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Ichida H, Imamura H, Takahashi A, Yoshioka R, Mise Y, Inoue Y, Takahashi Y, Saiura A. Evaluation of pancreatic morphometric parameters, exocrine function, and nutritional status and their causal relationships in long-term survivors following pancreatectomy. Surgery 2024; 176:1189-1197. [PMID: 39003090 DOI: 10.1016/j.surg.2024.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/14/2024] [Accepted: 05/24/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Patients undergoing pancreatectomy are at risk for pancreatic exocrine insufficiency and malnutrition. However, the incidence of these complications and the associated risk factors have not been sufficiently examined. This study aimed to investigate the changes in pancreatic morphology, pancreatic exocrine function, and long-term nutritional status after pancreatectomy. METHODS We assessed the nutritional status, pancreatic morphologic parameters, and pancreatic exocrine function in patients undergoing pancreaticoduodenectomy and distal pancreatectomy. Nutritional status was evaluated on the basis of body weight change, body mass index, and skeletal muscle mass. Pancreatic parenchymal texture at the time of surgery, remnant volume of the pancreatic parenchyma, and diameter of the pancreatic duct were measured. Exocrine function was measured using the N-benzoyl-L-tyrosyl-p-aminobenzoic acid excretion test and the clinical signs of steatorrhea and nonalcoholic steatohepatitis. We then investigated potential causal relationships. RESULTS Seventy patients were included in the study. Moderate and severe malnutrition were diagnosed in 19 (27%) and 15 patients (21%), respectively. Most patients with malnutrition before surgery were also found to be malnourished postoperatively. Body weight and skeletal muscle mass decreased after pancreatectomy in most patients, even in the longer term. Subclinical and clinical pancreatic exocrine insufficiency was found in 36 (51%) and 25 patients (36%), respectively, and pancreatic ductal adenocarcinoma, pancreaticoduodenectomy, dilated pancreatic duct, low preoperative body mass index, and pancreatic exocrine insufficiency grade were found to contribute to postoperative malnutrition. CONCLUSION Pancreatic ductal adenocarcinoma, dilated pancreatic duct, pancreaticoduodenectomy, low preoperative body mass index, and pancreatic exocrine insufficiency were risk factors for postoperative malnutrition.
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Affiliation(s)
- Hirofumi Ichida
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroshi Imamura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Atsushi Takahashi
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Ryuji Yoshioka
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yosuke Inoue
- Department of Hepatobiliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Takahashi
- Department of Hepatobiliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan.
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Spilseth B, Fogel EL, Toledo FG, Campbell-Thompson M. Imaging abnormalities of the pancreas in diabetes: implications for diagnosis and treatment. Curr Opin Gastroenterol 2024; 40:381-388. [PMID: 38967933 PMCID: PMC11305921 DOI: 10.1097/mog.0000000000001054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
PURPOSE OF REVIEW Radiographic imaging of the pancreas has drawn recent interest as pancreas volume may serve as a biomarker in identifying the likelihood of diabetes development, subtyping diabetes, and identifying prognostic indicators of poor ultimate outcomes. In this review, the role of pancreas imaging is discussed in various forms of diabetes including type 1 diabetes (T1D), type 2 diabetes (T2D), and diabetes of the exocrine pancreas, particularly diabetes following acute or chronic pancreatitis. RECENT FINDINGS Recent literature of quantitative pancreatic imaging correlating with various forms of diabetes was reviewed. Imaging-derived pancreas volumes are lower in individuals with diabetes, in particular those with T1D. Additionally, morphologic changes, enhancement characteristics, fat content, and MRI signal changes have been observed in different diabetes subtypes. These characteristics, as well as potential confounding variables, are reviewed. Additionally, future areas of research in MRI, CT radiomics, and pancreatitis-related imaging predictors of diabetes are discussed. SUMMARY Increased understanding of pancreas imaging features which predict diabetes and gauge prognosis has the potential to identify at-risk individuals and will become increasingly important in diabetes care. This article reviews the current knowledge of common pancreas imaging features as well as future directions of ongoing research in diabetes imaging.
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Affiliation(s)
| | - Evan L Fogel
- Digestive and Liver Disorders, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | | | - Martha Campbell-Thompson
- Department of Pathology immunology and Laboratory Medicine, University of Florida College of Medicine
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Funk Debleds P, Chambrier C, Slim K. Postoperative nutrition in the setting of enhanced recovery programmes. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106866. [PMID: 36914532 DOI: 10.1016/j.ejso.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/10/2023]
Abstract
Patients undergoing major surgery for gastrointestinal cancer are at high risk of developing or worsening malnutrition and sarcopenia. In malnourished patients, preoperative nutritional support may not be sufficient and so postoperative support is advised. This narrative review addresses several aspects of postoperative nutritional care in the setting of enhanced recovery programmes. Early oral feeding, therapeutic diet, oral nutritional supplements, immunonutrition, and probiotics are discussed. When postoperative intake is insufficient, nutritional support favouring the enteral route is recommended. Whether this approach should use a nasojejunal tube or jejunostomy is still a matter of debate. In the setting of enhanced recovery programmes with early discharge, nutritional follow-up and care should be continued beyond the short time in hospital. In enhanced recovery programmes, the main specific aspects of nutrition are patient education, early oral intake, and post-discharge care. The other aspects do not differ from conventional care.
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Affiliation(s)
- Pamela Funk Debleds
- Department of Supportive Care, Centre de Lutte Contre le Cancer Léon Bérard, Lyon, France
| | - Cécile Chambrier
- Intensive Clinical Nutrition Department, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre-Bénite, France
| | - Karem Slim
- Department of Digestive Surgery, University Hospital, CHU, Clermont-Ferrand, France; Francophone Group for Enhanced Recovery After Surgery, France.
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Arvanitakis M, Ockenga J, Bezmarevic M, Gianotti L, Krznarić Ž, Lobo DN, Löser C, Madl C, Meier R, Phillips M, Rasmussen HH, Van Hooft JE, Bischoff SC. ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2024; 43:395-412. [PMID: 38169174 DOI: 10.1016/j.clnu.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024]
Abstract
Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.
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Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, HUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Johann Ockenga
- Department of Gastroenterology, Endocrinology and Clinical Nutrition, Klinikum Bremen Mitte, Bremen, Germany
| | - Mihailo Bezmarevic
- Department of Hepatobiliary and Pancreatic Surgery, Clinic for General Surgery, Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Željko Krznarić
- Department of Gastroenterology, Hepatology and Nutrition, Clinical Hospital Centre & School of Medicine, Zagreb, Croatia
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Christian Madl
- Division of Gastroenterology and Hepatology, Krankenanstalt Rudolfstiftung, Krankenanstaltenverbund Wien (KAV), Vienna, Austria
| | - Remy Meier
- AMB-Praxis-MagenDarm Basel, Basel, Switzerland
| | - Mary Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Henrik Højgaard Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Jeanin E Van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany
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Huang Z, He A, Wang J, Lu H, Rao S, Huang Y, Feng Q. Minimally invasive enucleation versus open enucleation for benign or low-grade malignant pancreatic neoplasms: Effects on clinical outcomes and quality of life. J Minim Access Surg 2023; 19:419-426. [PMID: 37470631 PMCID: PMC10449040 DOI: 10.4103/jmas.jmas_182_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 04/08/2023] [Accepted: 05/03/2023] [Indexed: 06/27/2023] Open
Abstract
Introduction The efficacy and safety of minimally invasive pancreatic enucleation (PE) have rarely been investigated. This study aimed to compare the perioperative and long-term outcomes of minimally invasive enucleation (MIEn) with those of open enucleation (OEn) for benign/low-grade malignant pancreatic neoplasms. Patients and Methods Data collected from patients who underwent PE between January 2011 and June 2020 at our centre were analysed. Results Forty-two patients who underwent MIEn (10 - robot-assisted and 32 - laparoscopic) and 47 who underwent OEn were included in this study. Compared with the OEn group, the MIEn group showed shorter operation time (147.6 ± 71.3 min vs. 183.1 ± 64.3 min), shorter post-operative hospital stay (11.5 ± 3.9 days vs. 13.4 ± 4.2 days), shorter off-bed activity time (2.9 ± 0.9 days vs. 3.7 ± 1.0 days) and lower estimated blood loss (EBL) (118.5 ± 59.2 mL vs. 153.1 ± 85.0 mL). Overall complication rate (47.6% vs. 55.3%), overall post-operative pancreatic fistula (POPF) rate (40.5% vs. 44.7%) and Grade B + C POPF rate (11.9% vs. 19.1%) were similar in both the groups. For neoplasms located in the proximal pancreas, MIEn showed more favourable perioperative outcomes than OEn. Unlike MIEn for superficial neoplasms, MIEn for neoplasms deeply embedded in the pancreas resulted in a longer operative time and tended to increase EBL and the incidence of complications and POPF. During the follow-up period, no significant differences were observed between these two groups in terms of pancreatic function or quality of life. Conclusions Compared to OEn, MIEn is effective and safe for patients with benign or low-grade malignant pancreatic neoplasms. However, MIEn for embedded pancreatic neoplasms is recommended only in experienced centres because of the high rates of complications and POPF.
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Affiliation(s)
- Zhihao Huang
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Aoxiao He
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jiakun Wang
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hongcheng Lu
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shanshan Rao
- Department of Nursing, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yong Huang
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qian Feng
- Department of Emergency, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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Schleimer LE, Chabot JA, Kluger MD. Innovation in the Surgical Management of Pancreatic Cystic Neoplasms: Same Operations, Narrower Indications, and an Individualized Approach to Decision-Making. Gastrointest Endosc Clin N Am 2023; 33:655-677. [PMID: 37245941 DOI: 10.1016/j.giec.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Historically, the management of pancreatic cystic neoplasms (PCN) has been operative. Early intervention for premalignant lesions, including intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN), offers an opportunity to prevent pancreatic cancer-with potential decrement to patients' short-term and long-term health. The operations performed have remained fundamentally the same, with most patients undergoing pancreatoduodenectomy or distal pancreatectomy using oncologic principles. The role of parenchymal-sparing resection and total pancreatectomy remains controversial. We review innovations in the surgical management of PCN, focusing on the evolution of evidence-based guidelines, short-term and long-term outcomes, and individualized risk-benefit assessment.
