Lingwei Meng
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
- Departments of General Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, Sichuan Province, China
| | - Jun Li
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Guoqing Ouyang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Yongbin Li
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
- Departments of General Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, Sichuan Province, China
| | - Yunqiang Cai
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Zhong Wu
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Bing Peng
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
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Surgical treatment of pancreatic cancer: Currently debated topics on morbidity, mortality, and lymphadenectomy. Surg Oncol 2022; 45:101858. [DOI: 10.1016/j.suronc.2022.101858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/07/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022]
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Kalthoff H. How open is the therapeutic horizon for pancreatic cancer patients? Hepatobiliary Pancreat Dis Int 2022; 21:1-3. [PMID: 34789410 DOI: 10.1016/j.hbpd.2021.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/26/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Holger Kalthoff
- Institute for Experimental Cancer Research, Christian-Albrechts-University, Kiel, Germany.
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Arslan B, Kose E, Tazeoğlu D, Karahan SR. The Effect of Increase in Clinical Experience on Morbidity and Mortality After Pancreaticoduodenectomy Surgery. POLISH JOURNAL OF SURGERY 2021. [DOI: 10.5604/01.3001.0015.5993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<b> Introduction:</b> Pancreaticoduodenectomy surgery is widely accepted and applied worldwide for periampullary tumors. Despite the decline in mortality rates from 40% to 3% with the advances in surgical technique, morbidity is still high (40–50%). </br></br> <b>Aim:</b> We aimed to investigate the effect of increased clinical experience on the length of hospital stay, morbidity, mortality, and survival after pancreaticoduodenectomy. </br></br> <b> Materials and methods:</b> The files of patients who underwent pancreaticoduodenectomy in our hospital between January 2007 and January 2018 were retrospectively reviewed and divided into four groups by years. Demographics, body mass index (BMI, kg/m2), medical history, preoperative biliary drainage application, surgical technique, histopathological features, postoperative morbidity, mortality, and survival were investigated. </br></br> <b> Results: </b> There was no difference between the groups in terms of age, gender, comorbid disease, history of biliary drainage, surgical technique, and operation time (P > 0.05). The rate of postoperative complications has decreased over the years (P = 0.01). According to the Clavien-Dindo scale, the complication severity decreased significantly over the years (P = 0.05). The overall survival of the patients increased by years (P = 0.03); the Early postoperative mortality rate decreased in the first month (<30 days) (P = 0.04). </br></br> <b> Conclusion:</b> With increased clinical experience, morbidity and mortality decrease, overall survival is prolonged after pancreaticoduodenectomy procedure.
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Affiliation(s)
- Bilal Arslan
- Department of Surgery, Division of Surgical Oncology, Mersin University, Turkey
| | - Emin Kose
- Department of Surgery, Prof. Dr. Cemil Taşçıoğlu City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Deniz Tazeoğlu
- Department of Surgery, Division of Surgical Oncology, Mersin University, Turkey
| | - Servet Rüştü Karahan
- Department of Surgery, Prof. Dr. Cemil Taşçıoğlu City Hospital, University of Health Sciences, Istanbul, Turkey
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Sun PJ, Yu YH, Li JW, Cui XJ. A Novel Anastomosis Technique for Laparoscopic Pancreaticoduodenectomy: Case Series of Our Center's Experience. Front Surg 2021; 8:583671. [PMID: 33777996 PMCID: PMC7994857 DOI: 10.3389/fsurg.2021.583671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/22/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Laparoscopic pancreaticoduodenectomy has developed rapidly in recent years. Postoperative pancreatic fistula is still the most dangerous complication of laparoscopic pancreaticoduodenectomy. Baumgart pancreaticojejunostomy is considered one of the safest anastomosis procedures, with low rates of pancreatic fistula. We modified Blumgart pancreaticojejunostomy and applied the modified procedure during laparoscopic pancreaticoduodenectomy. The modified procedure entailed a longitudinal U-shaped suture through the pancreas for anastomosis of the pancreatic duct and the jejunal mucosa. Methods: We prospectively collected and retrospectively analyzed the data of 120 patients who underwent laparoscopic pancreaticoduodenectomy from January 2016. The total operative time, time for complete pancreaticojejunostomy, postoperative pancreatic fistula rate, postoperative delayed gastric emptying, postoperative bleeding, postoperative length of hospital stays, and mortality within 90 days after surgery were analyzed. An analysis of laparoscopic pancreaticojejunostomy compared with open pancreaticojejunostomy is also reported. Results: In the laparoscopic pancreaticojejunostomy group, the average total operative time, the average time for complete pancreaticojejunostomy, and the average intraoperative blood loss were 271 min, 35.3 min, and 184 ml, respectively. The total postoperative clinically relevant pancreatic fistula rate was 9.2% (Grade B and C fistulas). The incidence rates of postoperative delayed gastric emptying and postoperative biliary fistula were ~2.5 and 1.7%, respectively. The postoperative bleeding rate was 0.83%, and the average postoperative indwelling time of the abdominal drainage tube was 7.3 days. The postoperative length of hospital stay was 10.8 days, and the mortality rate within 90 days after surgery was 0.83%. The rates of clinically relevant postoperative clinically relevant pancreatic fistula are comparable between laparoscopic and open surgery, there were no other severe postoperative complications in either group. The mean postoperative length of hospital stay was significantly shorter in the laparoscopic pancreaticojejunostomy group. Conclusion: The modified laparoscopic-adapted Blumgart anastomosis simplifies and facilitates the creation of the pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy. The rates of clinically relevant postoperative pancreatic fistula are comparable with those obtained by open surgery, and length of stay are shoter.
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Affiliation(s)
- Pi-Jiang Sun
- Department of Hepatobiliary Surgery, Weihai Central Hospital Affiliated to Qingdao University, Weihai, China
| | - Yan-Hua Yu
- Department of Dermatology, Weihai Central Hospital Affiliated to Qingdao University, Weihai, China
| | - Jian-Wei Li
- Institute of Hepatopancreatobiliary Surgery, First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Xi-Jun Cui
- Department of Hepatobiliary Surgery, Weihai Central Hospital Affiliated to Qingdao University, Weihai, China
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Iwasaki T, Nara S, Kishi Y, Esaki M, Takamoto T, Shimada K. Proposal of a Clinically Useful Criterion for Early Drain Removal After Pancreaticoduodenectomy. J Gastrointest Surg 2021; 25:737-746. [PMID: 32221781 DOI: 10.1007/s11605-020-04565-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 03/01/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE This study aimed to establish a reliable criterion for early drain removal after pancreaticoduodenectomy (PD) based on predictive factors of clinically relevant postoperative pancreatic fistula (CR-POPF) available on postoperative day 3 (POD3). METHODS A total of 300 consecutive patients who underwent PD with pancreaticojejunostomy at our hospital from 2011 to 2015 were analyzed retrospectively. CR-POPF was defined as POPF grade B or C according to the definition by ISGPF. Clinicopathological factors available on or before POD3 were analyzed to identify predictors of CR-POPF. Using obtained predictors, we developed a criterion for no CR-POPF and internally validated its relevance in 100 consecutive patients. RESULTS The incidence rates of CR-POPF, severe complications (Clavien-Dindo ≥ grade IIIa), and postoperative mortality were 35%, 9.6%, and 0.3%, respectively. Multivariate analysis showed that drain amylase (d-AMY) levels ≥ 350 IU/l on POD3, C-reactive protein (CRP) levels ≥ 14 mg/dl on POD3, preoperative endoscopic retrograde biliary drainage, and no portal vein resection were significant predictors of CR-POPF. Using the strongest predictors (i.e., d-AMY and CRP), we established a criterion for no CR-POPF: d-AMY levels < 350 IU/l and CRP levels < 14 mg/dl on POD3. The incidence rates of CR-POPF were 6%, 38%, and 88% in patients who fulfilled both of (n = 149), each of (n = 74), and none of (n = 77) the two factors, respectively. In the internal validation cohort, the positive predictive value of CR-POPF was 89%. CONCLUSIONS A simple two-factor criterion available on POD3 after PD has a reliable predictive ability. In patients who fulfill this criterion, early drain removal is considered safe.
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Affiliation(s)
- Toshimitsu Iwasaki
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Satoshi Nara
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Yoji Kishi
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Minoru Esaki
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Takeshi Takamoto
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Kazuaki Shimada
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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Role of lymphadenectomy in resectable pancreatic cancer. Langenbecks Arch Surg 2020; 405:889-902. [PMID: 32902706 DOI: 10.1007/s00423-020-01980-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic cancer (PC) remains one of the most devastating malignant diseases, predicted to become the second leading cause of cancer-related death by 2030. Despite advances in surgical techniques and in systemic therapy, the 5-year relative survival remains a grim 9% for all stages combined. The extent of lymphadenectomy has been discussed intensively for decades, given that even in early stages of PC, lymph node (LN) metastasis can be detected in approximately 80%. PURPOSE The primary objective of this review was to provide an overview of the current literature evaluating the role of lymphadenectomy in resected PC. For this, we evaluated randomized controlled studies (RCTs) assessing the impact of extent of lymphadenectomy on OS and studies evaluating the prognostic impact of anatomical site of LN metastasis and the impact of the number of resected LNs on OS. CONCLUSIONS Lymphadenectomy plays an essential part in the multimodal treatment algorithm of PC and is an additional therapeutic tool to increase the chance for surgical radicality and to ensure correct staging for optimal oncological therapy. Based on the literature from the last decades, standard lymphadenectomy with resection of at least ≥ 15 LNs is associated with an acceptable postoperative complication risk and should be recommended to obtain local radicality and accurate staging of the disease. Although radical surgery including appropriate lymphadenectomy of regional LNs remains the only chance for long-term tumor control, future studies specifically assessing the impact of neoadjuvant therapy on extraregional LNs are warranted.
