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Biesel EA, Kuesters S, Chikhladze S, Ruess DA, Hipp J, Hopt UT, Fichtner-Feigl S, Wittel UA. Surgical complications requiring late surgical revisions after pancreatoduodenectomy increase postoperative morbidity and mortality. Scand J Surg 2024; 113:88-97. [PMID: 37962167 DOI: 10.1177/14574969231206132] [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] [Indexed: 11/15/2023]
Abstract
BACKGROUND Pancreatoduodenectomies are complex surgical procedures with considerable postoperative morbidity and mortality. Here, we describe complications and outcomes in patients requiring surgical revisions following pancreatoduodenectomy. METHODS A total of 1048 patients undergoing a pancreatoduodenectomy at our institution between 2002 and 2019 were analyzed retrospectively. All patients with surgical revisions were included. Revisions were divided into early and late using a cut-off of 5 days after the first surgery. Statistical significance was examined by using chi-square tests and Fisher's exact tests. Survival analysis was performed using Kaplan-Meier curves and log-rank tests. RESULTS A total of 150 patients with at least 1 surgical revision after pancreatoduodenectomy were included. Notably, 64 patients had a revision during the first 5 days and were classified as early revision. Compared with the 86 patients with late revisions, we found no differences concerning wound infections, delayed gastric emptying, or acute kidney failure. After late revisions, we found significantly more cases of sepsis (31.4% late versus 15.6% early, p = 0.020) and reintubation due to respiratory failure (33.7% versus 18.8%, p = 0.031). Postoperative mortality was significantly higher within the late revision group (23.2% versus 9.4%, p = 0.030). CONCLUSION Arising complications after pancreatoduodenectomy should be addressed as early as possible as patients requiring late surgical revisions frequently developed septic complications and multiorgan failure.
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Affiliation(s)
- Esther A Biesel
- Department of General and Visceral Surgery University Medical Center FreiburgUniversity of FreiburgHugstetter Str. 55 D-79106 Freiburg Germany
| | - Simon Kuesters
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Sophia Chikhladze
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Dietrich A Ruess
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Julian Hipp
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Ulrich T Hopt
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Uwe A Wittel
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
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Cioltean CL, Bartoș A, Muntean L, Brânzilă S, Iancu I, Pojoga C, Breazu C, Cornel I. The Learning Curve for Pancreaticoduodenectomy: The Experience of a Single Surgeon. Life (Basel) 2024; 14:549. [PMID: 38792572 PMCID: PMC11122127 DOI: 10.3390/life14050549] [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: 03/24/2024] [Revised: 04/18/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND AND AIMS Pancreaticoduodenectomy (PD) is a complex and high-skill demanding procedure often associated with significant morbidity and mortality. However, the results have improved over the past two decades. However, there is a paucity of research concerning the learning curve for PD. Our aim was to report the outcomes of 100 consecutive PDs representing a single surgeon's learning curve and to depict the factors that influenced the learning process. METHODS We reviewed the first 121 PDs performed at our academic center (2013-2019) by a single surgeon; 110 were PDs (5 laparoscopic and 105 open) and 11 were total PDs (1 laparoscopic and 10 open). Subsequent statistics was performed on the first 100 PDs, with attention paid to the learning curve and survival rate at 5 years. The data were analyzed comparing the first 50 cases (Group 1) to the last 50 cases (Group 2). RESULTS The most frequent histopathological tumor type was pancreatic ductal adenocarcinoma (50%). A total of 39% of patients had preoperative biliary drainage and 45% presented with positive biliary cultures. The preferred reconstruction technique included pancreaticogastrostomy (99%), in situ hepaticojejunostomy (70%), and precolic gastro-jejunal anastomosis (88%). Postoperative complications included biliary fistula (1%), pancreatic fistula (8%), pancreatic stump bleeding (4%), and delayed gastric emptying (13%). The mean operative time decreased after the first 50 cases (p < 0.001) and blood loss after 60 cases (p = 0.046). R1 resections lowered after 25 cases (p = 0.025). Vascular resections (17%) did not influence the rate of complications (p = 0.8). The survival rate at 5 years for pancreatic adenocarcinoma was 32.93%. CONCLUSIONS Outcomes improve as surgeon experience increases, with proper training being the most important factor for minimizing the impact of the learning curve over the postoperative complications. Analyzing the learning curve from the perspective of a single surgeon is mandatory for accurate statistical results and interpretation.