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Affiliation(s)
- Lauren E Schleimer
- Department of Surgery, Columbia University Irving Medical Center, 177 Fort Washington Avenue, 8 Garden South, New York, NY 10032, USA. https://twitter.com/lschleim
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 819, New York, NY 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 823, New York, NY 10032, USA.
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7
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Kumar TK, Tewari M, Shukla SK, Mishra SP. Pancreatic exocrine insufficiency occurs in most patients following pancreaticoduodenectomy. Indian J Cancer 2022; 58:511-517. [PMID: 34975096 DOI: 10.4103/ijc.ijc_764_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Pancreatic exocrine insufficiency (PEI) is a well-defined complication of malignant diseases and pancreatic resection; however, study results of PEI are less consistent. Assessment of PEI by estimation of fecal elastase (FE)-1 in stool by enzyme-linked immunosorbent essay (ELISA) is a relatively inexpensive, noninvasive, and simple test. This study assessed exocrine function of pancreas following pancreaticoduodenectomy (PD) by estimating FE-1. Methods This prospective hospital-based study involved 30 patients who had undergone PD for malignancy. All 30 patients had an uneventful postoperative period under the unit's enhanced recovery after surgery (ERAS) protocol with no Grade B, C postoperative pancreatic fistula/postpancreatectomy hemorrhage as per the International Study Group of Pancreatic Surgery (ISGPS) definitions. Stool samples were collected postoperatively 3 months after surgery from all patients irrespective of clinical symptoms. The analysis was based on a solid phase ELISA used for the quantitative determination of human elastase 1 in feces. Fecal elastase was considered normal if >200 μg/gm stool, moderately reduced if 100-200 μg/gm stool, and severely reduced if <100 μg/gm stool. Results Among 30 patients included, fecal elastase levels were moderately reduced in 10 (33.33%) and severely reduced in 20 (66.67%) patients (P <0.0001). Mean (± standard deviation) of fecal elastase was 87.12 ± 38.76 with median of 74.6 μg/gm stool. There was no significant difference in the fecal elastase levels between men and women (P = 0.057), age (P = 0.48), pancreatic duct diameter (P = 0.609), pancreatic texture (P = 0.286), and presence or absence of clinical symptoms (P = 0.181). Conclusions PD was frequently associated with PEI. Unfortunately PEI is an under recognized and under treated long-term sequel of PD. Fecal elastase 1 should be performed routinely in both symptomatic and asymptomatic patients. Pancreatic enzyme replacement therapy should be considered in every patient after PD.
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Affiliation(s)
- Thogari K Kumar
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Mallika Tewari
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - S K Shukla
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - S P Mishra
- Department of Biochemistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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8
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Cho A, Kim H, Sohn HJ, Lee M, Kang YH, Kim HS, Han Y, Kang JS, Kwon W, Jang JY. Risk factors deteriorating severe exocrine pancreatic insufficiency measured by stool elastase after pancreatoduodenectomy and the risk factors for weight loss. Ann Surg Treat Res 2022; 102:20-28. [PMID: 35071116 PMCID: PMC8753381 DOI: 10.4174/astr.2022.102.1.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/07/2021] [Accepted: 11/11/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose The measurement of stool elastase (SE) level is useful for evaluating pancreatic exocrine function. This study aimed to determine the risk factors for severe exocrine pancreatic insufficiency (EPI) after pancreatoduodenectomy (PD), and analyze serial changes in nutritional markers and weight based on the SE level. Methods Among patients who underwent PD for periampullary disease, patients whose preoperative and postoperative SE levels were measured were included in the study. The deteriorated (exocrine function) group comprised patients whose SE levels decreased from ≥100 µg/g preoperatively to <100 µg/g postoperatively. Patients whose weight 12 months postoperatively was greater than that 3 months postoperatively were classified into the weight-recovery group. Results Of the 202 included patients, the deteriorated group had a higher incidence of preoperative SE level above 200 µg/g, benign pathology, and the presence of a clinically relevant postoperative pancreatic fistula than the maintained group. Patients who did not undergo weight recovery had a higher rate of history of adjuvant radiotherapy compared to the no-recovery group. Conclusion The evaluation of EPI by measuring SE alone is not sufficient because it does not reflect the nutritional status of patients, and a comprehensive approach that considers other parameters is required for EPI management.
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Affiliation(s)
- Ara Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Ju Sohn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Mirang Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Hyung Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong Seok Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Mayeux SE, Kwon W, Rosario VL, Rossmer I, Schrope BA, Chabot JA, Kluger MD. Long-term health after pancreatic surgery: the view from 9.5 years. HPB (Oxford) 2021; 23:595-600. [PMID: 32988751 DOI: 10.1016/j.hpb.2020.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Discussing the impact of pancreatic surgery on long-term health is poorly understood, but necessary for informed consent. Given the increased number of pancreatic operations being performed annually, further investigation is necessary. METHODS Patients surviving longer than 5 years after pancreatic surgery were surveyed for postoperative hospitalizations, operations, pain, nutrition and diabetes. Variables were analyzed according to patient and peri-operative variables, and validated using medical records. RESULTS Eighty individuals completed the survey; median follow-up was 9.5 years (IQR:6.43,12.73). 47.5% underwent a pancreatoduodenectomy, and 25.0% a distal pancreatectomy; 40.0% had adenocarcinoma. 57.1% reported long-term weight loss, of which 65.9% was unintentional. While 1.3% took pancreatic enzymes before surgery, 38.8% utilized after. 12.5% had diabetes before, and 28.6% after surgery; 22 of 30 patients required insulin replacement therapy (73.3%). 41.3% reported hospitalizations, 17.5% required endoscopies and 28.8% additional operations after full recovery. Need for additional interventions were not related to pathology or post-operative complications, but were more common among patients undergoing a Whipple. CONCLUSION More than half of patients will have a long-term medical complication attributable to pancreatectomy. In comparison to the literature, it may be inferred that consequences occur within the first few years after surgery, and do not compound over time.
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Affiliation(s)
- Sophie E Mayeux
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Vilma L Rosario
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Irene Rossmer
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA.
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10
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Pathanki AM, Attard JA, Bradley E, Powell-Brett S, Dasari BVM, Isaac JR, Roberts KJ, Chatzizacharias NA. Pancreatic exocrine insufficiency after pancreaticoduodenectomy: Current evidence and management. World J Gastrointest Pathophysiol 2020; 11:20-31. [PMID: 32318312 PMCID: PMC7156847 DOI: 10.4291/wjgp.v11.i2.20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/13/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is the commonest procedure performed for pancreatic cancer. Pancreatic exocrine insufficiency (PEI) may be caused or exacerbated by surgery and remains underdiagnosed and undertreated. The aim of this review was to ascertain the incidence of PEI, its consequences and management in the setting of PD for indications other than chronic pancreatitis. A literature search of databases (MEDLINE, EMBASE, Cochrane and Scopus) was carried out with the MeSH terms “pancreatic exocrine insufficiency” and “Pancreaticoduodenectomy”. Studies that analysed PEI and its complications in the setting of PD for malignant and benign disease were included. Studies reporting PEI in the setting of PD for chronic pancreatitis, conference abstracts and reviews were excluded. The incidence of PEI approached 100% following PD in some series. The pre-operative incidence varied depending on the characteristics of the patient cohort and it was higher (46%-93%) in series where pancreatic cancer was the predominant indication for surgery. Variability was also recorded with regards to the method used for the diagnosis and evaluation of pancreatic function and malabsorption. Pancreatic enzyme replacement therapy is the mainstay of the management. PEI is common and remains undertreated after PD. Future studies are required for the identification of a well-tolerated, reliable and reproducible diagnostic test in this setting.
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Affiliation(s)
- Adithya M Pathanki
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Joseph A Attard
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Elizabeth Bradley
- Department of Nutrition and Dietetics, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Sarah Powell-Brett
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Bobby V M Dasari
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - John R Isaac
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Keith J Roberts
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Nikolaos A Chatzizacharias
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
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11
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ESPEN guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2020; 39:612-631. [DOI: 10.1016/j.clnu.2020.01.004] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
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12
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Shah KP, Baugh KA, Brubaker LS, Van Buren G, Villafane-Ferriol N, McElhany AL, Mohamed S, Silberfein EJ, Hsu C, Massarweh NN, Tran Cao HS, Mendez-Reyes JE, Fisher WE. Long-Term Assessment of Pancreatic Function After Pancreatectomy for Cystic Neoplasms. J Surg Res 2019; 247:547-555. [PMID: 31740011 DOI: 10.1016/j.jss.2019.09.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/20/2019] [Accepted: 09/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND With advances in cross-sectional imaging, pancreatic cysts are more frequently diagnosed and have become a common indication for pancreatectomy. The impact of pancreatectomy in these patients is important. The purpose of this study was to assess short-term outcomes, long-term nutritional status, quality of life (QOL), and pancreas function after pancreatectomy for cystic neoplasms. MATERIALS AND METHODS At a single institution, patients at least 3 y post-pancreatectomy for benign cystic neoplasms were identified. Using a validated questionnaire, short-term outcomes, long-term outcomes including endocrine and exocrine insufficiency, long-term nutritional status, and preoperative and postoperative QOL were compared based on operation and indication for resection. RESULTS Among 102 eligible patients, 70 had valid contact information and 51 (72.9%) agreed to participate. Median follow-up was 6 (4-8) y. Patients undergoing pancreatoduodenectomy for benign cysts had higher morbidity than a similar cohort resected for pancreatic adenocarcinoma (patients with at least 1 ≥ grade 2 complication [49.0% versus 31.6%, P = 0.038]). After long-term follow-up, pancreatectomy did not significantly affect perceived QOL. Half of patients had mild-moderate or severe malnourishment, but pancreatic enzyme replacement was reported by only 4 (7.8%) patients. New-onset diabetes was present in 15 (29.4%) patients with median time-to-diagnosis of 6 (1-12) mo after resection. CONCLUSIONS Pancreatectomy for benign cysts did not negatively impact patients' perceived QOL. However, after long-term follow-up, malnutrition and pancreatic insufficiency occurred in a significant percentage and may be greater than previously estimated. Consideration of short- and long-term outcomes should factor into preoperative counseling, especially in cysts with minimal risk of progression to malignancy.