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Zou SY, Wang WS, Zhan Q, Deng XX, Shen BY. Higher body mass index deteriorates postoperative outcomes of pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2020; 19:163-168. [PMID: 31862346 DOI: 10.1016/j.hbpd.2019.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 11/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies presented controversies in impact of body mass index (BMI) on perioperative complications in pancreatectomy, and mainly focused on Western population. This study aimed to explore the impact of BMI on perioperative outcomes in Chinese patients undergoing pancreaticoduodenectomy. METHODS Seven hundred and seven adult patients undergoing open pancreaticoduodenectomy between January 2005 and December 2016 at Ruijin Hospital were studied retrospectively and categorized as obese (BMI ≥25 kg/m2), overweight (BMI ≥23 kg/m2 and <25 kg/m2), or normal weight (BMI ≥18.5 kg/m2 and <23 kg/m2). Associations of these BMI groups with perioperative outcomes were evaluated. RESULTS The overweight and obese groups experienced higher risk of clinically related postoperative pancreatic fistula (CR-POPF) (7.6% vs. 9.9% vs. 17.6%, P = 0.002) and re-operation (1.1% vs. 2.5% vs. 5.1%, P = 0.017), and longer systemic inflammation response syndrome (SIRS) duration [2 (1-9) d vs. 2 (1-7) d vs. 3 (1-10) d, P = 0.003] and postoperative hospital stay [19 (2-84) d vs. 19 (7-158) d vs. 23 (8-121) d, P = 0.023] than the normal weight group did. The multiple logistic regression models showed obese as an independent risk factor for CR-POPF (P = 0.013). The multiple linear regression analysis confirmed BMI as a predictor for prolonged postoperative hospital stay (P = 0.005). CONCLUSIONS Higher BMI results in higher morbidity of Chinese patients undergoing open pancreaticoduodenectomy. Pancreaticoduodenectomy is still a safe surgery procedure for overweight and obese patients, with intensive perioperative management.
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Affiliation(s)
- Si-Yi Zou
- Pancreatic Disease Center, Research Institute of Pancreatic Disease, Shanghai Institute of Digestive Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Wei-Shen Wang
- Pancreatic Disease Center, Research Institute of Pancreatic Disease, Shanghai Institute of Digestive Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Qian Zhan
- Pancreatic Disease Center, Research Institute of Pancreatic Disease, Shanghai Institute of Digestive Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Xia-Xing Deng
- Pancreatic Disease Center, Research Institute of Pancreatic Disease, Shanghai Institute of Digestive Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Bai-Yong Shen
- Pancreatic Disease Center, Research Institute of Pancreatic Disease, Shanghai Institute of Digestive Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China.
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Smith H, Balaa FK, Martel G, Abou Khalil J, Bertens KA. Standardization of early drain removal following pancreatic resection: proposal of the "Ottawa pancreatic drain algorithm". Patient Saf Surg 2019; 13:38. [PMID: 31827615 PMCID: PMC6889288 DOI: 10.1186/s13037-019-0219-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023] Open
Abstract
Background Early drain removal after pancreatic resection is encouraged for individuals with low postoperative day 1 drain amylase levels (POD1 DA) to mitigate associated morbidity. Although various protocols for drain management have been published, there is a need to assess the implementation of a standardized protocol. Methods The Ottawa pancreatic drain algorithm (OPDA), based on POD1 DA and effluent volume, was developed and implemented at our institution. A retrospective cohort analysis was conducted of all patients undergoing pancreatic resection January 1, 2016-October 30, 2017, excluding November and December 2016 (one month before and after OPDA implementation). Results 42 patients pre-implementation and 53 patients post-implementation were included in the analysis. The median day of drain removal was significantly reduced after implementation of the OPDA (8 vs. 5 days; p = 0.01). Early drain removal appeared safe with no difference in reoperation or readmission rate after protocol implementation (p = 0.39; p = 0.76). On subgroup analysis, median length of stay was significantly shorter following OPDA implementation for patients who underwent DP and did not develop a postoperative pancreatic fistula (POPF) (6 vs 10 days, p = 0.03). Although the incidence of both surgical site infection and POPF were reduced following the intervention, neither reached statistical significance (38.1 to 28.3%, p = 0.31; and 38.1 to 28.3%, p = 0.31 respectively). Conclusions Implementing the OPDA was associated with earlier drain removal and decreased length of stay in patients undergoing distal pancreatectomy who did not develop POPF, without increased morbidity. Standardizing drain removal may help facilitate early drain removal after pancreatic resection at other institutions.
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Affiliation(s)
- Heather Smith
- Division of General Surgery, The Ottawa Hospital, University of Ottawa, 725 Parkdale Ave, Ottawa, ON K1Y4E9 Canada
| | - Fady K Balaa
- Hepatopancreaticobiliary Subunit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1667b, Ottawa, ON K1H 8L6 Canada
| | - Guillaume Martel
- Hepatopancreaticobiliary Subunit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1667b, Ottawa, ON K1H 8L6 Canada.,3Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON K1Y4E9 Canada
| | - Jad Abou Khalil
- Hepatopancreaticobiliary Subunit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1667b, Ottawa, ON K1H 8L6 Canada
| | - Kimberly A Bertens
- Hepatopancreaticobiliary Subunit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1667b, Ottawa, ON K1H 8L6 Canada.,3Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON K1Y4E9 Canada
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Zhou Y, Lin J, Wang W, Chen H, Deng X, Peng C, Cheng D, Shen B. Should a standard lymphadenectomy include the No. 9 lymph nodes for body and tail pancreatic ductal adenocarcinoma? Pancreatology 2019; 19:414-418. [PMID: 30902419 DOI: 10.1016/j.pan.2019.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/10/2019] [Accepted: 03/12/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES This study aimed to use a retrospective data base to investigate whether a standard lymphadenectomy during distal pancreatectomy should include the No. 9 lymph nodes (LNs) for resectable pancreatic ductal adenocarcinoma (PDAC) located in the body and tail of the pancreas. METHODS Data from 169 patients undergoing curative distal pancreatectomy for PDAC between Jan 1, 2013 and Dec 31, 2016 were collected. According to the tumor location, patients were divided into three groups: pancreatic neck tumor, pancreatic body and tail tumor with margin-to-bifurcation-distance (MTBD) ≤ 2.5 cm and pancreatic body and tail tumor with MTBD > 2.5 cm. The metastatic rate of the No. 9 LNs was compared among the 3 groups. The survival outcomes were analyzed. RESULTS The involvement rate for No. 9 LNs was 20.7% (6/29) for pancreatic neck tumors, 17.6% (15/85) for body and tail tumors with MTBD ≤ 2.5 cm and 1.8% (1/55) for MTBD > 2.5 cm. The No. 9 LNs were significantly more frequently involved in neck or body and tail tumors with MTBD ≤2.5 cm than with the cases with MTBD >2.5 cm (OR 0.082, P = 0.016). No. 9 LN involvement was not associated with worse survival compared with survival associated with involvement of other LNs (P = 0.780). CONCLUSIONS For PDAC located in the neck or in the body and tail of the pancreas with MTBD ≤ 2.5 cm, the involvement rate for No. 9 LNs is high. Standard lymphadenectomy should include the No. 9 LNs.
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Affiliation(s)
- Yiran Zhou
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Jiewei Lin
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Wei Wang
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Hao Chen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Xiaxing Deng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Chenghong Peng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Dongfeng Cheng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
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Dolay K, Malya FU, Akbulut S. Management of pancreatic head adenocarcinoma: From where to where? World J Gastrointest Surg 2019; 11:143-154. [PMID: 31057699 PMCID: PMC6478601 DOI: 10.4240/wjgs.v11.i3.143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 02/06/2023] Open
Abstract
Pancreatic head adenocarcinoma (PHAC) is one of the most aggressive malignancies, and it has low long-term survival rates. Surgery is the only option for long-term survival. The difficulties associated with PHAC include higher frequencies of regional or distant lymph node metastases and vascular involvement, and positive resection margins in pancreatic and retroperitoneal tissues. Radical resections increase margin negativity and life expectancy; however, the extend of the surgery applied is controversial. Thus, western and eastern centers may use different approaches. Multiorgan, peripancreatic nerve plexus, and vascular resections have been discussed in relation to radical surgery for pancreatic cancer as have the roles of neoadjuvant and adjuvant therapy regimens. Determining the appropriate limits for surgery, standardizing definitions and surgical techniques according to guidelines, and centralizing pancreatic surgery within high-volume institutions to reduce mortality and morbidity rates are among the most important issues to consider. In this review, we evaluate the basic concepts underlying and the roles of radical surgery for PHAC, and lymphadenectomy, nerve plexus, retroperitoneal tissue, vascular, and multivisceral resections, total pancreatectomy, and liver metastases are discussed.
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Affiliation(s)
- Kemal Dolay
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery, Istinye University, Liv Hospital, Istanbul 34340, Turkey
| | - Fatma Umit Malya
- Department of Surgery, Bezmialem Vakif University Faculty of Medicine, Istanbul 34093, Turkey
| | - Sami Akbulut
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya 44280, Turkey
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Goess R, Friess H. A look at the progress of treating pancreatic cancer over the past 20 years. Expert Rev Anticancer Ther 2018; 18:295-304. [PMID: 29334794 DOI: 10.1080/14737140.2018.1428093] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Pancreatic cancer is known to be the deadliest of all common cancers. Despite all efforts in pancreatic cancer treatment, the five-year survival rates at diagnosis over the past 20 years have only increased from 5% to 8%. Assuming that pancreatic cancer is going to become the second most frequent cause of cancer related death in the next 20 years, we are all encouraged to treat patients in clinical trials to gain improvements in this devastating disease. Areas covered: This review will provide a summary of pancreatic cancer treatment over the last 20 years, starting with the pivotal study in 1997 which showed the superiority of gemcitabine over 5-FU in advanced pancreatic cancer and is marked as the beginning of a new era in pancreatic cancer treatment. This review will also focus on improvements in different areas of treatment, including pancreatic surgery, adjuvant treatment, neoadjuvant therapy and palliative therapy. Expert commentary: The treatment of pancreatic cancer has changed substantially in the last 20 years compared to almost no improvements in the decades before. This provides hope that more effective treatment options will become available in the near future. Particularly, new concepts such as neoadjuvant therapy in resectable and borderline-resectable tumors may potentially shift treatment strategies.