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Affiliation(s)
- Cristian Liviu Cioltean
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania; (C.L.C.); (I.C.)
- Department of Surgery, Satu Mare County Emergency Hospital, 440192 Satu Mare, Romania
| | - Adrian Bartoș
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania; (C.L.C.); (I.C.)
- Department of Surgery, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
- Medicover Hospital, 407062 Cluj-Napoca, Romania; (S.B.); (I.I.)
| | - Lidia Muntean
- Department of Gastroenterology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Sandu Brânzilă
- Medicover Hospital, 407062 Cluj-Napoca, Romania; (S.B.); (I.I.)
| | - Ioana Iancu
- Medicover Hospital, 407062 Cluj-Napoca, Romania; (S.B.); (I.I.)
| | - Cristina Pojoga
- Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
- Department of Clinical Psychology and Psychotherapy, Babeș-Bolyai University (UBB Med), 400015 Cluj-Napoca, Romania
| | - Caius Breazu
- Department of ICU, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Department of ICU, Cluj-Napoca County Emergency Hospital, 400006 Cluj-Napoca, Romania
| | - Iancu Cornel
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania; (C.L.C.); (I.C.)
- Department of Surgery, Satu Mare County Emergency Hospital, 440192 Satu Mare, Romania
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Hofland J, Refardt JC, Feelders RA, Christ E, de Herder WW. Approach to the Patient: Insulinoma. J Clin Endocrinol Metab 2024; 109:1109-1118. [PMID: 37925662 PMCID: PMC10940262 DOI: 10.1210/clinem/dgad641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/02/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
Insulinomas are hormone-producing pancreatic neuroendocrine neoplasms with an estimated incidence of 1 to 4 cases per million per year. Extrapancreatic insulinomas are extremely rare. Most insulinomas present with the Whipple triad: (1) symptoms, signs, or both consistent with hypoglycemia; (2) a low plasma glucose measured at the time of the symptoms and signs; and (3) relief of symptoms and signs when the glucose is raised to normal. Nonmetastatic insulinomas are nowadays referred to as "indolent" and metastatic insulinomas as "aggressive." The 5-year survival of patients with an indolent insulinoma has been reported to be 94% to 100%; for patients with an aggressive insulinoma, this amounts to 24% to 67%. Five percent to 10% of insulinomas are associated with the multiple endocrine neoplasia type 1 syndrome. Localization of the insulinoma and exclusion or confirmation of metastatic disease by computed tomography is followed by endoscopic ultrasound or magnetic resonance imaging for indolent, localized insulinomas. Glucagon-like peptide 1 receptor positron emission tomography/computed tomography or positron emission tomography/magnetic resonance imaging is a highly sensitive localization technique for seemingly occult, indolent, localized insulinomas. Supportive measures and somatostatin receptor ligands can be used for to control hypoglycemia. For single solitary insulinomas, curative surgical excision remains the treatment of choice. In aggressive malignant cases, debulking procedures, somatostatin receptor ligands, peptide receptor radionuclide therapy, everolimus, sunitinib, and cytotoxic chemotherapy can be valuable options.
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Affiliation(s)
- Johannes Hofland
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
| | - Julie C Refardt
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
- ENETS Center of Excellence, Division of Endocrinology, Diabetology and Metabolism, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Richard A Feelders
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
| | - Emanuel Christ
- ENETS Center of Excellence, Division of Endocrinology, Diabetology and Metabolism, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Wouter W de Herder
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
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Lee JH, Shin J, Min JH, Jeong WK, Kim H, Choi SY, Lee J, Hong S, Kim K. Preoperative prediction of early recurrence in resectable pancreatic cancer integrating clinical, radiologic, and CT radiomics features. Cancer Imaging 2024; 24:6. [PMID: 38191489 PMCID: PMC10775464 DOI: 10.1186/s40644-024-00653-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/29/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES To use clinical, radiographic, and CT radiomics features to develop and validate a preoperative prediction model for the early recurrence of pancreatic cancer. METHODS We retrospectively analyzed 190 patients (150 and 40 in the development and test cohort from different centers) with pancreatic cancer who underwent pancreatectomy between January 2018 and June 2021. Radiomics, clinical-radiologic (CR), and clinical-radiologic-radiomics (CRR) models were developed for the prediction of recurrence within 12 months after surgery. Performance was evaluated using the area under the curve (AUC), Brier score, sensitivity, and specificity. RESULTS Early recurrence occurred in 36.7% and 42.5% of the development and test cohorts, respectively (P = 0.62). The features for the CR model included carbohydrate antigen 19-9 > 500 U/mL (odds ratio [OR], 3.60; P = 0.01), abutment to the portal and/or superior mesenteric vein (OR, 2.54; P = 0.054), and adjacent organ invasion (OR, 2.91; P = 0.03). The CRR model demonstrated significantly higher AUCs than the radiomics model in the internal (0.77 vs. 0.73; P = 0.048) and external (0.83 vs. 0.69; P = 0.038) validations. Although we found no significant difference between AUCs of the CR and CRR models (0.83 vs. 0.76; P = 0.17), CRR models showed more balanced sensitivity and specificity (0.65 and 0.87) than CR model (0.41 and 0.91) in the test cohort. CONCLUSIONS The CRR model outperformed the radiomics and CR models in predicting the early recurrence of pancreatic cancer, providing valuable information for risk stratification and treatment guidance.