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Affiliation(s)
- Kevin P Shah
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Katherine A Baugh
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Lisa S Brubaker
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - George Van Buren
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Amy L McElhany
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sadde Mohamed
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Eric J Silberfein
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Cary Hsu
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nader N Massarweh
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Hop S Tran Cao
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Jose E Mendez-Reyes
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - William E Fisher
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
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Andreasi V, Partelli S, Capurso G, Muffatti F, Balzano G, Crippa S, Falconi M. Long-Term Pancreatic Functional Impairment after Surgery for Neuroendocrine Neoplasms. J Clin Med 2019; 8:jcm8101611. [PMID: 31623399 PMCID: PMC6832294 DOI: 10.3390/jcm8101611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/23/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022] Open
Abstract
Radical surgery represents the only curative treatment for pancreatic neuroendocrine neoplasms (PanNEN). The aim of this study was to evaluate the postoperative onset of diabetes mellitus (DM) and/or pancreatic exocrine insufficiency (PEI) in surgically treated PanNEN. Consecutive PanNEN patients, without preoperative DM, who underwent partial pancreatic resection, were included. After a median follow-up of 72 months, overall 68/276 patients (24%) developed DM. Patients who developed DM were significantly older (p = 0.002) and they had a higher body mass index (BMI) (p < 0.0001) than those who did not; they were more frequently male (p = 0.017) and with nonfunctioning neoplasms (p = 0.019). BMI > 25 Kg/m2 was the only independent predictor of DM (p = 0.001). Overall, 118/276 patients (43%) developed a PEI, which was significantly more frequent after pancreaticoduodenectomy (p < 0.0001) and in patients with T3-T4 tumors (p = 0.001). Pancreaticoduodenectomy was the only independent predictor of PEI (p < 0.0001). Overall, 54 patients (20%) developed disease progression. Patients with and without DM had similar progression free survival (PFS), whereas patients without PEI had better five-year-PFS (p = 0.002), although this association was not confirmed in multivariate analysis. The risk of DM and PEI after surgery for PanNEN is relatively high but it does not affect PFS. BMI and pancreatic head resection are independent predictors of DM and PEI, respectively.
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Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Gabriele Capurso
- Biliopancreatic Endoscopy Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
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14
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Thogari K, Tewari M, Shukla SK, Mishra SP, Shukla HS. Assessment of Exocrine Function of Pancreas Following Pancreaticoduodenectomy. Indian J Surg Oncol 2019; 10:258-267. [PMID: 31168245 PMCID: PMC6527627 DOI: 10.1007/s13193-019-00901-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 01/07/2019] [Accepted: 03/03/2019] [Indexed: 12/31/2022] Open
Abstract
Pancreatic exocrine insufficiency (PEI) is a common long-term complication after pancreaticoduodenectomy (PD) and is observed in 23-80% of patients. As the postoperative mortality after PD has substantially decreased, it warrants more attention on the diagnosis and treatment of functional long-term consequences after PD. These include PEI and endocrine insufficiency that can result in significant nutritional impairment and often adversely impacts quality of life (QOL) of the patient. A PubMed search was performed for articles using key words "pancreatic exocrine insufficiency"; "pancreaticoduodenectomy"; "quality of life after pancreaticoduodenectomy"; "stool elastase"; "direct, indirect tests for pancreatic exocrine insufficiency"; "pancreatic enzyme replacement therapy." Relevant studies were shortlisted and analyzed. This review summarizes relevant studies addressing PEI following PD. We also discuss functional changes after PD, risk factors and predictive factors for postoperative PEI, clinical symptoms, direct and indirect tests for estimation of PEI, pancreatic enzyme replacement therapy (PERT), and QOL after pancreatic resection for malignancy. It was found that significant PEI occurs in most patients following PD. Fecal elastase 1 is an easy indirect test and should be performed routinely in both symptomatic and asymptomatic patients after PD. PERT should be considered in every patient after PD with the aim to improve the QOL and perhaps even their long time survival.
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Affiliation(s)
- Kiran Thogari
- Division of Hepatopancreatobiliary and GastroIntestinal Oncology, Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005 India
| | - Mallika Tewari
- Division of Hepatopancreatobiliary and GastroIntestinal Oncology, Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005 India
| | - S. K. Shukla
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005 India
| | - S. P. Mishra
- Department of Biochemistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005 India
| | - H. S. Shukla
- Division of Hepatopancreatobiliary and GastroIntestinal Oncology, Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005 India
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15
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Cho YJ, Namgoong JM, Kim DY, Kim SC, Kwon HH. Suggested Indications for Enucleation of Solid Pseudopapillary Neoplasms in Pediatric Patients. Front Pediatr 2019; 7:125. [PMID: 31001506 PMCID: PMC6456698 DOI: 10.3389/fped.2019.00125] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/15/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Solid pseudopapillary neoplasms (SPNs) are rare, low-grade, malignant neoplasms that can occur in pediatric patients. Although complete resection of the tumor is the principle treatment, SPN enucleation (EN) has been reported to be effective in children. This study aimed to examine the feasibility and safety of EN by comparing it with conventional pancreatectomy (CP), and to present the indications for its use in pediatric patients. Methods: We retrospectively reviewed the medical records of 66 patients who underwent surgery for SPN at our institution from October 1992 to April 2018. Surgical methods, postoperative complications, hospital stay, and recurrence were compared. Results: Of the 66 patients, 15 (22.7%) were treated with EN and 51 (77.3%) were treated with CP. The mean duration of EN operation was 262 min (±145 min) and of CP was 345 min (±195 min). There was no statistically significant difference between the two methods (P = 0.13). To objectively compare the mass size between patients, we introduced a tumor size/intraperitoneal width ratio, which also revealed no significant difference between the 2 surgery groups (P = 0.21). The EN group had one case of recurrence at the resection site. The complications observed were fluid collection, splenic infarctions, hematomas, pancreatic fistulas, portal vein thromboses, and chylous drainage, among which pancreatic fistulas were the most frequent followed by moderate-severe fistulas in the EN group (P < 0.001). The mean postoperative fasting time (EN 17.0 ± 8.7 days vs. CP 5.1 ± 3.3 days, P < 0.001) and mean hospital stay (EN 23.4 ± 10.0 days vs. CP 13.2 ± 6.5 days, P = 0.002) showed statistically significant differences. Conclusion: Compared with CP treatment, EN of SPNs in children has the disadvantages of prolonged fasting times and hospital stays to recover from moderate pancreatic fistulas. However, if appropriate indications are applied, EN can be considered a safe and effective surgical procedure for children.
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Affiliation(s)
- Yu Jeong Cho
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong Chul Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyun Hee Kwon
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
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16
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A Chinese consensus statement on the diagnosis and treatment of pancreatic exocrine insufficiency after pancreatic surgery (2018). JOURNAL OF PANCREATOLOGY 2018. [DOI: 10.1097/jp9.0000000000000004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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17
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Gianotti L, Besselink MG, Sandini M, Hackert T, Conlon K, Gerritsen A, Griffin O, Fingerhut A, Probst P, Abu Hilal M, Marchegiani G, Nappo G, Zerbi A, Amodio A, Perinel J, Adham M, Raimondo M, Asbun HJ, Sato A, Takaori K, Shrikhande SV, Del Chiaro M, Bockhorn M, Izbicki JR, Dervenis C, Charnley RM, Martignoni ME, Friess H, de Pretis N, Radenkovic D, Montorsi M, Sarr MG, Vollmer CM, Frulloni L, Büchler MW, Bassi C. Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS). Surgery 2018; 164:1035-1048. [PMID: 30029989 DOI: 10.1016/j.surg.2018.05.040] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal nutritional therapy in the field of pancreatic surgery is still debated. METHODS An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. RESULTS The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. CONCLUSION The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marta Sandini
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Kevin Conlon
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Arja Gerritsen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Oonagh Griffin
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Abe Fingerhut
- University of Graz Hospital, Surgical Research Unit, Graz, Austria
| | - Pascal Probst
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Antonio Amodio
- Unit of Gastroenterology, University of Verona Hospital Trust, Verona, Italy
| | - Julie Perinel
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Mustapha Adham
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Massimo Raimondo
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Horacio J Asbun
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Asahi Sato
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kyoichi Takaori
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Marco Del Chiaro
- Pancreatic Surgery Unit - Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) - Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christos Dervenis
- University of Cyprus and Department of Surgical Oncology and HPB Surgery Metropolitan Hospital, Athens, Greece
| | - Richard M Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marc E Martignoni
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | | | - Dejan Radenkovic
- Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marco Montorsi
- Department of Surgery, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Michael G Sarr
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Markus W Büchler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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18
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Lu WJ, Cai HL, Ye MD, Wu YL, Xu B. Enucleation of non-invasive tumors in the proximal pancreas: indications and outcomes compared with standard resections. J Zhejiang Univ Sci B 2018; 18:906-916. [PMID: 28990381 DOI: 10.1631/jzus.b1600597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and efficiency of enucleation (EU) for proximal pancreatic non-invasive neoplasms. METHODS Patients with solitary non-invasive neoplasms in the proximal pancreas from January 1998 to April 2014 at the Second Affiliated Hospital of Zhejiang University, Hangzhou, China were included. Different operations and outcomes were analyzed. RESULTS A total of 123 patients were enrolled. Forty patients (32.5%) underwent EU including 18 patients who had tumors close to the main pancreatic duct (MPD). Sixty-one patients (49.6%) had pancreaticoduodenectomy (PD) performed and 22 (17.9%) underwent central pancreatectomy (CP). Pathological outcomes included neuroendocrine tumors, cystic lesions, and solid pseudopapillary tumors. Operation time, intra-operative blood loss, and duration of hospital stay were significantly reduced in the EU group. PD was associated with the greatest complication rate (55.7%), followed by EU (50%) and CP (40.9%), though the pancreatic fistula rate after EU was the highest (50%), especially in patients with tumors larger than 3 cm and tumors close to the MPD. EU had advantages in the preservation of pancreatic parenchyma and endocrine and exocrine function. CONCLUSIONS EU can be carried out safely and effectively for tumors in the proximal pancreas with improved outcomes compared with standard resections, even if the tumor is larger than 3 cm and close to the MPD.