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Affiliation(s)
- Ruediger Goess
- a Department of Surgery, School of Medicine , Technical University of Munich , Munich , Germany
| | - Helmut Friess
- a Department of Surgery, School of Medicine , Technical University of Munich , Munich , Germany
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Marchegiani G, Andrianello S, Nessi C, Sandini M, Maggino L, Malleo G, Paiella S, Polati E, Bassi C, Salvia R. Neoadjuvant Therapy Versus Upfront Resection for Pancreatic Cancer: The Actual Spectrum and Clinical Burden of Postoperative Complications. Ann Surg Oncol 2017; 25:626-637. [PMID: 29214453 DOI: 10.1245/s10434-017-6281-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) is used for borderline-resectable or locally advanced pancreatic cancer (PDAC) and exhibits promising results in terms of pathological outcomes. However, little is known about its effect on surgical complications. METHODS We analyzed 445 pancreatic resections for PDAC from 2014 to 2016 at The Pancreas Institute, Verona University Hospital. The Modified Accordion Severity Grading System and average complication burden (ACB) were used to compare patients treated with NAT with patients who underwent upfront surgery (UFS). RESULTS Of 305 pancreaticoduodenectomies (PD), patients treated with NAT (n = 99) had less pancreatic fistula (POPF, 9.1% vs. 15.6%, p = 0.05) without grade C cases, but grade B ACB was increased (0.28 for NAT vs. 0.24 for UFS, p = 0.05). The postpancreatectomy hemorrhage (PPH) rate was lower in the NAT group (9.1% vs. 14.6%, p = 0.02), but ACB grades B (0.37 for NAT vs. 0.26 for UFS, p = 0.03) and C (0.43 for NAT vs. 0.29 for UFS, p = 0.05) were increased. Delayed gastric emptying (DGE) was increased in NAT cases (15.2% vs. 8.3%, p = 0.04), with higher grade C ACB (0.43 for NAT vs. 0.29 for UFS, p = 0.03). Of 94 distal pancreatectomies (DP), NAT patients (n = 26) developed more grade C POPF (11.5% vs. 1.5%, p = 0.04) and DGE (11.5% vs. 2.9%, p = 0.01) without differences in ACB. CONCLUSIONS Patients undergoing PD for PDAC after NAT exhibited reduced incidence of POPF and PPH but increased incidence of DGE compared with patients treated with UFS. Among patients developing postoperative complications after PD, those receiving NAT were associated with increased clinical burden.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Chiara Nessi
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Marta Sandini
- Department of Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Laura Maggino
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Enrico Polati
- Department of Anesthesia and Intensive Care Unit, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
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Roeyen G, Jansen M, Hartman V, Chapelle T, Bracke B, Ysebaert D, De Block C. The impact of pancreaticoduodenectomy on endocrine and exocrine pancreatic function: A prospective cohort study based on pre- and postoperative function tests. Pancreatology 2017; 17:974-982. [PMID: 28958898 DOI: 10.1016/j.pan.2017.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/07/2017] [Accepted: 09/08/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVES Studies reporting on function after pancreatic surgery are frequently based on diabetes history, fasting glycemia or random glycemia. The aim of this study was to investigate prospectively the evolution of pancreatic function in patients undergoing pancreaticoduodenectomy based on proper pre- and postoperative function tests. It was hypothesised that pancreatic function deteriorates after pancreaticoduodenectomy. METHODS Between 2013 and 2016, 78 patients undergoing pancreaticoduodenectomy for oncologic indications had a prospective evaluation of their endocrine and exocrine pancreatic function. Endocrine function was evaluated with the 75 g oral glucose tolerance test (OGTT) and the 1 mg intravenous glucagon test. Exocrine function was evaluated with a 13C-labelled mixed-triglyceride breath test. Tests were performed pre- and postoperatively. RESULTS In 90.5% (19/21) of patients with preoperatively known diabetes, no change in endocrine function was observed. In contrast, endocrine function improved in 68.1% (15/22) of patients with newly diagnosed diabetes. 40% (14/35) of patients with a preoperative normal OGTT or prediabetes experienced deterioration in function. In multivariate analysis, improvement of newly diagnosed diabetes was correlated with preoperative bilirubin levels (p = 0.045), while progression towards diabetes was correlated with preoperative C-peptidogenic index T30 (p = 0.037). A total of 20.5% (16/78) of patients had pancreatic exocrine insufficiency preoperatively. Another 51.3% (40/78) of patients deteriorated on exocrine level. In total, 64.1% (50/78) of patients required pancreatic enzyme-replacement therapy postoperatively. CONCLUSIONS Although deterioration of endocrine function was expected after pancreatic resection, improvement is frequently observed in patients with newly diagnosed diabetes. Exocrine function deteriorates after pancreaticoduodenectomy.
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Affiliation(s)
- Geert Roeyen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium.
| | - Miet Jansen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Vera Hartman
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Thiery Chapelle
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Bart Bracke
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Dirk Ysebaert
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Belgium
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The More the Better-Lower Rate of Stage Migration and Better Survival in Patients With Retrieval of 20 or More Regional Lymph Nodes in Pancreatic Cancer: A Population-Based Propensity Score Matched and Trend SEER Analysis. Pancreas 2017; 46:648-657. [PMID: 28196023 DOI: 10.1097/mpa.0000000000000784] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to assess the influence of regional lymph node (RLN) retrieval on stage migration and survival in pancreatic cancer. METHODS A total of 7685 stage I and II pancreatic cancer patients were identified in the Surveillance, Epidemiology, and End Results database in 2004-2011. The impact of RLN was assessed using Cox regression, propensity score methods, and joinpoint regression. RESULTS In 3079 patients, 1 to 10 RLNs were retrieved; in 2799 patients, 11 to 19 RLNs, and in 1807 patients, 20+ RLNs. The rate of node-positive pancreatic cancer increased with the number of retrieved RLN. This trend continued beyond 10 retrieved RLN (P < 0.001). In unadjusted analysis, retrieval of RLN did not influence survival (P = 0.178). When adjusting for significant bias in staging variables (P < 0.001), retrieval of 20+ RLNs compared to 11 to 19 RLNs was associated with an increased survival in node-negative (hazard ratio, 0.78; 95% confidence interval, 0.62-0.98; P = 0.033) and node-positive cancer (hazard ratio, 0.83; 95% confidence interval, 0.74-0.93; P = 0.002). CONCLUSIONS This population-based propensity score-adjusted investigation demonstrated that more retrieved RLNs in pancreatic cancer decreases the rate of stage migration and improves the oncological outcome in node-negative and positive cancer. Contradictory results may be explained by a bias in the cancer characteristics for a different extent of RLN retrieval.
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17
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Surgical resection of pancreatic head cancer: What is the optimal extent of surgery? Cancer Lett 2016; 382:259-265. [DOI: 10.1016/j.canlet.2016.01.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/24/2015] [Accepted: 01/18/2016] [Indexed: 01/17/2023]
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18
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Sierzega M, Bobrzyński Ł, Matyja A, Kulig J. Factors predicting adequate lymph node yield in patients undergoing pancreatoduodenectomy for malignancy. World J Surg Oncol 2016; 14:248. [PMID: 27644962 PMCID: PMC5029025 DOI: 10.1186/s12957-016-1005-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/13/2016] [Indexed: 12/29/2022] Open
Abstract
Background Most pancreatoduodenectomy resections do not meet the minimum of 12 lymph nodes recommended by the American Joint Committee on Cancer for accurate staging of periampullary malignancies. The purpose of this study was to investigate factors affecting the likelihood of adequate nodal yield in pancreatoduodenectomy specimens subject to routine pathological assessment. Methods Six hundred sixty-two patients subject to pancreatoduodenectomy between 1990 and 2013 for pancreatic, ampullary, and common bile duct cancers were reviewed. Predictors of yielding at least 12 lymph nodes were evaluated with a logistic regression model, and a survival analysis was carried out to verify the prognostic implications of nodal counts. Results The median number of evaluated nodes was 17 (interquartile range 11 to 25), and less than 12 lymph nodes were reported in surgical specimens of 179 (27 %) patients. Tumor diameter ≥20 mm (odds ratio [OR] 2.547, 95 % confidence interval [CI] 1.225 to 5.329, P = 0.013), lymph node metastases (OR 2.642, 95 % CI 1.378 to 5.061, P = 0.004), and radical lymphadenectomy (OR 5.566, 95 % CI 2.041 to 15.148, P = 0.01) were significant predictors of retrieving 12 or more lymph nodes. Lymph node counts did not influence the overall prognosis of the patients. However, a subgroup analysis carried out for individual cancer sites demonstrated that removing at least 12 lymph nodes is associated with better prognosis for pancreatic cancer. Conclusions Few variables affect adequate nodal yield in pancreatoduodenectomy specimens subject to routine pathological assessment. Considering the ambiguities related to the only modifiable factor identified, appropriate pathology training should be considered to increase nodal yield rather than more aggressive lymphatic dissection.
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Affiliation(s)
- Marek Sierzega
- First Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, 31-501, Krakow, Poland.
| | - Łukasz Bobrzyński
- First Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, 31-501, Krakow, Poland
| | - Andrzej Matyja
- First Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, 31-501, Krakow, Poland
| | - Jan Kulig
- First Department of Surgery, Jagiellonian University Medical College, 40 Kopernika Street, 31-501, Krakow, Poland
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Beisani M, Roca I, Cardenas R, Blanco L, Abu-Suboh M, Dot J, Armengol J, Olsina J, Balsells J, Charco R, Castell J. Initial experience in sentinel lymph node detection in pancreatic cancer. Rev Esp Med Nucl Imagen Mol 2016. [DOI: 10.1016/j.remnie.2015.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a malignant tumor of the digestive system with a high degree of malignancy, accounting for about 90% of cases of pancreatic cancer. It has an occult onset and progresses rapidly, with a poor treatment effect and prognosis. It is one of malignant tumors with the worst prognosis. Surgical resection, as the only effective treatment, can be performed in only 20%-30% of patients, and the average period of survival after surgery is still less than 2 years. The main treatment strategy for PDAC are surgery-based individualized treatment modalities under comprehensive multidisciplinary collaboration. Currently, the therapeutic effect on pancreatic cancer is still not satisfactory. In recent years, various treatments for PDAC is becoming a hot spot of research. This article reviews the progress in the treatment of PDAC in terms of radical surgery, palliative surgery, adjuvant therapy, and other treatment opinions.
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21
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Beisani M, Roca I, Cardenas R, Blanco L, Abu-Suboh M, Dot J, Armengol JR, Olsina JJ, Balsells J, Charco R, Castell J. Initial experience in sentinel lymph node detection in pancreatic cancer. Rev Esp Med Nucl Imagen Mol 2015; 35:287-91. [PMID: 26670326 DOI: 10.1016/j.remn.2015.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 10/06/2015] [Accepted: 10/08/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND The local recurrence of pancreatic cancer is around 30% when complete resection can be achieved. Extended lymphatic resections may improve survival, but increases severe morbidity. As accurate patient selection should be mandatory, a new method is presented for pancreatic sentinel lymph node (SLN) detection with lymphoscintigraphy and gamma probe. MATERIALS AND METHODS Seven patients with cT2N0M0 pancreatic head cancer were enrolled between 2009 and 2012 in this prospective study. One day prior to surgery, preoperative lymphoscintigraphy with echoendoscopic intratumoural administration of Tc(99m)-labelled nanocolloid was performed, with planar and SPECT-CT images obtained 2h later. Gamma probe detection of SLN was also carried out during surgery. RESULTS Radiotracer administration was feasible in all patients. Scintigraphy images showed inter-aortocaval lymph nodes in 2 patients, hepatoduodenal ligament lymph nodes in 1, intravascular injection in 3, intestinal transit in 5, and main pancreatic duct visualisation in 1. Surgical resection could only be achieved in 4 patients owing to locally advanced disease. Intraoperative SLN detection was accomplished in 2 patients, both with negative results. Only in one patient could SLN be confirmed as truly negative by final histopathological analysis. CONCLUSIONS This new method of pancreatic SLN detection is technically feasible, but challenging. Our preliminary results with 7 patients are not sufficient for clinical validation.