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Affiliation(s)
- Jeong Hyun Lee
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jaeseung Shin
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Ji Hye Min
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Honsoul Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Seo-Youn Choi
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Jisun Lee
- Department of Radiology, College of Medicine, Chungbuk National University, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Sungjun Hong
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Kyunga Kim
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
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Malhotra P, Palanisamy R, Caparros-Martin JA, Falasca M. Bile Acids and Microbiota Interplay in Pancreatic Cancer. Cancers (Basel) 2023; 15:3573. [PMID: 37509236 PMCID: PMC10377396 DOI: 10.3390/cancers15143573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
Evidence suggests the involvement of the microbiota, including oral, intra-tumoral and gut, in pancreatic cancer progression and response to therapy. The gut microbiota modulates the bile acid pool and is associated with maintaining host physiology. Studies have shown that the bile acid/gut microbiota axis is dysregulated in pancreatic cancer. Bile acid receptor expression and bile acid levels are dysregulated in pancreatic cancer as well. Studies have also shown that bile acids can cause pancreatic cell injury and facilitate cancer cell proliferation. The microbiota and its metabolites, including bile acids, are also altered in other conditions considered risk factors for pancreatic cancer development and can alter responses to chemotherapeutic treatments, thus affecting patient outcomes. Altogether, these findings suggest that the gut microbial and/or bile acid profiles could also serve as biomarkers for pancreatic cancer detection. This review will discuss the current knowledge on the interaction between gut microbiota interaction and bile acid metabolism in pancreatic cancer.
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Affiliation(s)
- Pratibha Malhotra
- Metabolic Signalling Group, Curtin Health Innovation Research Institute, Curtin Medical School, Curtin University, Perth, WA 6102, Australia
| | - Ranjith Palanisamy
- Metabolic Signalling Group, Curtin Health Innovation Research Institute, Curtin Medical School, Curtin University, Perth, WA 6102, Australia
| | | | - Marco Falasca
- Metabolic Signalling Group, Curtin Health Innovation Research Institute, Curtin Medical School, Curtin University, Perth, WA 6102, Australia
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Pancreaticoduodenectomy After Liver Transplantation: A Single-Center Experience. World J Surg 2023; 47:1018-1022. [PMID: 36637476 DOI: 10.1007/s00268-022-06887-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND The aim of this study is to report the feasibility and short-term outcomes of pancreaticoduodenectomy (PD) in patients who have undergone orthotopic liver transplantation (OLT). METHODS We performed a retrospective review of a prospectively maintained pancreatic surgical database for all patients undergoing pancreaticoduodenectomy (PD) after liver transplant from January 1995 until June 2022. Demographics, indications for pancreatic resection, liver transplant and time from liver transplant to PD were reported. Operative mortality and morbidity were recorded within 90 days of surgery. Continuous variables were recorded as mean and range, while categorical variables were summarized using frequency and percentage. Postoperative complications within 90 days from PD were graded based on Clavien-Dindo classification with major complication recorded as grade IIIa or higher. Additionally, a comprehensive literature review was performed. RESULTS A total of 916 patients who underwent PD at our institution between January 1995 and June 2022 were identified, and 9 patients had previous OLT. Five patients were females and 4 males with a mean age of 65 years (range 51-78). Average body mass index (BMI) was 30.8. Two patients had major complications, and three patients had minor complications. No clinically relevant POPF, PPH or DGE were observed. One patient died within 90 days from PD due to ischemic biliary pancreatic limb causing intrabdominal sepsis. CONCLUSION Although uncommon, PD after OLT is feasible with acceptable outcomes at high volume institutions and if performed by experienced surgeons.