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Affiliation(s)
- Wen-Jie Lu
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Hao-Lei Cai
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Ma-Dong Ye
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Yu-Lian Wu
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Bin Xu
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
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19
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Diabetes after pancreaticoduodenectomy: can we predict it? J Surg Res 2018; 227:211-219. [PMID: 29804855 DOI: 10.1016/j.jss.2018.02.010] [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] [Received: 07/03/2017] [Revised: 12/07/2017] [Accepted: 02/13/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is limited literature about the perioperative factors which can predict endocrine insufficiency after pancreaticoduodenectomy (PD). The primary aim was to correlate percentage pancreatic remnant volume (%RV) after PD in nondiabetic patients with the development of new-onset impaired glucose tolerance/diabetes mellitus (IGT/DM). The secondary aim was to identify the risk factors for new-onset IGT/DM. METHODS In this prospective study, all consecutive patients with resectable periampullary carcinoma and without IGT/DM were evaluated with fasting and postprandial plasma glucose, HbA1c, insulin, and C-peptide levels preoperatively and at 3 mo postoperatively. After that, all patients were followed up with fasting and postprandial plasma glucose level assessed at 3-mo intervals for 24 mo or till death, whichever occurred earlier. The %RV was determined from computed tomography measurements preoperatively. RESULTS Of the 50 patients, 11 (22%) patients developed IGT/DM after median follow-up of 32 mo. The patients' with/without IGT/DM were similar in demographic/perioperative variables. The %RV was found to be an independent factor associated with new-onset IGT/DM. A %RV of <48.8% was found to be a predictor of new-onset IGT/DM (sensitivity, 89.7%; specificity, 73.6%). Plasma sugar and glycosylated hemoglobin levels were significantly higher postoperatively after PD than the preoperative levels. Insulin and C-peptide levels were significantly lower after PD, irrespective of new-onset IGT/DM. CONCLUSIONS The incidence of IGT/DM after PD was 22%, and %RV < 48.8% was found to be a significant risk factor for new-onset IGT/DM. (CTRI/2013/12/004233).
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20
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Beger HG, Mayer B. Early postoperative and late metabolic morbidity after pancreatic resections: An old and new challenge for surgeons - A review. Am J Surg 2018; 216:131-134. [PMID: 29478825 DOI: 10.1016/j.amjsurg.2018.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/09/2018] [Accepted: 02/14/2018] [Indexed: 01/15/2023]
Abstract
The metrics for measuring early postoperative morbidity after resection of pancreatic neoplastic tumors are overall morbidity, severe surgery-related morbidity, frequency of reoperation and reintervention, in-hospital, 30-day and 90-day mortality and length of hospital stay. Thirty-day readmission after discharge is additionally an indispensable criterion to assess quality of surgery. The metrics for surgery-associated long-term results after pancreatic resections are survival times, new onset of diabetes (DM), impaired glucose tolerance, exocrine pancreatic insufficiency, body mass index and GI motility dysfunctions. Following pancreaticoduodenectomy (PD) performed on pancreatic normo-glycemic patients for malignant and benign tumors, 4-30% develop postoperative new onset of diabetes. Long-term persistence of diabetes mellitus is observed after surgery for benign tumors in 14% and in 15.5% of patients after cancer resection. Pancreatic exocrine insufficiency after PD is observed in the early postoperative period in 23-80% of patients. Persistence of exocrine dysfunctions exists in 25% and 49% of patients. Following left-sided pancreatic resection, new onset DM is observed in 14% of cases; an exocrine insufficiency persisting in the long-term outcome is observed in 16-28% of patients.
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Affiliation(s)
- Hans G Beger
- c/o University of Ulm, Germany; Center of Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum, Neu-Ulm, Germany.
| | - Benjamin Mayer
- Department of Epidemiology and Medical Biometry, University of Ulm, Germany
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21
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New Onset of Diabetes and Pancreatic Exocrine Insufficiency After Pancreaticoduodenectomy for Benign and Malignant Tumors. Ann Surg 2018; 267:259-270. [DOI: 10.1097/sla.0000000000002422] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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22
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Elliott IA, Epelboym I, Winner M, Allendorf JD, Haigh PI. Population-Level Incidence and Predictors of Surgically Induced Diabetes and Exocrine Insufficiency after Partial Pancreatic Resection. Perm J 2017; 21:16-095. [PMID: 28406793 DOI: 10.7812/tpp/16-095] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
CONTEXT Endocrine and exocrine insufficiency after partial pancreatectomy affect quality of life, cardiovascular health, and nutritional status. However, their incidence and predictors are unknown. OBJECTIVE To identify the incidence and predictors of new-onset diabetes and exocrine insufficiency after partial pancreatectomy. DESIGN We retrospectively reviewed 1165 cases of partial pancreatectomy, performed from 1998 to 2010, from a large population-based database. MAIN OUTCOME MEASURES Incidence of new onset diabetes and exocrine insufficiency RESULTS: Of 1165 patients undergoing partial pancreatectomy, 41.8% had preexisting diabetes. In the remaining 678 patients, at a median 3.6 months, diabetes developed in 274 (40.4%) and pancreatic insufficiency developed in 235 (34.7%) patients. Independent predictors of new-onset diabetes were higher Charlson Comorbidity Index (CCI; hazard ratio [HR] = 1.62 for CCI of 1, p = 0.02; HR = 1.95 for CCI ≥ 2, p < 0.01) and pancreatitis (HR = 1.51, p = 0.03). There was no difference in diabetes after Whipple procedure vs distal pancreatic resections, or malignant vs benign pathologic findings. Independent predictors of exocrine insufficiency were female sex (HR = 1.32, p = 0.002) and higher CCI (HR = 1.85 for CCI of 1, p < 0.01; HR = 2.05 for CCI ≥ 2, p < 0.01). Distal resection and Asian race predicted decreased exocrine insufficiency (HR = 0.35, p < 0.01; HR = 0.54, p < 0.01, respectively). CONCLUSION In a large population-based database, the rates of postpancreatectomy endocrine and exocrine insufficiency were 40% and 35%, respectively. These data are critical for informing patients' and physicians' expectations.
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Affiliation(s)
- Irmina A Elliott
- Surgical Resident at the University of California, Los Angeles David Geffen School of Medicine.
| | - Irene Epelboym
- Surgical Oncology Fellow at the University of Pittsburgh in PA.
| | - Megan Winner
- Surgeon at the Winthrop-University Hospital in Mineola, NY.
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González-Sánchez V, Amrani R, González V, Trigo C, Picó A, de-Madaria E. Diagnosis of exocrine pancreatic insufficiency in chronic pancreatitis: 13C-Mixed Triglyceride Breath Test versus Fecal Elastase. Pancreatology 2017; 17:580-585. [PMID: 28291656 DOI: 10.1016/j.pan.2017.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 03/01/2017] [Accepted: 03/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic enzyme replacement therapy (PERT) is indicated in case of clinically relevant exocrine pancreatic insufficiency (EPI). Clinical trials addressing PERT have used the coefficient of fat absorption (CFA) to define EPI but this test is cumbersome to perform. Our aim was to compare two easier-to-perform tests to detect clinically relevant EPI: Fecal Elastase-1 (FE-1) and 13C-Mixed Triglyceride Breath Test (TGBT). METHODS We prospectively included 54 patients with chronic pancreatitis (CP), 24.1% operated, 29.6% had EPI. EPI was defined as a CFA <93%. The sensitivity (Se), specificity (Sp), positive (PPV) and negative (NPV) predictive values for different cut-offs of FE-1 and TGBT were calculated. RESULTS The area under the ROC curve for FE-1/TGBT was 0.861/0.876 for the global sample, 0.842/0.794 for non-operated patients and 0.917/1 for operated patients respectively. Se, Sp, PPV and NPV for a cut-off of FE-1 <200 μg/g were 93.8%, 63.2%, 51.7% and 96% respectively. The best cut-off point for FE-1 was 84 μg/g, which yielded an 87.5% Se, 81.6% Sp, 66.7% PPV and 93.9% NPV. The same parameters for a TGBT <29% were 81.3%, 84.2%, 68.4% and 91.4% respectively. The best cut-off point for TGBT was <23%, which yielded an 81.3% Se, 94.7% Sp, 86.7% PPV and 92.3% NPV. Diabetes was associated to decreased FE-1 levels, even in multivariate analysis. CONCLUSIONS FE-1 and TGBT showed similar results for the diagnosis of EPI in CP. In non-operated CP patients, TGBT does not offer any advantage to FE-1 but in operated CP patients TGBT seems a more accurate test.
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Affiliation(s)
- Víctor González-Sánchez
- Sección de Endocrinología y Nutrición, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Alicante, Spain
| | - Rahma Amrani
- Sección de Endocrinología y Nutrición, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Alicante, Spain
| | - Victoria González
- Servicio de Análisis Clínicos, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Alicante, Spain
| | - Celia Trigo
- Servicio de Análisis Clínicos, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Alicante, Spain
| | - Antonio Picó
- Sección de Endocrinología y Nutrición, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Alicante, Spain
| | - Enrique de-Madaria
- Servicio de Gastroenterología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Alicante, Spain.
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Yun SP, Seo HI, Kim S, Kim DU, Baek DH. Does the pancreatic volume reduction rate using serial computed tomographic volumetry predict new onset diabetes after pancreaticoduodenectomy? Medicine (Baltimore) 2017; 96:e6491. [PMID: 28353594 PMCID: PMC5380278 DOI: 10.1097/md.0000000000006491] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Volume reduction of the pancreatic tissues following a pancreatectomy can lead to the deterioration of glucose homeostasis. This is defined as pancreatogenic diabetes mellitus (DM). The objective of this study was to investigate the occurrence of new-onset DM (NODM) and evaluate the risk factors, including the pancreas volume reduction rate in patients undergoing pancreaticoduodenectomy (PD).Sixty-six patients without preoperative DM underwent PD for periampullary tumors between August 2007 and December 2012 and were included in this analysis. These patients underwent follow-up tests and abdominal computed tomography (CT) scan 7 days, 6 months, 12 months, 24 months, and 36 months after the operation. The pancreas volume reduction rate was calculated by CT volumetry. The patients were divided into 2 groups according to the postoperative development of DM.After PD, newly diagnosed DM occurred in 16 patients (24.2%). The incidence of DM was highest among patients with carcinomas with an advanced T stage. The pancreatic volume reduction rate after 6 and 12 months in the NODM group was significantly higher than the normal glucose group in the univariate analysis. In the multivariate analysis, the pancreatic volume reduction rate 6 months after PD was the only significant predictive factor for the development of NODM (P = 0.002).This study suggests that the pancreatic volume reduction rate 6 months after PD was the only significant predictive factor for the development of NODM. CT volumetry of the pancreas may be useful as a predictor of NODM after PD.