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Affiliation(s)
- M Beisani
- Department of HPB Surgery, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - I Roca
- Department of Nuclear Medicine, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - R Cardenas
- Department of Nuclear Medicine, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - L Blanco
- Department of HPB Surgery, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - M Abu-Suboh
- Department of Digestive Endoscopy, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - J Dot
- Department of Digestive Endoscopy, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - J R Armengol
- Department of Digestive Endoscopy, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - J J Olsina
- Department of Surgery, Hospital Arnau de Vilanova, University of Lleida, Lleida, Spain
| | - J Balsells
- Department of HPB Surgery, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - R Charco
- Department of HPB Surgery, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - J Castell
- Department of Nuclear Medicine, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
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Extended versus standard lymphadenectomy in patients undergoing pancreaticoduodenectomy for periampullary adenocarcinoma: a prospective randomized single center trial. Eur Surg 2015. [DOI: 10.1007/s10353-015-0371-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Sun J, Yang Y, Wang X, Yu Z, Zhang T, Song J, Zhao H, Wen J, Du Y, Lau WY, Zhang Y. Meta-analysis of the efficacies of extended and standard pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas. World J Surg 2015; 38:2708-15. [PMID: 24912627 DOI: 10.1007/s00268-014-2633-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The purpose of the present study was to evaluate the efficacy of extended pancreatoduodenectomy (EPD) and standard pancreatoduodenectomy (SPD) for ductal adenocarcinoma of the head of the pancreas via meta-analysis. METHODS Relevant articles (published between 1995 and 2012) were compiled from online data sources. A total of nine studies satisfied the selection criteria, including a total of 973 patients (478 in the SPD group and 495 in the EPD group). Evaluation parameters included 1-, 3-, and 5-year survival, as well as mortality, morbidity, and specific morbidity outcomes. RESULTS Meta-analysis revealed (1) differences in morbidity (Odds ratio [OR] = 1.740; 95 % confidence interval [CI], 0.840-3.600; P = 0.140), mortality (OR = 0.890; 95 % CI, 0.560-1.400; P = 0.620), 1-year overall survival (OS) rate (OR = 1.20; 95 % CI, 0.490-2.930; P = 0.69), 3-year OS rate (OR = 0.770; 95 % CI, 0.460-1.280; P = 0.190), and 5-year OS rate (OR = 1.12; 95 % CI, 0.690-1.810; P = 0.560) were not significant between EPD and SPD. (2) For bile leak (OR = 2.640; 95 % CI, 1.040-6.700; P = 0.040), pancreatic leak (OR = 1.740; 95 % CI, 1.040-2.91; P = 0.030), delayed gastric emptying (OR = 2.090; 95 % CI, 1.240-3.520; P = 0.006), and lymphatic fistula (OR = 6.120; 95 % CI, 1.06-35.320; P = 0.040) differences between EPD and SPD were significant, whereas other specific morbidities were not significantly different. CONCLUSIONS Extended pancreatoduodenectomy does not improve 1-, 3-, 5-year OS rates compared to SPD and there is a trend toward increased bile leak, pancreatic leak, delayed gastric emptying, and lymphatic fistula after EPD.
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Affiliation(s)
- Jingfeng Sun
- Department of Hepatobiliary & Pancreatic Surgery, Affiliated Jiangsu Cancer Hospital of Nanjing Medical University, Nanjing, 210009, People's Republic of China
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Assessing surgical quality: comparison of general and procedure-specific morbidity estimation models for the risk adjustment of pancreaticoduodenectomy outcomes. World J Surg 2015; 38:2412-21. [PMID: 24705780 DOI: 10.1007/s00268-014-2554-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The use of outcomes to evaluate surgical quality implies the need for detailed risk adjustment. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a generally applicable risk adjustment model suitable for pancreatic surgery. A pancreaticoduodenectomy (PD)-specific intraoperative pancreatic risk assessment (IPRA) estimates the risk of postoperative pancreatic fistula (POPF) and associated morbidity based on factors that are not incorporated into POSSUM. OBJECTIVE The aim of the study was to compare the risk estimations of POSSUM and IPRA in patients undergoing PD. METHODS An observational single-center cohort study was conducted including 195 patients undergoing PD in 2008-2010. POSSUM and IPRA data were recorded prospectively. Incidence and severity of postoperative morbidity was recorded according to established definitions. The cohort was grouped by POSSUM and IPRA risk groups. The estimated and observed outcomes and morbidity profiles of POSSUM and IPRA were scrutinized. RESULTS POSSUM-estimated risk (62 %) corresponded with observed total morbidity (65 %). Severe morbidity was 17 % and in-hospital-mortality 3.1 %. Individual and grouped POSSUM risk estimates did not reveal associations with incidence (p = 0.637) or severity (p = 0.321) of total morbidity or POPF. The IPRA model identified patients with high POPF risk (p < 0.001), but was even associated with incidence (p < 0.001) and severity (p < 0.001) of total morbidity. CONCLUSION The risk factors defined by a PD-specific model were significantly stronger predictive indicators for the incidence and severity of postoperative morbidity than the factors incorporated in POSSUM. If available, reliable procedure-specific risk factors should be utilized in the risk adjustment of surgical outcomes. For pancreatic surgery, generally applicable tools such as POSSUM still have to prove their relevance.
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Pedrazzoli S. Extent of lymphadenectomy to associate with pancreaticoduodenectomy in patients with pancreatic head cancer for better tumor staging. Cancer Treat Rev 2015; 41:577-87. [PMID: 26045226 DOI: 10.1016/j.ctrv.2015.04.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/28/2015] [Accepted: 04/29/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To define the extent of lymphadenectomy to associate with surgery for pancreatic head cancer. BACKGROUND Pancreaticoduodenectomy with extended lymphadenectomy fails to prolong patient survival. METHODS Prospective randomized and nonrandomized controlled trials (RCTs and NRCTs), meta-analyses, retrospective reviews, consensus conferences and pre- and intraoperative diagnoses of lymph node (LN) metastases were retrieved. Standard and extended lymphadenectomies were reviewed, including their effects on postoperative complications, mortality rate and long-term survival. The minimum total number of LN examined (TNLE) for adequate tumor staging, and the incidence of metastasis to each LN station were also considered. A pros and cons analysis was performed on the removal of each LN station. RESULTS Eleven retrospective studies (2514 patients), five prospective NRCTs (545 patients), and five prospective RCTs (586 patients) described different lymphadenectomies, which obtained similar long-term results. Five meta-analyses showed they did not influence long-term survival. However, N status is an important component of tumor staging. The recommended minimum TNLE is 15. The percent incidence of metastasis to each LN station was calculated considering at least 385 and up to 3725 patients. Preoperative imaging and intraoperative exploration frequently fail to identify metastatic nodes. A pros and cons analysis suggests that lymph node status is better established removing the following LN stations: 6, 8a-p, 12a-b-c, 13a-b, 14a-b-c-d, 16b1, 17a-b. Metastasis to 16b1 LNs significantly worsens prognosis. Their removal and frozen section examination, before proceeding with resection, may contraindicate resection. CONCLUSION A standard lymphadenectomy demands an adequate TNLE and removal of the LN stations metastasizing more frequently, without increasing the surgical risk.
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Beisani M, Dopazo C, Blanco L, Caralt M, Sapisochín G, Olsina JJ, Balsells J. Antecolic anastomosis and delayed gastric emptying: still a benefit in patients without intra-abdominal complications? Eur Surg 2015. [DOI: 10.1007/s10353-015-0311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Peparini N. Mesopancreas: A boundless structure, namely the rationale for dissection of the paraaortic area in pancreaticoduodenectomy for pancreatic head carcinoma. World J Gastroenterol 2015; 21:2865-2870. [PMID: 25780282 PMCID: PMC4356904 DOI: 10.3748/wjg.v21.i10.2865] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/27/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
This review highlights the rationale for dissection of the 16a2 and 16b1 paraaortic area during pancreaticoduodenectomy (PD) for carcinoma of the head of the pancreas. Recent advances in surgical anatomy of the mesopancreas indicate that the retropancreatic area is not a single entity with well defined boundaries but an anatomical site of embryological fusion of peritoneal layers, and that continuity exists between the neuro lymphovascular adipose tissues of the retropancreatic and paraaortic areas. Recent advances in surgical pathology and oncology indicate that, in pancreatic head carcinoma, the mesopancreatic resection margin is the primary site for R1 resection, and that epithelial-mesenchymal transition-related processes involved in tumor progression may impact on the prevalence of R1 resection or local recurrence rates after R0 surgery. These concepts imply that mesopancreas resection during PD for pancreatic head carcinoma should be extended to the paraaortic area in order to maximize retropancreatic clearance and minimize the likelihood of an R1 resection or the persistence of residual tumor cells after R0 resection. In PD for pancreatic head carcinoma, the rationale for dissection of the paraaortic area is to control the spread of the tumor cells along the mesopancreatic resection margin, rather than to control or stage the nodal spread. Although mesopancreatic resection cannot be considered “complete” or “en bloc”, it should be “extended as far as possible” or be “maximal”, including dissection of 16a2 and 16b1 paraaortic areas.
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Peparini N. Resection of the mesopancreas in pancreatic head adenocarcinoma: Is it outside of the International Study Group on Pancreatic Surgery definition and consensus statement for standard and extended pancreatectomy? Surgery 2015; 158:310-1. [PMID: 25704416 DOI: 10.1016/j.surg.2015.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 01/13/2015] [Indexed: 01/15/2023]
Affiliation(s)
- Nadia Peparini
- Azienda Sanitaria Locale Roma H- Distretto 3 Ciampino, via Mario Calò, 5-00043, Ciampino, Rome, Italy.