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Aghalarov I, Beyer E, Niescery J, Belyaev O, Uhl W, Herzog T. Outcome of combined pancreatic and biliary fistulas after pancreatoduodenectomy. HPB (Oxford) 2023:S1365-182X(23)00051-5. [PMID: 36842945 DOI: 10.1016/j.hpb.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/22/2023] [Accepted: 02/13/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) as well as postoperative biliary fistula (POBF) are considered the main source of postoperative morbidity and mortality after pancreatoduodenectomy (PD). However, little is known about the incidence and complications of combined POPF/POBF compared to isolated POPF or POBF. METHODS This single-center study investigated retrospectively the incidence and postoperative outcome of combined POPF/POBF compared to isolated fistulas following PD in a tertiary German pancreatic center between 2009 and 2018. RESULTS A total of 678 patients underwent PD for benign and malignant periampullary lesions. Combined fistulas occurred in 6%, isolated POPF in 16%, and isolated POBF in 2%. Pancreatic ductal adenocarcinoma and chronic pancreatitis had a protective effect on the occurrence of combined fistulas, whereas serous cystadenoma and pancreatic metastasis were risk factors. Morbidity (Grade C fistula, post-pancreatectomy hemorrhage, revisional surgery) and mortality was significantly higher in patients with combined fistulas than in those with isolated fistula. Moreover, the duration of ICU stay was longer. CONCLUSIONS A combined POPF/POBF is associated with a significant increase of morbidity and mortality compared to isolated fistulas after PD. Early surgical revision in these patients may improve the postoperative survival rate.
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Affiliation(s)
- Ilgar Aghalarov
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Germany.
| | - Elisabeth Beyer
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Jennifer Niescery
- Department of Anesthesiology, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Orlin Belyaev
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Waldemar Uhl
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Torsten Herzog
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
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Hyman DW, Almerey T, Mujkanovic A, Hammons I, Tice M, Stauffer JA. Comparing Post-Operative Outcomes of Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: Neoadjuvant Therapy Versus Surgery First Approach. Am Surg 2022; 88:1868-1874. [PMID: 35465681 DOI: 10.1177/00031348221087900] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Optimal use of surgery first (SF) vs neoadjuvant therapy (NAT) for localized pancreatic ductal adenocarcinoma (PDAC) is still unclear. There is concern that NAT may result in worsened post-operative outcomes. Our study objectives were to show the impact of NAT on post-operative morbidity and mortality. METHODS All patients undergoing resection for PDAC between 1/1/2010 and 12/31/2020 were reviewed and those who underwent pancreaticoduodenectomy (PD) were included. Demographics, perioperative details, and pathology details were gathered. Data pertaining to 90-day complications were obtained and graded according to international consensus guidelines. Those undergoing SF were compared to those who had NAT. Categorical variables were compared by Fisher's exact test and continuous variables by Student's t-test. RESULTS Two hundred and forty-one subjects who underwent PD for PDAC were included in this review. There was no significant difference in the rate of major morbidity between subjects who received NAT vs SF (19.4 vs 20.3%, P = 1.0). Similarly, there were no significant differences in the rates of mortality (3.1 vs 4.2%, P = .742), post-operative pancreatic fistula (8.2 vs 10.5%, P = .658), or post-pancreatectomy hemorrhage (7.1 vs 7.7%, P = 1.0), respectively. CONCLUSION Post-operative outcomes are not worsened by the use of the NAT approach prior to PD for PDAC. Further investigation is needed to reveal which patient subgroups may benefit from the use of NAT, especially regarding survival.