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Affiliation(s)
| | | | | | - Dong Uk Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dong Hoon Baek
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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25
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Sabater L, Ausania F, Bakker OJ, Boadas J, Domínguez-Muñoz JE, Falconi M, Fernández-Cruz L, Frulloni L, González-Sánchez V, Lariño-Noia J, Lindkvist B, Lluís F, Morera-Ocón F, Martín-Pérez E, Marra-López C, Moya-Herraiz Á, Neoptolemos JP, Pascual I, Pérez-Aisa Á, Pezzilli R, Ramia JM, Sánchez B, Molero X, Ruiz-Montesinos I, Vaquero EC, de-Madaria E. Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery. Ann Surg 2016; 264:949-958. [PMID: 27045859 DOI: 10.1097/sla.0000000000001732] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery. BACKGROUND EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients. METHODS Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement. RESULTS These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement. CONCLUSIONS EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.
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Affiliation(s)
- Luis Sabater
- *Department of Surgery, Hospital Clinico, University of Valencia, Valencia, Spain †Department of Surgery, Complejo Hospitalario Universitario de Vigo, Vigo, Spain ‡Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands §Department of Gastroenterology, Consorci Sanitari de Terrassa, Terrassa, Spain ¶Department of Gastroenterology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain ||Department of Surgery, Università Vita e Salute, Ospedale San Raffaele IRCCS, Milano, Italy **Department of Surgery, Institut de Malalties Digestives I Metabòliques, Hospital Clínic, IDIBAPS, Barcelona, Spain ††Department of Medicine, Pancreas Center, University of Verona, Verona, Italy ‡‡Department of Endocrinology and Nutrition, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. §§Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ¶¶Department of Surgery, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. ||||Department of Surgery, Hospital Universitario de La Princesa, Madrid, Spain ***Department of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain †††Unidad de Cirugía Hepato-bilio-pancreática y Trasplante, Hospital Universitari i Politecnic. La Fe, Valencia, Spain ‡‡‡NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK §§§Department of Gastroenterology, Hospital Clinico, University of Valencia, Valencia, Spain ¶¶¶Unit of Digestive Disease, Agencia Sanitaria Costa del Sol, Marbella, Málaga ||||||Department Digestive System, Sant'Orsola-Malpighi Hospital, Bologna, Italy ****Department of Surgery, Hospital Universitario de Guadalajara, Guadalajara, Spain ††††Department of HPB Surgery and Liver Transplantation, Hospital Carlos Haya, Malaga, Spain ‡‡‡‡Exocrine Pancreas Research Unit, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, CIBEREHD, Barcelona, Spain §§§§Department of Digestive Surgery- Division of HBP Surgery, Hospital Universitario Donostia, San Sebastián, Spain ¶¶¶¶Department of Gastroenterology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, IDIBAPS, CiberEHD, Barcelona, Spain ||||||||Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
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26
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Clinical influence of anastomotic stricture caused by pancreatogastrointestinalstomy following pancreatoduodenectomy. Surg Today 2016; 47:581-586. [DOI: 10.1007/s00595-016-1412-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
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27
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Arthur AE, Delk A, Demark-Wahnefried W, Christein JD, Contreras C, Posey JA, Vickers S, Oster R, Rogers LQ. Pancreatic cancer survivors' preferences, barriers, and facilitators related to physical activity and diet interventions. J Cancer Surviv 2016; 10:981-989. [PMID: 27138993 DOI: 10.1007/s11764-016-0544-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 04/18/2016] [Indexed: 01/26/2023]
Abstract
PURPOSE To conduct a telephone survey establishing pancreatic cancer survivors' level of interest in, preferences for, and perceived barriers and facilitators to participating in exercise and diet intervention programming. These data will inform the development of such interventions for newly-diagnosed patients. METHODS Seventy-one survivors treated for resectable pancreatic adenocarcinoma from October 2011 to August 2014 were identified through an institutional cancer registry and contacted via telephone. A telephone survey was conducted to query survivors' level of interest in, preferences for, and perceived barriers and facilitators to participating in an exercise and dietary intervention program shortly after disease diagnosis. Acceptability of a technology-based visual communication (e.g., Skype™, FaceTime®) intervention was also assessed. RESULTS Fifty participants completed the survey (response rate 71.8 %). Over two-thirds of participants reported interest in exercise and diet intervention programming. Over half reported comfort with a technology-delivered visual communication intervention. Barriers to participation included older age and physical, personal, and emotional problems. The most common facilitator was program awareness. Outcomes for future research important to participants were supportive care and quality of life. CONCLUSIONS Most pancreatic cancer patients are interested in exercise and diet interventions shortly after diagnosis; however, some barriers to program participation exist. IMPLICATIONS FOR CANCER SURVIVORS Future research and intervention planning for pancreatic cancer survivors should focus on developing messaging and strategies that provide support for survivorship outcomes, increase survivor awareness, address lack of familiarity with technology, reduce fears about potential barriers, and help survivors overcome these barriers. In so doing, survivorship needs can be better met and quality of life improved in this understudied population.
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Affiliation(s)
- Anna E Arthur
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashley Delk
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - John D Christein
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Carlo Contreras
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James A Posey
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Selwyn Vickers
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert Oster
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Laura Q Rogers
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA.
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Helmink BA, Snyder RA, Idrees K, Merchant NB, Parikh AA. Advances in the Surgical Management of Resectable and Borderline Resectable Pancreas Cancer. Surg Oncol Clin N Am 2016; 25:287-310. [PMID: 27013365 PMCID: PMC10181830 DOI: 10.1016/j.soc.2015.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Successful surgical resection offers the only chance for cure in patients with pancreatic cancer. However, pancreatic resection is feasible in less than 20% of the patients. In this review, the current state of surgical management of pancreatic cancer is discussed. The definition of resectability based on cross-sectional imaging and the technical aspects of surgery, including vascular resection and/or reconstruction, management of aberrant vascular anatomy and extent of lymphadenectomy, are appraised. Furthermore, common pancreatic resection-specific postoperative complications and their management are reviewed.
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Affiliation(s)
- Beth A Helmink
- Division of Surgical Oncology, Vanderbilt University Medical Center, 597 PRB, 2220 Pierce Avenue, Nashville, TN 37232, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit Number: 1484, Houston, TX 77030, USA
| | - Kamran Idrees
- Division of Surgical Oncology, Vanderbilt University Medical Center, 597 PRB, 2220 Pierce Avenue, Nashville, TN 37232, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Sylvester Comprehensive Cancer Center, University of Miami Medical Center, 1120 Northwest 14th Street, Clinical Research Building, Suite 410, Miami, FL 33136, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, Vanderbilt University Medical Center, 597 PRB, 2220 Pierce Avenue, Nashville, TN 37232, USA.
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29
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Cioffi JL, McDuffie LA, Roch AM, Zyromski NJ, Ceppa EP, Schmidt CM, Nakeeb A, House MG. Pancreaticojejunostomy Stricture After Pancreatoduodenectomy: Outcomes After Operative Revision. J Gastrointest Surg 2016; 20:293-9. [PMID: 26553264 DOI: 10.1007/s11605-015-3012-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 10/27/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The natural history of radiographic strictures of the pancreaticojejunostomy (PJ) after pancreatoduodenectomy (PD) is difficult to characterize. The purpose of this study was to identify the indications for operative revision of PJ strictures after PD for benign and malignant disease and to evaluate its safety and clinical efficacy. METHODS A retrospective review of all patients undergoing operative revision of PJ strictures following PD at a single academic institution over an 8-year period (2006-2014) was performed. RESULTS Twenty-seven patients underwent revision of a symptomatic radiographically detectable PJ stricture. The median time from PD to PJ stricture diagnosis was 46 months. The median increase in the main pancreatic duct diameter between the time of PD and PJ revision was 2 mm. The overall morbidity after PJ revision was 26 %. No postoperative mortality occurred. Twenty-one (78 %) patients experienced resolution of symptoms without recurrent acute pancreatitis after PJ revision during a median follow-up of 30 months. Durable symptom resolution was reported among 60 % of patients with chronic pancreatitis. CONCLUSIONS Surgical revision of pancreaticojejunostomy strictures is technically safe and clinically effective for selected patients who experience recurrent acute pancreatitis after pancreatoduodenectomy for either benign or malignant disease.
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Affiliation(s)
- Jessica L Cioffi
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 513, Indianapolis, IN, 46202, USA
| | - Lucas A McDuffie
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 513, Indianapolis, IN, 46202, USA
| | - Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 513, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 513, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 513, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 513, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 513, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 513, Indianapolis, IN, 46202, USA.
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30
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Arvaniti M, Danias N, Theodosopoulou E, Smyrniotis V, Karaoglou M, Sarafis P. Quality of Life Variables Assessment, Before and After Pancreatoduodenectomy (PD): Prospective Study. Glob J Health Sci 2015; 8:203-10. [PMID: 26755486 PMCID: PMC4954876 DOI: 10.5539/gjhs.v8n6p203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/17/2015] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION The treatment of pancreatic cancer is a complex problem, due to late diagnosis, the need for specialized surgical treatment, the large number of relapses and poor survival. OBJECTIVE To evaluate the quality of life of patients with periampulary pancreatic cancer before and after pancreatoduodenectomy (PD). MATERIAL & METHOD The sample was collected in the "Attikon" University General Hospital (Chaidari). It consists of 20 subjects with a mean age of 65.9 years (SD = 10,2 years). For the quality of life measurement, we used the (EORTC) QLQ-C30 version 3.0., as well as the EORTC QOL-PAN26. RESULTS From the sample of 20 patients who participated, full data were collected for 18 of them during the first month, 17 during the third month and 16 during the sixth month.Regarding symptoms, as they were recorded with the QLQ-30 questionnaire, there was a significant increase of fatigue, a significant reduction of pain and constipation, while economic difficulties increased. As for the mean and median values for the dimensions of the PAN-26 questionnaire during monitoring, there was a significant decrease in pancreatic and liver pain symptoms during follow-up, while the gastrointestinal symptoms increased in frequency. In addition, the body image and sexuality worsened. CONCLUSIONS The surgical treatment of pancreatic cancer with pancreatoduodenectomy (PD), according to the early survey data using the (EORTC) QLQ-C30 version3.0, and the EORTC QOL-PAN26 questionnaires, seems to have a favorable impact on quality of life, as evidenced by the improvement of most parameters evaluated during the study period.