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Chong CCN, Lee KF, Ip PCT, Liu SYW, Chan MCK, Cheung YS, Wong J, Lai PBS. Risk factors for delayed gastric emptying after pancreatoduodenectomy. SURGICAL PRACTICE 2015. [DOI: 10.1111/1744-1633.12100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
| | - Kit-Fai Lee
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Philip Ching-Tak Ip
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Shirley Yuk-Wah Liu
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Micah Chi-King Chan
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Yue-Sun Cheung
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - John Wong
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Paul Bo-San Lai
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
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Comparison of Pathological Radicality between Open and Laparoscopic Pancreaticoduodenectomy in a Tertiary Centre. Indian J Surg Oncol 2015; 6:20-5. [PMID: 25937759 DOI: 10.1007/s13193-014-0372-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 12/17/2014] [Indexed: 02/07/2023] Open
Abstract
Laparoscopic pancreaticoduodenectomy (LPD) remained a formidable challenge owing to retroperitoneal location, difficult dissection near great vessels and critical intracorporeal anastomoses. Recent reviews of literature have established the feasibility and comparable short term outcomes of laparoscopic pancreaticoduodenectomy (LPD) with that of open pancreaticoduodenectomy (OPD). This study was undertaken to compare the pathological radicality of LPD with OPD. A prospective database of all patients who underwent standard pancreaticoduodenectomy from Mar 2006 to Feb 2011 was taken up for this study. 45 patients who underwent LPD and 118 patients who underwent OPD for periampullary and pancreatic head malignancy were taken up for analysis. The study groups were comparable in terms of age of presentation, ASA grades, comorbidity, type of surgery and BMI. There was no statistically significant difference with regard to tumor size, lymph node yield, node positivity rates, R1 rates and margin lengths. The pathological radicality of laparoscopic pancreaticoduodenectomy is comparable with that of open approach when performed by experienced minimal-access surgeons. Standardized protocols for evaluation of the resection margins should be mandatory in studies reporting outcomes of pancreaticoduodectomy.
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Svoronos C, Tsoulfas G, Katsourakis A, Noussios G, Chatzitheoklitos E, Marakis NG. Role of extended lymphadenectomy in the treatment of pancreatic head adenocarcinoma: review and meta-analysis. ANZ J Surg 2014; 84:706-11. [PMID: 24165093 DOI: 10.1111/ans.12423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND Extended lymph node dissection has been established as the method of choice in the treatment of many digestive malignancies, but its role in the treatment of adenocarcinoma of the pancreas remains controversial. OBJECTIVES The goal is to evaluate the role of extended lymph node dissection in pancreatic head adenocarcinoma and to review how it affects survival, morbidity, mortality and post-operative quality of life. METHODS A computerized search was made of the Medline database from January 1973 to October 2012. Fifteen non-duplicated studies, four randomized and 11 non-randomized, comparing extended radical pancreaticoduodenectomy (ERP) and standard pancreaticoduodenectomy were reviewed. Five-year overall survivals were compared using the MetaXL software in eight of these studies, where the necessary data were available. RESULTS The 5-year survival after ERP ranged from 6 to 33.4% and the local recurrence incidence from 8 to 36.1%, while the incidence of severe diarrhoea, one of the main complications, ranged from 10.8 to 42.4%. Meta-analysis showed that there was no significant difference in the 5-year overall survival (95% confidence interval (CI): -0.21-0.20, Z=0.07, P=0.94) for randomized control trials, (95% CI: -0.51-0.02, Z=1.85, P=0.07) for non-randomized control trials and (95% CI: -0.26-0.06, Z=1.20, P=0.23) for all the studies. CONCLUSIONS Although ERP is a safe procedure, it did not offer a significant improvement in survival, while at the same time leading to an increased incidence of severe diarrhoea for at least 1 year, thus leaving the standard pancreaticoduodenectomy as the surgical method of choice for the treatment of pancreatic head adenocarcinoma.
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Affiliation(s)
- Christos Svoronos
- Department of Surgery, General Hospital of Thessaloniki, Agios Dimitrios, Thessaloniki, Greece
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de Virgilio C, Frank PN, Grigorian A. Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS). Surgery 2014; 156:591-600. [PMID: 25061003 PMCID: PMC7120678 DOI: 10.1016/j.surg.2014.06.016] [Citation(s) in RCA: 440] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 06/19/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The lymph node (Ln) status of patients with resectable pancreatic ductal adenocarcinoma is an important predictor of survival. The survival benefit of extended lymphadenectomy during pancreatectomy is, however, disputed, and there is no true definition of the optimal extent of the lymphadenectomy. The aim of this study was to formulate a definition for standard lymphadenectomy during pancreatectomy. METHODS During a consensus meeting of the International Study Group on Pancreatic Surgery, pancreatic surgeons formulated a consensus statement based on available literature and their experience. RESULTS The nomenclature of the Japanese Pancreas Society was accepted by all participants. Extended lymphadenectomy during pancreatoduodenectomy with resection of Ln's along the left side of the superior mesenteric artery (SMA) and around the celiac trunk, splenic artery, or left gastric artery showed no survival benefit compared with a standard lymphadenectomy. No level I evidence was available on prognostic impact of positive para-aortic Ln's. Consensus was reached on selectively removing suspected Ln's outside the resection area for frozen section. No consensus was reached on continuing or terminating resection in cases where these nodes were positive. CONCLUSION Extended lymphadenectomy cannot be recommended. Standard lymphadenectomy for pancreatoduodenectomy should strive to resect Ln stations no. 5, 6, 8a, 12b1, 12b2, 12c, 13a, 13b, 14a, 14b, 17a, and 17b. For cancers of the body and tail of the pancreas, removal of stations 10, 11, and 18 is standard. Furthermore, lymphadenectomy is important for adequate nodal staging. Both pancreatic resection in relatively fit patients or nonresectional palliative treatment were accepted as acceptable treatment in cases of positive Ln's outside the resection plane. This consensus statement could serve as a guide for surgeons and researchers in future directives and new clinical studies.
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Affiliation(s)
| | - Paul N. Frank
- General Surgery, Harbor-UCLA Medical Center, Torrance, California USA
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, Orange, California USA
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Zhou J, Song S, Li D, He S, Zhang B, Wang Z, Zhu X. Decoy receptor 3 (DcR3) overexpression predicts the prognosis and pN2 in pancreatic head carcinoma. World J Surg Oncol 2014; 12:52. [PMID: 24597666 PMCID: PMC3946126 DOI: 10.1186/1477-7819-12-52] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 02/19/2014] [Indexed: 12/16/2022] Open
Abstract
Background This study was carried out to examine decoy receptor 3 (DcR3) expression and investigate its clinical and prognostic significance in patients with pancreatic head carcinoma. Methods Tissue samples were obtained from 50 patients with pancreatic head carcinoma. DcR3 protein expression in tissues and sera was assessed by immunohistochemistry and ELISA. Correlations between DcR3 and clinicopathologic features and prognoses were analyzed statistically. Results Serum DcR3 levels were significantly elevated in patients with pancreatic head carcinoma compared with patients with cystadenoma and healthy individuals (P < 0.01 and P < 0.01, respectively). DcR3 overexpression correlated with lymph node metastases and TNM stages (P < 0.05 and P < 0.05, respectively). Median overall survival for the high DcR3 group was 16.3 months, compared to 21.6 months for the low DcR3 group (P < 0.05). In the low DcR3 group, no significant difference was found in the overall survival between patients who underwent standard pancreatoduodenectomy (SPD) and those who had radical pancreatoduodenectomy (RPD) (P > 0.05). In the high DcR3 group, the median overall survival rates were 16.8 months in the RPD group and 13.5 months in the SPD group (P < 0.05). Conclusions We found that DcR3 was overexpressed in pancreatic head carcinoma. The patients with high DcR3 levels had higher pN2 stages than those with low DcR3 levels. Detecting serum DcR3 level preoperatively might be an additional approach for evaluating pN2 stage and guiding the range of lymphadenectomy.
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Affiliation(s)
| | | | | | | | | | | | - Xinguo Zhu
- Department of General Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, China.
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Ansorge C, Nordin JZ, Lundell L, Strömmer L, Rangelova E, Blomberg J, del Chiaro M, Segersvärd R. Diagnostic value of abdominal drainage in individual risk assessment of pancreatic fistula following pancreaticoduodenectomy. Br J Surg 2013; 101:100-8. [DOI: 10.1002/bjs.9362] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2013] [Indexed: 12/15/2022]
Abstract
Abstract
Background
The use of prophylactic abdominal drainage following pancreaticoduodenectomy (PD) is controversial as its therapeutic value is uncertain. However, the diagnosis of postoperative pancreatic fistula (POPF), the main cause of PD-associated morbidity, is often based on drain pancreatic amylase (DPA) levels. The aim of this study was to assess the predictive value of DPA, plasma pancreatic amylase (PPA) and serum C-reactive protein (CRP) for diagnosing POPF after PD.
Methods
Patients undergoing PD with prophylactic drainage between 2008 and 2012 were studied prospectively. DPA, PPA and CRP levels were obtained daily. Differences between groups with clinically relevant POPF (International Study Group on Pancreatic Fistula (ISGPF) grade B/C) and without clinically relevant POPF (no POPF or ISGPF grade A) were evaluated. Receiver operating characteristic (ROC) analyses were performed to determine the value of DPA, PPA and CRP in prediction of POPF. Risk profiles for clinically relevant POPF were constructed and related to the intraoperative pancreatic risk assessment.
Results
Fifty-nine (18·7 per cent) of 315 patients developed clinically relevant POPF. DPA, PPA and CRP levels on postoperative day (POD) 1–3 differed significantly between the study groups. In predicting POPF, the DPA level on POD 1 (cut-off at 1322 units/l; odds ratio (OR) 24·61, 95 per cent confidence interval 11·55 to 52·42) and POD 2 (cut-off at 314 units/l; OR 35·45, 14·07 to 89·33) was superior to that of PPA on POD 1 (cut-off at 177 units/l; OR 13·67, 6·46 to 28·94) and POD 2 (cut-off at 98 units/l; OR 16·97, 8·33 to 34·59). When DPA was combined with CRP (cut-off on POD 3 at 202 mg/l; OR 16·98, 8·43 to 34·21), 90·3 per cent of postoperative courses could be predicted correctly (OR 44·14, 16·89 to 115·38).
Conclusion
The combination of serum CRP and DPA adequately predicted the development of clinically relevant pancreatic fistula following PD.