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Affiliation(s)
- David W Hyman
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Tariq Almerey
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Amer Mujkanovic
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Isaac Hammons
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Mary Tice
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - John A Stauffer
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
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Clancy TE, Baker EH, Maegawa FA, Raoof M, Winslow E, House MG. AHPBA guidelines for managing VTE prophylaxis and anticoagulation for pancreatic surgery. HPB (Oxford) 2022; 24:575-585. [PMID: 35063354 DOI: 10.1016/j.hpb.2021.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Major abdominal surgery and malignancy lead to a hypercoagulable state, with a risk of venous thromboembolism (VTE) of approximately 3% after pancreatic surgery. No guidelines exist to assist surgeons in managing VTE prophylaxis or anticoagulation in patients undergoing elective pancreatic surgery for malignancy or premalignant lesions. A systematic review specific to VTE prophylaxis and anticoagulation after resectional pancreatic surgery is herein provided. METHODS Six topic areas are reviewed: pre- and perioperative VTE prophylaxis, early postoperative VTE prophylaxis, extended outpatient VTE prophylaxis, management of chronic anticoagulation, anti-coagulation after vascular reconstruction, and treatment of VTE. A Medline and PubMED search was completed with systematic medical literature review for each topic. Level of evidence was graded and strength of recommendation ranked according to the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system for practice guidelines. RESULTS Levels of evidence and strength of recommendations are presented. DISCUSSION While strong data exist to guide management of chronic anticoagulation and treatment of VTE, data for anticoagulation after reconstruction is inconclusive and support for perioperative chemoprophylaxis with pancreatic surgery is similarly limited. The risk of post-pancreatectomy hemorrhage often exceeds that of thrombosis. The role of universal chemoprophylaxis must therefore be examined critically, particularly in the preoperative setting.
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10
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Vilhav C, Fagman JB, Holmberg E, Naredi P, Engström C. C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage. Langenbecks Arch Surg 2022; 407:1949-1959. [PMID: 35306601 PMCID: PMC9399186 DOI: 10.1007/s00423-022-02440-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 01/13/2022] [Indexed: 11/29/2022]
Abstract
Background Postpancreatectomy hemorrhage grade C (PPH C) is a dreaded complication after pancreaticoduodenectomy (PD) with high mortality rate. Concurrent risk factors for PPH C have been difficult to recognize. Connection between postoperative pancreatic fistulas (POPF) and PPH C is well known, but POPF is often unknown prior to the PPH. The aim of this retrospective study was to define potential predictive factors for PPH C. Methods Retrospectively, 517 patients who underwent PD between 2003 and 2018 were included in the study. Twenty-three patients with PPH C were identified, and a matched control group of 92 patients was randomly selected. Preoperative data (body mass index, cardiovascular disease, history of abdominal surgery, biliary stent, C-reactive protein (CRP), ASA-score), perioperative data (bleeding, pancreatic anastomosis, operation time), and postoperative data (CRP, drain amylase, POPF, biliary fistula) were analyzed as potential predictors of PPH C. Results High postoperative CRP (median 140 mg/L on day 5 or 6) correlated with the development of PPH C (p < 0.05). Postoperative drain amylase levels were not clinically relevant for occurrence of PPH C. Grade C POPF or biliary leak was observed in the majority of the PPH C patients, but the leaking anastomoses were not detected before the bleeding started. Discussion High postoperative CRP levels are related to an increased risk of PPH C.
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Affiliation(s)
- C Vilhav
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - J B Fagman
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - E Holmberg
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - P Naredi
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - C Engström
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Cao Z, Qiu J, Guo J, Xiong G, Jiang K, Zheng S, Kuang T, Wang Y, Zhang T, Sun B, Qin R, Chen R, Miao Y, Lou W, Zhao Y. A randomised, multicentre trial of somatostatin to prevent clinically relevant postoperative pancreatic fistula in intermediate-risk patients after pancreaticoduodenectomy. J Gastroenterol 2021; 56:938-948. [PMID: 34453212 DOI: 10.1007/s00535-021-01818-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/11/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Prophylactic somatostatin to reduce the incidence of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy remains controversial. We assessed the preventive efficacy of somatostatin on clinically relevant postoperative pancreatic fistula in intermediate-risk patients who underwent pancreaticoduodenectomy at pancreatic centres in China. METHODS In this multicentre, prospective, randomised controlled trial, we used the updated postoperative pancreatic fistula classification criteria and cases were confirmed by an independent data monitoring committee to improve comparability between centres. The primary endpoint was the rate of clinically relevant postoperative pancreatic fistula within 30 days after pancreaticoduodenectomy. RESULTS Eligible patients (randomised, n = 205; final analysis, n = 199) were randomised to receive postoperative intravenous somatostatin (250 μg/h over 120 h; n = 99) or conventional therapy (n = 100). The primary endpoint was significantly lower in the somatostatin vs control group (n = 13 vs n = 25; 13% vs 25%, P = 0.032). There were no significant differences for biochemical leak (P = 0.289), biliary fistula (P = 0.986), abdominal infection (P = 0.829), chylous fistula (P = 0.748), late postoperative haemorrhage (P = 0.237), mean length of hospital stay (P = 0.512), medical costs (P = 0.917), reoperation rate (P > 0.99), or 30 days' readmission rate (P = 0.361). The somatostatin group had a higher rate of delayed gastric emptying vs control (n = 33 vs n = 21; 33% vs 21%, P = 0.050). CONCLUSIONS Prophylactic somatostatin treatment reduced clinically relevant postoperative pancreatic fistula in intermediate-risk patients after pancreaticoduodenectomy. TRIAL REGISTRATION NCT03349424.