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Affiliation(s)
- Maria Arvaniti
- "Attikon" University General Hospital (Chaidari), Athens, Greece.
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Chua TC, Yang TX, Gill AJ, Samra JS. Systematic Review and Meta-Analysis of Enucleation Versus Standardized Resection for Small Pancreatic Lesions. Ann Surg Oncol 2015; 23:592-9. [PMID: 26307231 DOI: 10.1245/s10434-015-4826-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The appropriate surgical strategy in patients with small pancreatic lesions of low malignant potential, such as pancreatic neuroendocrine tumors, remains unknown. Increasing reports suggest limited pancreatic surgery may be a safe option for parenchymal preservation. METHODS PubMed and MEDLINE were searched in the English literature for studies from January 2000 to February 2015 examining enucleation for pancreatic lesions that were single-arm and comparative studies (versus resection). Single-arm enucleation studies were systematically reviewed. Comparative studies were included for meta-analysis. Endpoints include safety, complications, mortality, survival, and parenchymal-related outcomes. RESULTS Thirteen studies comprising of 1101 patients undergoing enucleation were included. Seven studies were comparative studies of enucleation and standardized pancreatic resection. Enucleation was a shorter procedure (pooled mean differences (MD) = 109, 95 % confidence interval (CI) 105-114; Z = 46.37; P < 0.001) associated with less blood loss (pooled MD = 314, 95 % CI 297-330; Z = 37.47; P < 0.001). Both enucleation and resection had similar mortality and complication rates, but the rate of pancreatic fistula (all grades) (pooled odds ratio (OR) = 1.99; 95 % CI 1.2-3.4; Z = 2.57; P = 0.01] and rate of pancreatic fistula (grade B/C) (pooled OR = 1.58; 95 % CI 1.0-2.5; Z = 2.06; P = 0.04) was higher in the enucleation group. Enucleation resulted in lower rates of endocrine (pooled OR = 0.22; 95 % CI 0.1-0.5; Z = 3.21; P = 0.001) and exocrine (pooled OR = 0.07; 95 % CI 0.02-0.2; Z = 5.08; P < 0.001) insufficiency. The median 5-year survival was 95 % (range 93-98) and 84 % (range 79-90). CONCLUSIONS Enucleation appears to be a safe procedure and achieves parenchymal preservation for small pancreatic lesions of low malignant potential. Its oncologic efficacy compared with standardized pancreatic resection with respect to long-term survival and recurrences have not been reported adequately and hence may not be concluded as being comparable.
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Affiliation(s)
- Terence C Chua
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia. .,Discipline of Surgery, University of Sydney, Sydney, NSW, Australia.
| | - Timothy X Yang
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia.,Discipline of Surgery, University of Sydney, Sydney, NSW, Australia
| | - Anthony J Gill
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, St Leonards, NSW, Australia.,University of Sydney, Sydney, NSW, Australia.,Deparment of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Jaswinder S Samra
- Macquarie University Hospital, Macquarie University, Sydney, NSW, Australia. .,Department of Gastrointestinal Surgery, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia.
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Phillips ME. Pancreatic exocrine insufficiency following pancreatic resection. Pancreatology 2015; 15:449-455. [PMID: 26145836 DOI: 10.1016/j.pan.2015.06.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 05/06/2015] [Accepted: 06/10/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Untreated pancreatic exocrine dysfunction is associated with poor quality of life and reduced survival, but is difficult to diagnose following pancreatic resection. Many factors including the extent of the surgery, the health of the residual pancreas and the type of reconstruction must be considered. Patients remain undertreated, and consequently there is much debate to whether or not pancreatic enzyme replacement therapy should be routinely prescribed following pancreatic resection. METHODS A review of the literature was undertaken to establish the incidence of PEI and factors identifying treatment. RESULTS Forty two to forty five percent of patients undergoing pancreatico-duodenectomy (PD) experience pancreatic exocrine insufficiency pre-operatively, whilst the post-operative incidence is 56-98% in PD, and 12-80% following distal and central pancreatectomy. CONCLUSIONS Routine use of pancreatic enzyme replacement should be considered at a starting dose of 50 to 75,000 units lipase with meals and 25,000 to 50,000 units with snacks in this patient group. Patients who have had a central or distal pancreatectomy should be individually assessed for pancreatic exocrine insufficiency in the post operative period, with those undergoing extensive resection most likely to experience insufficiency. Patients who fail to respond to pancreatic enzyme replacement therapy should be referred to a specialist dietitian, be advised on dose adjustment, and undergo investigation to exclude other gastro-intestinal pathology, including small bowel bacterial overgrowth and bile acid malabsorption.
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Affiliation(s)
- Mary E Phillips
- Royal Surrey County Hospital, Regional HPB Unit, Egerton Road, Guildford GU2 7XX, United Kingdom.
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Abstract
OBJECTIVE The true rate of new-onset diabetes (NODM) after distal pancreatectomy (DP) is not known. This systematic review was carried out to obtain exact percentages regarding the incidence of NODM after DP for different indications. BACKGROUND Distal pancreatectomy is the standard procedure for removal of benign or (potentially) malignant lesions from the pancreatic body or tail and increasingly used for removal of often benign lesions. It is associated with low mortality rates, though postoperative diabetes remains a serious problem. METHODS Embase, PubMed, Medline, Web of Science, the Cochrane Library, and Google Scholar were searched for articles reporting incidence of NODM after DP. Methodological quality of the included studies was assessed by means of the Newcastle-Ottawa scale for cohort studies and the Moga scale for case series. Mean weighted overall percentages of NODM after DP for different indications were calculated with 95% confidence intervals (CI) and corresponding P values. RESULTS Twenty-six studies were included, comprising 1.731 patients undergoing DP. The average cumulative incidence of NODM after DP performed for chronic pancreatitis was 39% and for benign or (potentially) malignant lesions it was 14%. Comparing the proportions of these 2 groups showed a significant difference (95% CI: 0.351-0.434 and 0.110-0.172, respectively, P < 0.000). The average percentage of insulin-dependent diabetes among patients with NODM after DP was 77%. CONCLUSIONS This review is the largest of its kind to assess the cumulative incidence of NODM after DP and shows that NODM is a frequently occurring complication, with incidence depending on the preexisting disease and follow-up time. Because NODM can affect quality of life, patients undergoing DP should be preoperatively provided with this information as specific as possible.
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Scavini M, Dugnani E, Pasquale V, Liberati D, Aleotti F, Di Terlizzi G, Petrella G, Balzano G, Piemonti L. Diabetes after pancreatic surgery: novel issues. Curr Diab Rep 2015; 15:16. [PMID: 25702096 DOI: 10.1007/s11892-015-0589-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In the developed world, pancreatic surgery is becoming more common, with an increasing number of patients developing diabetes because of either partial or total pancreatectomy, with a significant impact on quality of life and survival. Although these patients are expected to consume increasing health care resources in the near future, many aspects of diabetes after pancreatectomy are still not well defined. The treatment of diabetes in these patients takes advantage of the therapies used in type 1 and 2 diabetes; however, no specific guidelines for its management, both immediately after pancreatic surgery or in the long term, have been developed. In this article, on the basis of both the literature and our clinical experience, we address the open issues and discuss the most appropriate therapeutic options for patients with diabetes after pancreatectomy.
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Affiliation(s)
- Marina Scavini
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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Fujita Y, Kozawa J, Iwahashi H, Yoneda S, Uno S, Yoshikawa A, Okita K, Eguchi H, Nagano H, Imagawa A, Shimomura I. Increment of serum C-peptide measured by glucagon test closely correlates with human relative beta-cell area. Endocr J 2015; 62:329-37. [PMID: 25740613 DOI: 10.1507/endocrj.ej14-0456] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pancreatic beta-cell mass contributes to glucose tolerance. The aim of this study was to evaluate the relationships between human beta-cell mass and various clinical parameters, including insulin secretory capacity. The study included 32 Japanese patients who underwent pancreatectomy and were naive to oral hypoglycemic agents and insulin. They were classified into those with normal glucose tolerance (n=13), impaired glucose tolerance (n=9) and diabetes (n=10), and their insulin secretory capacity and insulin resistance were evaluated. Immunohistochemistry was used to determine relative beta-cell area (%) which represented the proportion of insulin-positive cell area to whole pancreatic section. Increment of C-peptide immunoreactivity level by glucagon test (ΔC-peptide, increment of serum C-peptide [nmol/L] at 6 min after intravenous injection of 1-mg glucagon; r=0.64, p=0.002), homeostasis model assessment of beta-cell function (HOMA-beta, fasting immunoreactive insulin [μIU/mL] x 20 / (fasting plasma glucose [mmol/L] - 3.5); r=0.50, p=0.003), C-peptide index (CPI, fasting C-peptide [nmol/L] / fasting plasma glucose [mmol/L]; r=0.36, p=0.042), and fasting immunoreactive insulin (F-IRI [pmol/L]; r=0.36, p=0.044) correlated significantly and positively with the relative beta-cell area. The area under the curve of plasma glucose level from 0 to 120 min by 75 g-OGTT (AUC0-120) also correlated significantly and inversely with the relative beta-cell area (r=-0.36, p=0.045). Stepwise multiple regression analysis identified ΔC-peptide as the only independent and significant determinant of the relative beta-cell area. We conclude that ΔC-peptide, HOMA-beta, CPI, F-IRI and AUC0-120 correlated closely with the relative beta-cell area, and ΔC-peptide was the most valuable index for the prediction of the area.