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Affiliation(s)
- C Ansorge
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - J Z Nordin
- Department of Laboratory Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - L Lundell
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - L Strömmer
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - E Rangelova
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - J Blomberg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - M del Chiaro
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - R Segersvärd
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
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Peparini N, Chirletti P. Mesopancreas: a boundless structure, namely R1 risk in pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol 2013; 39:1303-8. [PMID: 24188796 DOI: 10.1016/j.ejso.2013.10.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 09/28/2013] [Accepted: 10/12/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The mesopancreatic resection margin after pancreaticoduodenectomy for carcinoma of the head of the pancreas is of great interest with respect to curative resection, since the neoplastic involvement of this margin was shown to be the primary site for R1 resection. In this review the current knowledges of the surgical anatomy of the so-called mesopancreas and the mesopancreas excision techniques are summarized. METHODS References were identified by searching Pubmed database using the search terms "mesopancreas" and "meso-pancreatoduodenum" until June 2013 and through searches of the authors' own files. Five studies were included in this review. RESULTS Original contributions with regard to the anatomy of the retropancreatic area and specific technical descriptions of so-called "total mesopancreas excision" provided by published studies are pointed out. CONCLUSIONS Because there is no "meso" of the pancreas, and due to the continuity of the mesopancreatic and para-aortic areas, surgical dissection should be extended to the left of the superior mesenteric artery and include the para-aortic area to achieve the most complete possible resection of the so-called mesopancreas and minimize the rate of R1 resections due to mesopancreatic margin involvement. This extended mesopancreatic resection cannot be accomplished en bloc even if the removal of the dissected mesopancreatic tissues is performed en bloc with the head, uncus, and neck of the pancreas, i.e., with the pancreaticoduodenectomy specimen.
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Affiliation(s)
- N Peparini
- Azienda Sanitaria Locale Roma H, Distretto H3, via Mario Calò, 5, Ciampino, 00043 Rome, Italy.
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Cheng K, Shen BY, Peng CH, Na LM, Cheng DF. Middle-preserving pancreatectomy: report of two cases and review of the literature. World J Surg Oncol 2013; 11:106. [PMID: 23702284 PMCID: PMC3681594 DOI: 10.1186/1477-7819-11-106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 05/09/2013] [Indexed: 11/23/2022] Open
Abstract
Background Middle-preserving pancreatectomy (MPP) is a parenchyma-sparing surgical procedure which has recently been sporadically reported for the treatment of multicentric periampullary-pancreatic lesions. However, a comprehensive recognition of this procedure has not been clearly elucidated. Case presentation We herein report two patients undergoing MPP due to synchronous multicentric pancreatic neoplasm. Patient one was a 24-year-old woman with a multicentric solid pseudopapillary neoplasm (SPN) and patient two was a 36-year-old woman with a multicentric serous cystic neoplasm (SCN). Simultaneous atypical pancreaticoduodenectomy and atypical left pancreatectomy were performed in patient one; simultaneous standard pancreaticoduodenectomy and atypical left pancreatectomy with spleen preservation were performed in patient two. Approximately 6 cm and 5 cm segments of the middle portion of the pancreas were preserved, respectively. At follow-up at 36 months and 6 months respectively, patient one had developed diabetes and malabsorption requiring dietary control, exercise and pancreatic enzyme supplement whereas patient two showed normal fasting blood glucose without diarrhea. Both patients were disease-free and in good nutritional condition. We reviewed twenty cases of MPP that were previously reported in the literature. Patient characteristics, surgical techniques and short- and long-term outcomes were analyzed. Conclusion MPP is mainly beneficial for multicentric noninvasive periampullary-pancreatic lesions. However, for multicentric periampullary-pancreatic lesions involving even primary invasive cancers, as long as the invasive cancers affect only one side of the pancreas (proximal or distal), MPP could serve as a rational choice in well-selected patients.
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Affiliation(s)
- Kun Cheng
- Department of General Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, 197, Ruijin Er Road, Shanghai 200025, China
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Sierzega M, Kulig P, Kolodziejczyk P, Kulig J. Natural history of intra-abdominal fluid collections following pancreatic surgery. J Gastrointest Surg 2013; 17:1406-13. [PMID: 23715649 PMCID: PMC3709084 DOI: 10.1007/s11605-013-2234-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 05/09/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Little data are available for non-abscess abdominal fluid collections (AFCs) after pancreatic surgery and their clinical implications. We sought to analyze the natural history of such collections in a population of patients subject to routine postoperative imaging. METHODS From 1995 to 2011, 709 patients underwent pancreatic resections and routine postoperative monitoring with abdominal ultrasound according to a unit protocol. AFCs were classified as asymptomatic (no interventional treatment), symptomatic (need for percutaneous drainage of sterile, amylase-poor fluid), and pancreatic fistula (drainage of amylase-rich fluid). RESULTS Ninety-seven of 149 AFCs (65 %) were asymptomatic and resolved spontaneously after a median follow-up of 22 days (interquartile range, 9-52 days). Among 52 (35 %) AFCs requiring percutaneous drainage, there were 20 pancreatic fistulas and 32 symptomatic collections. A stepwise logistic regression model identified three factors associated with the need for interventional treatment, i.e., body mass index ≥25 (odds ratio, 3.23; 95 % confidence interval (CI), 1.32 to 7.91), pancreatic fistula (odds ratio, 2.93; 95 % CI, 1.20 to 7.17), and biliary fistula (odds ratio, 3.92; 95 % CI, 1.35 to 11.31). CONCLUSIONS One fourth of patients develop various types of non-abscess AFCs after pancreatic surgery. Around half of them are asymptomatic and resolve spontaneously.
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Affiliation(s)
- Marek Sierzega
- First Department of General and GI Surgery, Jagiellonian University Medical College, 40 Kopernika Street, 31-501 Krakow, Poland
| | - Piotr Kulig
- First Department of General and GI Surgery, Jagiellonian University Medical College, 40 Kopernika Street, 31-501 Krakow, Poland
| | - Piotr Kolodziejczyk
- First Department of General and GI Surgery, Jagiellonian University Medical College, 40 Kopernika Street, 31-501 Krakow, Poland
| | - Jan Kulig
- First Department of General and GI Surgery, Jagiellonian University Medical College, 40 Kopernika Street, 31-501 Krakow, Poland
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Rau BM, Moritz K, Schuschan S, Alsfasser G, Prall F, Klar E. R1 resection in pancreatic cancer has significant impact on long-term outcome in standardized pathology modified for routine use. Surgery 2012; 152:S103-11. [PMID: 22766366 DOI: 10.1016/j.surg.2012.05.015] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND The quality of a histopathologic workup after oncologic resection of pancreatic malignancies has changed the central role of surgery substantially for radical tumor clearance over the past years. The development of standardized protocols for pathologic workup increased the rate of R1 resections from around 20% up to 80%. In the present study, we investigated the incidence of R1 and its impact on survival after oncologic pancreatic resections using a standardized pathologic routine protocol. PATIENTS AND METHODS We performed 265 pancreatic resections from September 2003 to September 2010. Among 128 patients with malignant neoplasms, histology revealed ductal pancreatic adenocarcinoma in 97, ampullary cancer in 10, and distal bile duct cancer in 21 patients. Resected specimens were analyzed according to this improved standardized pathology protocol introduced in 2000. Follow-up data on overall and cancer-related survival, presence and site of tumor recurrence, and chemotherapy were obtained from 120 patients. RESULTS Pancreatic resection comprised a pylorus-preserving or classical pancreaticoduodenectomy in 112, a distal pancreatectomy in 8, and a total pancreatectomy in 7 patients. In the overall series, 56 (44%) were classified R1 resections and 68 (43%) R0 resections, 3 patients with R2 resections were excluded, leaving 125 patients for analysis. In pancreatic adenocarcinoma, the rate of R1 was 51% (48/94). R1 resection involved most frequently the circumferential margin in 86% (48/125) of the total group and in 92% (44/48) in pancreatic cancer. Follow-up was performed after a median of 17 months (range, 1-85) postoperatively. Cancer-related death rate in R0 and R1-resected patients was 60% and 83% (P < .02) in all cancers (n = 117) and 66% and 80% in patients with pancreatic adenocarcinoma (n = 88). Median tumor-related survival in R0 and R1 resections was 22 (range, 4-85) vs 14 months (range, 2-48) in all cancers (P < .002), and 19 (range, 4-85) vs 14 months (range, 2-48) in pancreatic adenocarcinoma (P < .04). Kaplan-Meier survival analysis revealed a survival benefit after R0 resection in both all cancers (P = .002) and pancreatic adenocarcinoma (P < .02). The pattern of tumor recurrence had a greater rate of regional metastases in the R1 group (P < .05). CONCLUSION Our 51% rate of R1 resections in ductal pancreatic carcinoma indicates a high quality standard of pathologic evaluation. The vast majority of R1 margins are located at the retroperitoneal dissection surface. Standardization of histopathologic analysis has a clinically relevant impact on survival after oncologic resection of pancreatic cancer and can be achieved by less extensive protocols.
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Affiliation(s)
- Bettina M Rau
- Department of General, Thoracic, Vascular, and Transplantation Surgery, University of Rostock, Germany.
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van der Gaag NA, Kloek JJ, de Bakker JK, Musters B, Geskus RB, Busch ORC, Bosma A, Gouma DJ, van Gulik TM. Survival analysis and prognostic nomogram for patients undergoing resection of extrahepatic cholangiocarcinoma. Ann Oncol 2012; 23:2642-2649. [PMID: 22532585 DOI: 10.1093/annonc/mds077] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Tumor location of extrahepatic cholangiocarcinoma (CCA) might influence survival after resection. METHODS A consecutive series of 175 patients who had undergone a potentially curative resection of extrahepatic CCA was analyzed. We calculated concordance indices of different constructed prognostic models for survival including TNM (tumour-node-metastasis) staging and developed a nomogram of the most sensitive model. RESULTS Overall cancer-specific survival rates were 83%, 58%, and 26% at 1, 2, and 5 years, respectively. Cancer-specific survival according to location was 42% for proximal, 23% for mid, and 19% for distal CCA after 5 years. Tumor location was not an independent significant predictor (P = 0.06). A prognostic model using all potential prognostic variables predicted survival better compared with TNM staging (concordance index 0.65 versus 0.63). A reduced model containing only lymph node status, microscopically residual tumor status, and tumor differentiation grade, also outperformed TNM staging (concordance index 0.66). CONCLUSIONS Tumor location of extrahepatic CCA does not independently predict cancer-specific survival after resection. We developed a nomogram, based on a prognostic model with lymph node status, microscopically residual tumor status of resection margins, and tumor differentiation grade, that predicted survival better than TNM staging.
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Affiliation(s)
| | - J J Kloek
- Departments of Surgery, Amsterdam, The Netherlands
| | | | - B Musters
- Departments of Surgery, Amsterdam, The Netherlands
| | - R B Geskus
- Departments of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam, The Netherlands
| | - O R C Busch
- Departments of Surgery, Amsterdam, The Netherlands
| | - A Bosma
- Departments of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - D J Gouma
- Departments of Surgery, Amsterdam, The Netherlands
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Kaťuchová J, Bober J, Kaťuch V, Radoňak J. Significance of lymph node micrometastasis in pancreatic cancer patients. ACTA ACUST UNITED AC 2011; 48:10-5. [PMID: 22398863 DOI: 10.1159/000334171] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 08/15/2011] [Indexed: 12/19/2022]
Abstract
UNLABELLED BACKGROUND /AIMS: The present study deals with the significance of lymph node micrometastasis in the survival rate for pancreatic cancer patients. METHODS Between January 2006 and December 2010 at the First Department of Surgery in Košice, a prospective trial was done in which we investigated the survival rate after radical pancreatic resection. All negative lymph nodes removed during standard radical lymphadenectomy were subjected to immunohistochemical staining to detect occult micrometastasis. A comparison of the median survival rate in groups of patients with immunohistochemistry-positive and -negative lymph nodes was performed. RESULTS Radical pancreatic resection with standard radical lymphadenectomy was performed on 64 pancreatic cancer patients. The median survival time was 15 months. Out of the 319 histopathologically negative lymph nodes (34 patients), 134 lymph nodes were classified as immunohistochemistry positive (21 patients). The median survival rate in the group of patients with immunohistochemistry-negative lymph nodes was 23 months, but in the group of patients with immunohistochemistry-positive lymph nodes it was 14 months. There was a statistically significant difference between these 2 groups of patients (p ≤ 0.01). CONCLUSION The immunohistochemical examination of histopathologically negative lymph nodes can lead to positive lymph node detection. The presence of lymph node micrometastasis could predict the survival rate.
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Affiliation(s)
- J Kaťuchová
- First Department of Surgery, University Hospital Košice, Košice, Slovakia.
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Halloran CM, Cox TF, Chauhan S, Raraty MGT, Sutton R, Neoptolemos JP, Ghaneh P. Partial pancreatic resection for pancreatic malignancy is associated with sustained pancreatic exocrine failure and reduced quality of life: a prospective study. Pancreatology 2011; 11:535-45. [PMID: 22094930 DOI: 10.1159/000333308] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 09/16/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pancreatic resection for cancer may produce pancreatic exocrine insufficiency (PEI), which is poorly understood. This study examined the coefficient of fat absorption (CFA), symptoms, quality of life (QoL) and the accuracy of faecal elastase-1 (FE-1) measurement to predict PEI. METHODS Forty patients were analysed following resection for pancreatic malignancy. The primary endpoint was PEI diagnosis defined by CFA <93%; secondary endpoints were PEI diagnosis using FE-1 <200 μg/g, body mass index (BMI), and symptom and QoL analysis. Interventions were 3-day stool collection, EORTC QLQ-C30 (version 1) questionnaire and patient's diary, at 6 weeks and 3, 6 and 12 months after surgery. RESULTS CFA <93% was present in 67% of patients at 6 weeks and in 55% at 12 months. PEI using FE-1 was present in 77 and 83% of patients, respectively. No significant changes between time-points were observed. Sensitivity, specificity, PPV, NPV and accuracy for FE-1 in detecting CFA <93% were 91, 35, 70, 71 and 70%, respectively. CFA and FE-1 levels were uncorrelated. Overall, QoL increased at 6 (p = 0.0212) and 12 (p < 0.0001) months after surgery, mainly driven by physical, role and social functioning, and by appetite. Importantly, however, BMI and symptoms were unaffected by PEI, which suggests a subclinical presentation; such patients had attributes indicating poorer QoL (notably insomnia, p = 0.0012). CONCLUSIONS PEI was common and sustained following resection and not associated with significant symptoms. These patients had a tendency toward poorer QoL. FE-1 is a poor surrogate for diagnosing impaired fat absorption. Postoperative pancreatic enzyme replacement should be considered more routinely. and IAP.
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Affiliation(s)
- Christopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, and National Institute for Pancreas Biomedical Research Unit, Liverpool, UK
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Tan WJ, Kow AWC, Liau KH. Moving towards the New International Study Group for Pancreatic Surgery (ISGPS) definitions in pancreaticoduodenectomy: a comparison between the old and new. HPB (Oxford) 2011; 13:566-72. [PMID: 21762300 PMCID: PMC3163279 DOI: 10.1111/j.1477-2574.2011.00336.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The International Study Group for Pancreatic Surgery (ISGPS) has proposed several definitions for postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and post-pancreatectomy haemorrhage (PPH). We assessed the effects of implementing these definitions on predicting outcomes. METHODS A database of 77 patients who underwent pancreaticoduodenectomy between January 2005 and December 2009 was analysed. Morbidities were defined and classified using the ISGPS definitions and recalculated based on the definitions adopted by our institution ('Old' definitions) prior to the implementation of ISGPS definitions. Data for the two groups were then compared. RESULTS The morbidity rate rose to 70.1% from 27.2% when ISGPS rather than Old definitions were used to define morbidities (P < 0.001). Incidences of DGE, POPF and PPH were 20.7%, 39.0% and 10.4%, respectively. Rates of DGE and POPF were significantly higher according to ISGPS definitions than to Old definitions (20.7% vs. 5.2% [P= 0.001] and 39.0% vs. 15.6% [P= 0.004], respectively). According to the ISGPS definitions, all of the 12 additional patients with DGE and 12 of the 18 additional patients with POPF had grade A morbidities. Patients with ISGPS-defined morbidity had a longer intensive care unit (ICU) stay, longer postoperative stay and longer total stay (P= 0.030, P= 0.007 and P= 0.001, respectively). CONCLUSIONS The morbidity rate more than doubled when ISGPS definitions were applied (an additional 42.9% of patients demonstrated morbidities). The majority of patients with DGE and POPF had grade A morbidities. The ISGPS definitions correlate well with ICU stay, postoperative stay and total length of stay.
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Affiliation(s)
- Winson Jianhong Tan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore.
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Kow AWC, Sadayan NA, Ernest A, Wang B, Chan CY, Ho CK, Liau KH. Is pancreaticoduodenectomy justified in elderly patients? Surgeon 2011; 10:128-36. [PMID: 22525414 DOI: 10.1016/j.surge.2011.02.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 01/29/2011] [Accepted: 02/25/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although mortality & morbidity for pancreaticoduodenectomy (PD) have improved significantly over the last two decades, the concern for elderly undergoing PD remains. This study examines the outcome of the elderly patients who had pancreaticoduodenectomy in our institution. METHODS A prospective database comprising 69 patients who underwent pancreaticoduodenectomy between 2001 and May 2008 was analyzed. Using WHO definition, elderly patient is defined as age 65 and above in this study. Two groups of patients were compared [Group 1: Age ≤65 & Group 2: Age >65]. RESULTS The mean age of our patients was 62 ± 11 years. There were 37 (54%) patients in Group 1 and 32 (46%) patients in Group 2. There was no statistical difference between the two groups in terms of gender and race. However, there were more patients in the Group 2 with >2 comorbidities (p = 0.03). The median duration of operation was significantly longer in Group 2 (550 min vs 471 min, p = 0.04). Morbidity rate in Group 2 was higher (56% vs. 44%, p = 0.04). There was higher proportion of post-operative pancreatic fistula (POPF) in the elderly group (37.5% vs. 16.7%, p = 0.05). Majority of them are Grade A POPF according to the ISG definition. The median post-operative length-of-stay (LOS) in hospital was 9 days longer in Group 2 (p = 0.01). Mortality rate between the 2 groups of patients was comparable (0% vs. 3%, p = 0.28). CONCLUSION Elderly patients are at increased risk of morbidity in pancreatocoduodenectomy, in particular POPF. However, morbidity and mortality rates are acceptable. It is therefore justified to offer PD to elderly patients who do not have significant cardiopulmonary comorbidities.
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Affiliation(s)
- A W C Kow
- Department of Surgery, Digestive Disease Centre, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 304833, Singapore
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Current state of surgical management of pancreatic cancer. Cancers (Basel) 2011; 3:1253-73. [PMID: 24212660 PMCID: PMC3756412 DOI: 10.3390/cancers3011253] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 02/19/2011] [Accepted: 03/10/2011] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cancer is still associated with a poor prognosis and remains—as the fourth leading cause of cancer related mortality—a therapeutic challenge. Overall long-term survival is about 1–5%, and in only 10–20% of pancreatic cancer patients is potentially curative surgery possible, increasing five-year survival rates to approximately 20–25%. Pancreatic surgery is a technically challenging procedure and has significantly changed during the past decades with regard to technical aspects as well as perioperative care. Standardized resections can be carried out with low morbidity and mortality below 5% in high volume institutions. Furthermore, there is growing evidence that also more extended resections including multivisceral approaches, vessel reconstructions or surgery for tumor recurrence can be carried out safely with favorable outcomes. The impact of adjuvant treatment, especially chemotherapy, has increased dramatically within recent years, leading to significantly improved postoperative survival, making pancreatic cancer therapy an interdisciplinary approach to achieve best results.
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Pavlidis TE, Pavlidis ET, Sakantamis AK. Current opinion on lymphadenectomy in pancreatic cancer surgery. Hepatobiliary Pancreat Dis Int 2011; 10:21-5. [PMID: 21269930 DOI: 10.1016/s1499-3872(11)60002-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Adenocarcinoma of the pancreas exhibits aggressive behavior in growth, inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%. Curative resection is the only potential therapeutic opportunity. DATA SOURCES A PubMed search of relevant articles published up to 2009 was performed to identify information about the value of lymphadenectomy and its extent in curative resection of pancreatic adenocarcinoma. RESULTS Despite recent advances in chemotherapy, radiotherapy or even immunotherapy, surgery still remains the major factor that affects the outcome. The initial promising performance in Japan gave conflicting results in Western countries for the extended and more radical pancreatectomy; it has failed to prove beneficial. Four prospective, randomized trials on extended versus standard lymphadenectomy during pancreatic cancer surgery have shown no improvement in long-term survival by the extended resection. The exact lymph node status, including malignant spread and the total number retrieved as well as the lymph node ratio, is the most important prognostic factor. Positive lymph nodes after pancreatectomy are present in 70%. Paraaortic lymph node spread indicates poor prognosis. CONCLUSIONS Undoubtedly, a standard lymphadenectomy including >15 lymph nodes must be no longer preferred in patients with the usual head location. The extended lymphadenectomy does not have any place, unless in randomized trials. In cases with body or tail location, the radical antegrade modular pancreatosplenectomy gives promising results. Nevertheless, accurate localization and detailed examination of the resected specimen are required for better staging.