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Affiliation(s)
- Yukari Fujita
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Suita 565-0871, Japan
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Morera-Ocon FJ, Sabater-Orti L, Muñoz-Forner E, Pérez-Griera J, Ortega-Serrano J. Considerations on pancreatic exocrine function after pancreaticoduodenectomy. World J Gastrointest Oncol 2014; 6:325-329. [PMID: 25232457 PMCID: PMC4163730 DOI: 10.4251/wjgo.v6.i9.325] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 11/16/2013] [Indexed: 02/05/2023] Open
Abstract
The pancreaticoduodenectomy (PD) procedure may lead to pancreatic exocrine and endocrine insufficiency. There are several types of reconstruction for this kind of operation. Pancreaticogastrostomy (PG) was introduced to reduce the rate of postoperative pancreatic fistula. Although some randomized control trials have shown no differences regarding pancreatic leakage between PG and pancreaticojejunostomy (PJ), recently some reports reveal benefits from the PG over the PJ. Some surgeons concern about the performing of the PG and inactivation of pancreatic enzymes being in contact with the gastric juice, and the detrimental results over the exocrine pancreatic function. The pancreatic exocrine function can be measured with direct and indirect tests. Direct tests have the highest sensitivity and specificity for detection of exocrine insufficiency but require tube placement. Among the tubeless indirect tests, the van de Kamer stool fat analysis remains the standard to diagnose fat malabsorption. The patient compliance and time consuming makes it not so suitable for its clinical use. Fecal immunoreactive elastase test is employed for screening of exocrine insufficiency, is not cumbersome, and has been used to study pancreatic function after resection. We analyze the FE1 levels in our patients after the PD with two types of reconstruction, PG and PJ, and we discuss some considerations about the pancreaticointestinal drainage method after pancreaticoduodenectomy.
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Park SY, Shin WY, Choe YM, Lee KY, Ahn SI. Extended distal pancreatectomy for advanced pancreatic neck cancer. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2014; 18:77-83. [PMID: 26155255 PMCID: PMC4492328 DOI: 10.14701/kjhbps.2014.18.3.77] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/02/2014] [Accepted: 08/14/2014] [Indexed: 12/17/2022]
Abstract
Backgrounds/Aims We investigated the clinical application of extended distal pancreatectomy in patients with pancreatic neck cancer accompanied by distal pancreatic atrophy. In this study, we have emphasized on the technical aspects of using the linear stapling device for a bulky target organ. Methods From March 2010 to September 2013, 46 patients with pancreatic adenocarcinoma, who underwent pancreatic resection with radical intent at our institute, were reviewed retrospectively. Among them, three patients (6.5%) underwent extended distal pancreatectomy. A linear stapling device and vise-grip locking pliers were used for en bloc resection of the distal pancreas, first duodenal portion, and distal common bile duct. The results were compared with those after standard pancreatectomy. Results All three patients presented with jaundice, and the ratio of pancreatic duct to parenchymal thickness of the pancreatic body was greater than 0.5. Grade A pancreatic fistula developed in all of the cases, but none of these fistulae were lethal. Pathological staging was T3N1M0 in all of the patients. The postoperative daily serum glucose fluctuations and insulin requirements were comparable to those in patients who received pancreaticoduodenectomy or distal pancreatectomy. At the last follow-up, two patients were alive with liver metastasis at 4 and 10 months postoperatively, respectively, and one patient died of liver metastasis at 5 months postoperatively. Conclusions While the prognosis of advanced pancreatic neck adenocarcinoma is still dismal, extended distal pancreatectomy is a valid treatment option, especially when there is atrophy of the distal pancreas. Also, the procedure is technically feasible, and further refinement is necessary to improve patient survival.
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Affiliation(s)
- Shin-Young Park
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
| | - Woo Young Shin
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
| | - Yun-Mee Choe
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
| | - Keon-Young Lee
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
| | - Seung-Ik Ahn
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
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Ward-Boahen D, Wallace-Kazer M. Improving surgical outcomes in pancreatic surgery with preoperative nutrition. J Adv Pract Oncol 2014; 5:100-6. [PMID: 25032044 PMCID: PMC4093512 DOI: 10.6004/jadpro.2014.5.2.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The purposes of this study were (1) to describe the relationship between preoperative physical status and postoperative outcomes in patients undergoing Whipple resection, and (2) to determine if the use of specialized immunonutrition with IMPACT Advanced Recovery supplementation improved postoperative outcomes (pancreatic leak rate, length of stay, and postoperative complications) in patients undergoing Whipple resection. The trial was a case-controlled prospective pilot study that took place in an outpatient gastrointestinal surgical oncology office in an urban community hospital in the northeast United States. The study population consisted of nine patients undergoing Whipple surgery. Patients were given IMPACT Advanced Recovery supplementation 4 days prior to Whipple surgery. Prospective data were collected on all patients and then compared to national averages in terms of outcomes. Study approval was obtained from the Fairfield University Institutional Review Board (IRB), though IRB approval was not required by the study facility due to the fact that this was a pilot study. Consent was also not required for retrospective chart review. Patients with lower scores according to the American Society of Anesthesiologists Physical Status Classification System have a shorter operating time in the setting of preoperative nutrition. Patients in this study who received preoperative nutrition with IMPACT Advanced Recovery supplementation had outcomes comparable to the national average. This pilot study suggests that there is a need for a multi-institutional randomized study powered to further evaluate the effectiveness of preoperative nutrition in pancreatic surgery. The literature supports the fact that preoperative nutritional supplementation should be offered to patients undergoing Whipple surgery. Optimization of nutritional status can translate to decreased length of stay and cost savings.
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Affiliation(s)
- Dwanna Ward-Boahen
- St. Vincent's Medical Center, Bridgeport, Connecticut, and Fairfield University School of Nursing, Fairfield, Connecticut
| | - Meredith Wallace-Kazer
- St. Vincent's Medical Center, Bridgeport, Connecticut, and Fairfield University School of Nursing, Fairfield, Connecticut
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Abstract
OBJECTIVES The objectives of this study were to assess the long-term quality of life (QOL) after the resection of a primary pancreatic cyst and to determine predictors of outcome. Secondary outcomes were pancreatic function and survival. METHODS One hundred eight consecutive patients, who underwent resection between 1992 and 2007 and had nearly 60 months follow-up, were reviewed. Questionnaires and function tests were collected during scheduled outpatient clinic visits. RESULTS At follow-up, 20 patients had died. Five-year overall survival was 94% for benign and 62% for malignant neoplasia. Of 88 living patients, 65 (74%) returned questionnaires. Generic physical and mental QOL scores were equal or better compared with healthy references. None of the disease-specific symptom scales were above mean 50, implicating none to mild complaints. Independent predictors for good generic QOL were young age (P < 0.05) and resected malignancy (P < 0.05); predictors for good gastrointestinal QOL were male sex (P < 0.1), limited resection (P < 0.05), endocrine insufficiency (P < 0.05), and employment (P < 0.05). Endocrine insufficiency prevalence was 40%, and 59% for exocrine insufficiency. CONCLUSIONS After cyst resection, long-term QOL is equal to healthy references, pancreatic insufficiency is prevalent but does not impair QOL, and survival relates positive compared with solid pancreatic adenocarcinoma. The excellent long-term outcome justifies proceeding with surgery once a medical indication for resection has been established.
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Havre RF, Ødegaard S, Gilja OH, Nesje LB. Characterization of solid focal pancreatic lesions using endoscopic ultrasonography with real-time elastography. Scand J Gastroenterol 2014; 49:742-51. [PMID: 24713038 DOI: 10.3109/00365521.2014.905627] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES. The aim of this study was to evaluate the diagnostic potential of strain assessment in solid focal pancreatic lesions using real-time elastography in combination with endoscopic ultrasonography (EUS). MATERIAL AND METHODS. Forty-eight solid focal pancreatic lesions in 39 patients were included prospectively over a 3-year period and studied by EUS with real-time elastography (EUS-RTE). Lesions previously described as cystic by CT were not included. Distribution patterns of tissue strain were assessed using strain ratio (SR) measurements, continuous visual analog scale (VAS), and a visual categorical score (VCS), based on color coding of relative strain. Final diagnosis was based on histopathology, fine-needle aspiration cytology, and/or follow-up for ≥6 months. RESULTS. The 48 lesions included 11 adenocarcinomas, 7 malignant neuroendocrine tumors (NETs), 11 benign or indeterminate NETs, 8 focal pancreatic lesions, 2 microcystic adenomas, and 9 other benign lesions. Malignant lesions had significantly higher median SR (7.05 vs. 1.56) and VAS scores (93.0 vs. 63.5) than benign lesions. A receiver operation characteristic curve analysis showed sensitivity of 67% and specificity of 71%, when using SR = 4.4 as a cut-off for malignancy. The highest SR values were found in two benign microcystic adenomas. CONCLUSIONS. EUS-RTE with SR measurements and VAS evaluation demonstrated a significant strain difference between benign and malignant lesions. However, the variation within the entities was substantial and some benign lesions presented with low strain. Benign lesions were generally characterized by a strain similar to reference tissue, whereas malignant lesions were harder. The recorded strain pattern in individual lesions must be interpreted with caution.
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Affiliation(s)
- Roald Flesland Havre
- Department of Medicine, Haukeland University Hospital , Jonas Lies vei, Bergen , Norway
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Berry AJ. Pancreatic Enzyme Replacement Therapy During Pancreatic Insufficiency. Nutr Clin Pract 2014; 29:312-21. [DOI: 10.1177/0884533614527773] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Amy J. Berry
- University of Virginia Health System, Charlottesville, Virginia
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Sikkens ECM, Cahen DL, de Wit J, Looman CWN, van Eijck C, Bruno MJ. Prospective assessment of the influence of pancreatic cancer resection on exocrine pancreatic function. Br J Surg 2013; 101:109-13. [DOI: 10.1002/bjs.9342] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 12/18/2022]
Abstract
Abstract
Background
Exocrine insufficiency frequently develops in patients with pancreatic cancer owing to tumour ingrowth and pancreatic duct obstruction. Surgery might restore this function by removing the primary disease and restoring duct patency, but it may also have the opposite effect, as a result of resection of functional parenchyma and anatomical changes. This study evaluated the course of pancreatic function, before and after pancreatic resection.
Methods
This prospective cohort study included patients with tumours in the pancreatic region requiring pancreatic resection in a tertiary referral centre between March 2010 and August 2012. Starting before surgery, exocrine function was determined monthly by measuring faecal elastase 1 levels (normal value over 0·200 µg per g faeces). Endocrine function, steatorrhoea-related symptoms and bodyweight were also evaluated before and after surgery. Subjects were followed from diagnosis until 6 months after surgery, or until death.
Results
Twenty-nine patients were included, 12 with pancreatic cancer, 14 with ampullary carcinoma and three with bile duct carcinoma (median tumour size 2·6 cm). Twenty-six patients underwent pancreaticoduodenectomy and three distal pancreatectomy. Thirteen patients had exocrine insufficiency at preoperative diagnosis. After a median follow-up of 6 months, this had increased to 24 patients. Diabetes was present in seven patients at diagnosis, and developed in one additional patient within 1 month after surgery.
Conclusion
Most patients with tumours in the pancreatic region requiring pancreatic resection either had exocrine insufficiency at diagnosis or became exocrine-insufficient soon after surgical resection.
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Affiliation(s)
- E C M Sikkens
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - D L Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J de Wit
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C W N Looman
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C van Eijck
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Berry AJ. Pancreatic surgery: indications, complications, and implications for nutrition intervention. Nutr Clin Pract 2013; 28:330-57. [PMID: 23609476 DOI: 10.1177/0884533612470845] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Pancreatic surgery is a complicated procedure leaving postoperative patients with an altered gastrointestinal (GI) anatomy and a potential for further surgical complications such as leaks and fistulas. Beyond surgical complications, these patients are prone to delayed gastric emptying, fat malabsorption, and hyperglycemia, with early satiety and poor appetite further compromising nutrition status. Many of these patients are malnourished prior to this major surgical procedure, and significant weight loss is common postoperatively. Does this affect their outcome? There seems to be a lack of consensus in this patient population regarding how to optimize nutrition and limit potential deleterious effects of this surgery. It is important to first understand the underlying disease condition and the effects to the gland, different forms of surgery with subsequent GI alterations, and common surgical and digestive complications. Once this is reviewed, existing nutrition support literature will be explored in attempts to determine the best nutrition management in this patient population.
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Affiliation(s)
- Amy J Berry
- University of Virginia Health System, Surgical Nutrition Support/Nutrition Services, Charlottesville, VA 22908-0673, USA.
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Abstract
BACKGROUND Pancreatectomy affects gastrointestinal (GI) symptoms. Our purpose was to assess the quality of life of pancreatectomy patients in relation to GI function. METHODS Pancreatectomy patients were asked qualitative, open-ended questions about symptoms. They also completed the Gastrointestinal Symptom Rating Scale (GSRS) for reflux syndrome, acute pain syndrome, indigestion syndrome, diarrhoea syndrome and constipation syndrome. RESULTS A total of 52 patients participated. Of these, 69% reported an improvement and 31% reported no change in preoperative symptoms. No patients reported a worsening of symptoms. Half (50%) of the patients experienced new, different symptoms. Median GSRS scores were 0 for reflux syndrome [interquartile range (IQR): 0-1.0], 0 for acute pain syndrome (IQR: 0-1.0), 2.0 for indigestion syndrome (IQR: 1.0-4.0), 2.0 for diarrhoea syndrome (IQR: 0.5-4.5), and 0 for constipation syndrome (IQR: 0-1.0). Whipple operation patients scored higher on the reflux syndrome (0.5 vs. 0; P= 0.08) and indigestion syndrome (3.5 vs. 1.5; P= 0.06) domains. A total of 68% of Whipple operation patients experienced new symptoms, compared with 32% of patients who had undergone other types of pancreatectomy (P= 0.002). Scores of patients who had undergone surgery <2 years and >2 years earlier, respectively, did not differ. CONCLUSIONS Patients who underwent pancreatectomy frequently experienced an improvement in preoperative symptoms, but also experienced new postoperative symptoms. This was more common after Whipple operations. However, these symptoms were relatively mild in severity. These mild symptoms seem to persist over time.
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Yoshikawa A, Kozawa J, Okita K, Yoneda S, Okauchi Y, Uno S, Iwahashi H, Ohira T, Takiuchi D, Eguchi H, Takeda Y, Imagawa A, Shimomura I. Preoperative insulin secretion ability and pancreatic parenchymal thickness as useful parameters for predicting postoperative insulin secretion in patients undergoing pancreaticoduodenectomy. Endocr J 2012; 59:383-92. [PMID: 22374239 DOI: 10.1507/endocrj.ej11-0322] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Periampullary malignant neoplasms have been increasing in Japan, mainly in response to an increase in the incidences of pancreatic cancer, and glucose intolerance due to deterioration of insulin secretion is an important problem. We investigated preoperative parameters to predict postoperative insulin secretion and the need for insulin therapy in patients undergoing pancreaticoduodenectomy (PD). Thirty-six patients with malignant neoplasms of periampullary lesions were enrolled. Preoperative pancreatic parenchymal thickness was evaluated by computed tomography. Insulin secretion and glucose tolerance were evaluated by a 75-g oral glucose tolerance test and an intravenous glucagon loading test. The relationships between postoperative insulin secretion and preoperative parameters and the cut-off values for predicting the need for postoperative insulin therapy for glycemic control were investigated. Pancreatic parenchymal thickness and other preoperative parameters, including the increment of serum C-peptide (Δ C-peptide), fasting plasma C-peptide (F-CPR), insulinogenic index (I.I.) and fasting plasma glucose (FPG), were significantly associated with postoperative insulin secretion. Multiple regression analyses revealed that preoperative Δ C-peptide or F-CPR was the most significant determinant of postoperative insulin secretion, followed by pancreatic parenchymal thickness. In the receiver operating characteristic curve, the best preoperative cut-off values for predicting the need for postoperative insulin therapy were a Δ C-peptide of 0.65 ng/mL, a F-CPR of 0.85 ng/mL and a pancreatic parenchymal thickness of 6.0 mm. Both preoperative insulin secretion and pancreatic parenchymal thickness effectively predict postoperative insulin secretion and identify subjects who need postoperative insulin therapy for glycemic control.
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Affiliation(s)
- Atsushi Yoshikawa
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Suita 565-0871, Japan
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Pandey D, Aiyer HM, Pandey R. Diabetes Cured by Pancreaticoduodenectomy: A Case Report of Glucagonoma Masquerading as Carcinoma of the Head of Pancreas. J Gastrointest Cancer 2011; 43 Suppl 1:S114-6. [PMID: 22086709 DOI: 10.1007/s12029-011-9343-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Affiliation(s)
- Durgatosh Pandey
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India.
| | | | - Rambha Pandey
- Department of Radiation Oncology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India
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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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Song SC, Choi SH, Choi DW, Heo JS, Kim WS, Kim MJ. Potential risk factors for nonalcoholic steatohepatitis related to pancreatic secretions following pancreaticoduodenectomy. World J Gastroenterol 2011; 17:3716-23. [PMID: 21990953 PMCID: PMC3181457 DOI: 10.3748/wjg.v17.i32.3716] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 04/16/2011] [Accepted: 04/23/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify risk factors for nonalcoholic steatohepatitis following pancreaticoduodenectomy, with a focus on factors related to pancreatic secretions.
METHODS: The medical records of 228 patients who had a pancreaticoduodenectomy over a 16-mo period were reviewed retrospectively. The 193 patients who did not have fatty liver disease preoperatively were included in the final analysis. Hepatic steatosis was diagnosed using the differences between splenic and hepatic attenuation and liver-to-spleen attenuation as measured by non-enhanced computed tomography.
RESULTS: Fifteen patients (7.8%) who showed postoperative hepatic fatty changes were assigned to Group A, and the remaining patients were assigned to Group B. Patient demographics, preoperative laboratory findings (including levels of C-peptide, glucagon, insulin and glucose tolerance test results), operation types, and final pathological findings did not differ significantly between the two groups; however, the frequency of pancreatic fistula (P = 0.020) and the method of pancreatic duct stenting (P = 0.005) showed significant differences between the groups. A multivariate analysis identified pancreatic fistula (HR = 3.332, P = 0.037) and external pancreatic duct stenting (HR = 4.530, P = 0.017) as independent risk factors for the development of postoperative steatohepatitis.
CONCLUSION: Pancreatic fistula and external pancreatic duct stenting were identified as independent risk factors for the development of steatohepatitis following pancreaticoduodenectomy.
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Abstract
OBJECTIVE The objective of the study was to evaluate clinical features and quality of life (QoL) in a 2-year follow-up study in subjects who underwent pancreatic head resection (PHR). METHODS One hundred ninety-seven patients with benign and malignant diseases who underwent PHR were studied. A dedicated clinical form and the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire C-30 were administered at evaluation times (immediately before surgery and 6, 12, 18, and 24 months after discharge). A sample of 197 sex- and age-matched norms was also included into the study as reference group. RESULTS Of the 197 patients studied, 164 (83.2%) had malignant disease, and 33 had benign disease (16.8%). At initial evaluation, global health was significantly lower (P = 0.001) in the study population as compared with the norms. At the end of the study, the QoL was not significantly different from the norms, although the QoL of the 30 patients with benign disease was significantly better than that of the 72 patients with malignant disease. CONCLUSIONS The QoL before PHR was impaired in study patients before resection as compared with the normative population, whereas in patients who survived resection, it significantly improved in the 24 months after surgery.
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Szafranska-Schwarzbach AE, Adai AT, Lee LS, Conwell DL, Andruss BF. Development of a miRNA-based diagnostic assay for pancreatic ductal adenocarcinoma. Expert Rev Mol Diagn 2011; 11:249-57. [PMID: 21463235 DOI: 10.1586/erm.11.10] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diagnosis of pancreatic cancer remains a clinical challenge. Both chronic pancreatitis and pancreatic cancer may present with similar symptoms and similar imaging features, often leading to incorrect interpretation. Thus, the use of an objective molecular test that can discriminate between chronic pancreatitis and pancreatic cancer will be a valuable asset in obtaining a definitive diagnosis of pancreatic cancer. Following Clinical Laboratory Improvement Amendments and College of American Pathologists guidelines, Asuragen Clinical Services Laboratory has developed and validated a laboratory-developed test, miRInform(®) Pancreas, to aid in the identification of pancreatic ductal adenocarcinoma. This molecular diagnostic tool uses reverse-transcription quantitative PCR to measure the expression difference between two miRNAs, miR-196a and miR-217, in fixed tissue specimens. This article describes the test validation process as well as determination of performance parameters of miRInform Pancreas.
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