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Affiliation(s)
- Theodoros E Pavlidis
- Second Surgical Propedeutical Department, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Konstantinoupoleos 49, 54642 Thessaloniki, Greece.
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Shrikhande SV, Barreto SG. Extended pancreatic resections and lymphadenectomy: An appraisal of the current evidence. World J Gastrointest Surg 2010; 2:39-46. [PMID: 21160848 PMCID: PMC2999214 DOI: 10.4240/wjgs.v2.i2.39] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 12/11/2009] [Accepted: 12/18/2009] [Indexed: 02/06/2023] Open
Abstract
Surgery remains the mainstay of treatment for pancreatic ductal adenocarcinoma and complete removal of the cancer confers a definite survival advantage, especially in early disease. However, the majority of patients do not present with early disease, thus precluding the chance of a cure by standard pancreatoduodenectomy (PD), distal pancreatectomy or total pancreatectomy. For this reason, pancreatic surgeons have attempted to push the limits of resection over the last three decades. The aim of these resections has been to determine whether obtaining a complete resection by extending the limits of conventional resection in patients with advanced disease will yield the results seen with PD alone in early disease. This article revisits the data from such studies in an attempt to determine if the available literature supports the performance of extended resections for pancreatic cancer in terms of improvement of survival.
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Affiliation(s)
- Shailesh V Shrikhande
- Shailesh V Shrikhande, Department of Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Mumbai 400 012, India
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de Castro SMM, de Nes LCF, Nio CY, Velseboer DC, Kate FJWT, Busch ORC, van Gulik TM, Gouma DJ. Incidence and characteristics of chronic and lymphoplasmacytic sclerosing pancreatitis in patients scheduled to undergo a pancreatoduodenectomy. HPB (Oxford) 2010; 12:15-21. [PMID: 20495640 PMCID: PMC2814399 DOI: 10.1111/j.1477-2574.2009.00112.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 07/09/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND The determination of the exact nature of a pancreatic head mass in a patient scheduled to undergo a pancreatoduodenectomy can be very difficult. This is important as patients who suffer from benign disease such as pancreatitis do not always require surgery. The aim of the present study was to analyse the incidence of pancreatitis and the signs and symptoms associated with these tumours mistaken for pancreatic cancer and the diagnostic procedures performed. METHODS A consecutive group of patients who underwent a pancreatoduodenectomy between 1992 and 2005 with histopathologically proven pancreatic adenocarcinoma (PCA) and pancreatitis were analysed. RESULTS The incidence of pancreatitis after pancreatoduodenectomy is 63 out of 639 patients who underwent a pancreaticoduodenectomy (9.9%). Of these patients, 24 patients (38%) had lymphoplasmacytic sclerosing pancreatitis (LPSP) and 31 patients (49%) had focal chronic pancreatitis. Eight patients (13%) had an intermediate form with characteristics of both. Pancreatic adenocarcinoma occurred in 227 patients (36%). The presence of pancreatitis without a discrete mass on endoscopic ultrasonography (EUS) seemed to have clinical relevance with a positive likelihood ratio of 5.1. Mortality after resection was nil in both groups. CONCLUSION The incidence of pancreatitis is 9.9% for patients scheduled to undergo a pancreatoduodenectomy. Of these patients, 38% had LPSP, 13% had a intermediate form and 49% had focal chronic pancreatitis. The determination of the exact nature of a pancreatic head mass remains difficult.
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Affiliation(s)
- Steve MM de Castro
- Departments of Surgery, Academic Medical CenterAmsterdam, the Netherlands
| | - Lindsey CF de Nes
- Departments of Surgery, Academic Medical CenterAmsterdam, the Netherlands
| | - C Yung Nio
- Departments of Radiology, Academic Medical CenterAmsterdam, the Netherlands
| | - Daan C Velseboer
- Departments of Pathology, Academic Medical CenterAmsterdam, the Netherlands
| | - Fiebo JW Ten Kate
- Departments of Pathology, Academic Medical CenterAmsterdam, the Netherlands
| | - Olivier RC Busch
- Departments of Surgery, Academic Medical CenterAmsterdam, the Netherlands
| | - Thomas M van Gulik
- Departments of Surgery, Academic Medical CenterAmsterdam, the Netherlands
| | - Dirk Jan Gouma
- Departments of Surgery, Academic Medical CenterAmsterdam, the Netherlands
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Sendler A. [Tumors of the upper gastro-intestinal tract]. Chirurg 2010; 81:103-6; 108-10. [PMID: 20076935 DOI: 10.1007/s00104-009-1813-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The appropriate extent of lymph node dissection in tumors of the upper gastro-intestinal tract continues to be debated. The basic tenet of surgical oncology that cancerous lymph nodes are indicators not governors of survival is under question and derives from the different theories of metastasis. Is the metastatic flow linear (indicators) or does it occur in parallel to tumorigenesis (governor)? If the latter theory is true there would be only a limited indication for lymphadenectomy (LA).Extended LA leads to an ameliorated staging of the N category. Following LA locoregional tumor control is significantly improved for esophageal and gastric cancer. In case of gastric cancer it is evident that there is a group of patients in which extended LA lead to improved long-term survival. This gain in prognosis affects patients in which lymph node metastasis is not or only slightly advanced. In locally advanced tumors there is no prognostic benefit. Patients who might benefit from the extended procedure cannot be assessed during preoperative staging. Therefore, the indications for the procedure should be liberally carried out by experienced hands and in experienced centers. According to randomized studies there is no indication for extended radical LA in pancreatic cancer.
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Sperti C, Pasquali C, Bissoli S, Chierichetti F, Liessi G, Pedrazzoli S. Tumor relapse after pancreatic cancer resection is detected earlier by 18-FDG PET than by CT. J Gastrointest Surg 2010; 14:131-40. [PMID: 19777315 DOI: 10.1007/s11605-009-1010-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 08/25/2009] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Pancreatic cancer recurrence is often difficult to detect by conventional imaging. Our aim was to evaluate the impact of fluorodeoxyglucose-positron emission tomography (FDG-PET) in the diagnosis of recurrent pancreatic cancer. METHODS One-hundred thirty-eight patients were followed after resection for pancreatic cancer. Sixty-six underwent only CT and were excluded. Seventy-two patients also had FDG-PET. Recurrent patients were divided in two groups: group-1, CT positive and group 2, CT non diagnostic, FDG-PET positive. Characteristics and survival curves of the two groups were compared. Significance was set at p < 0.05. RESULTS Overall, tumors recurred in 63 of 72 (87.5%) patients; two patients had a second cancer resected, thanks to FDG-PET. Tumor relapse was detected by CT in 35 patients and by FDG-PET in 61. Prognostic factors were similar in groups 1 and 2. Five out of 35 group 1 patients underwent surgery (two R0, two bypass, and one exploratory). Ten out of 28 group 2 patients underwent surgery (four R0, two R2, two bypass, and two exploratory). FDG-PET influenced treatment strategies in 32 of 72 patients (44.4%). Group 2 patients survived longer (P = 0.09), but the difference was not significant. Disease-free survival was similar in groups 1 and 2. CONCLUSION Tumor relapse is detected earlier by FDG-PET than by CT. FDG-PET can help select the best candidates for surgical exploration, although the real benefit is still to be defined. It influences treatment strategies in a significant percentage of patients. An earlier diagnosis did not influence survival due to the lack of effective therapies.
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Affiliation(s)
- Cosimo Sperti
- Department of Medical and Surgical Sciences, IV Surgery Clinic, University of Padova, Padova, Italy
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50
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Shukla PJ, Barreto SG, Bedi MMS, Bheerappa N, Chaudhary A, Gandhi MD, Jacob M, Jesvanth S, Kannan DG, Kapoor VK, Kumar A, Maudar KK, Ramesh H, Sastry RA, Saxena R, Sewkani A, Sharma S, Shrikhande SV, Singh A, Singh RK, Surendran R, Varshney S, Verma V, Vimalraj V. Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study. HPB (Oxford) 2009; 11:638-44. [PMID: 20495631 PMCID: PMC2799616 DOI: 10.1111/j.1477-2574.2009.00105.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 06/16/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres. MATERIALS AND METHODS Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India. RESULTS Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9-54). The median number of PDs per surgeon per year was 16 (range 7-38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2-5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3-32.2%), and the median post-operative duration of hospital stay was 16 days (range 4-100 days). CONCLUSIONS This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.
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Affiliation(s)
- Parul J Shukla
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryTata Memorial Hospital, Mumbai
| | - Savio G Barreto
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryTata Memorial Hospital, Mumbai
| | - MMS Bedi
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryLakeshore Hospital, Cochin
| | - N Bheerappa
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryNizam's Institute, Hyderabad
| | - Adarsh Chaudhary
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySir Ganga Ram Hospital, New Delhi
| | - MD Gandhi
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryLakeshore Hospital, Cochin
| | - M Jacob
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryLakeshore Hospital, Cochin
| | - S Jesvanth
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryStanley Medical College, Chennai
| | - DG Kannan
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryStanley Medical College, Chennai
| | - Vinay K Kapoor
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - A Kumar
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - KK Maudar
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryBhopal Memorial Hospital and Research Center, Bhopal, India
| | - Hariharan Ramesh
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryLakeshore Hospital, Cochin
| | - RA Sastry
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryNizam's Institute, Hyderabad
| | - Rajan Saxena
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - Ajit Sewkani
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryBhopal Memorial Hospital and Research Center, Bhopal, India
| | - S Sharma
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryBhopal Memorial Hospital and Research Center, Bhopal, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryTata Memorial Hospital, Mumbai
| | - A Singh
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySir Ganga Ram Hospital, New Delhi
| | - Rajneesh K Singh
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - R Surendran
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryStanley Medical College, Chennai
| | - Subodh Varshney
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryBhopal Memorial Hospital and Research Center, Bhopal, India
| | - V Verma
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryNizam's Institute, Hyderabad
| | - V Vimalraj
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryStanley Medical College, Chennai
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