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Affiliation(s)
- Zhe Cao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiangdong Qiu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junchao Guo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guangbing Xiong
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei, China
| | - Kuirong Jiang
- Department of General Surgery, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Shangyou Zheng
- Department of Hepato-Pancreato-Biliary Surgery, Sun Yat-Sen Memorial Hospital, Guangdong, China
- Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong, China
| | - Tiantao Kuang
- Department of Pancreatic Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
| | - Yongwei Wang
- Department of Pancreatic and Biliary Surgery, Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Heilongjiang, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Heilongjiang, China
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei, China
| | - Rufu Chen
- Department of Hepato-Pancreato-Biliary Surgery, Sun Yat-Sen Memorial Hospital, Guangdong, China
- Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong, China
| | - Yi Miao
- Department of General Surgery, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Wenhui Lou
- Department of Pancreatic Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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12
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Postoperative Outcome of Surgery with Pancreatic Resection for Retroperitoneal Soft Tissue Sarcoma: Results of a Retrospective Bicentric Analysis on 50 Consecutive Patients. J Gastrointest Surg 2021; 25:2299-2306. [PMID: 33236323 DOI: 10.1007/s11605-020-04882-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/12/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUNDS Multivisceral resection is the standard treatment for retroperitoneal sarcoma (RPS) during which pancreas resection may be necessary. METHODS All consecutive patients operated for RPS with pancreatectomy in 2 expert centers between 1993 and 2018 were retrospectively analyzed. RESULTS Fifty patients (median age: 57 years, IQR: [46-65]) with a primary (n = 33) or recurrent (n = 17) RPS underwent surgery requiring pancreas resection (distal pancreatectomy (DP) (n = 43), pancreaticoduodenectomy (PD) (n = 5), central pancreatectomy (n = 1), and atypical resection (n = 1)). Severe postoperative morbidity (Clavien-Dindo III-IV) was observed in 14 patients (28%), and 7 of them (14%) required reoperation for anastomotic bowel leakage (n = 5), gastric volvulus (n = 1), or hemorrhage (n = 1). Pancreas-related complications occurred in 25 patients (50%): 10 postoperative pancreatic fistulas (POPF) (grade A (n = 12), grade B (n = 6), grade C (n = 1)), 13 delayed gastric emptying (grade A (n = 8), grade B (n = 4), grade C (n = 1)), 1 hemorrhage (grade C). Postoperative mortality was 4% (n = 2), all following PD, caused by a massive intraoperative air embolism and by a multiple organ failure after anastomotic leakage. Pathological analysis confirmed pancreatic involvement in 17 (34%) specimens. Microscopically complete resection (R0) was achieved in 22 (44%) patients. After a follow-up of 60 months, 36 patients (75%) were still alive, among whom 27 without recurrence (56%). CONCLUSION Pancreatic resection during RPS surgery is associated with significant postoperative morbidity and mortality. PD should be avoided whenever possible while other procedures seemed achievable without excessive morbidity and with long-term survival.
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13
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Yu Q, Jobin C, Thomas RM. Implications of the microbiome in the development and treatment of pancreatic cancer: Thinking outside of the box by looking inside the gut. Neoplasia 2021; 23:246-256. [PMID: 33418277 PMCID: PMC7804346 DOI: 10.1016/j.neo.2020.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 12/19/2022]
Abstract
Pancreatic ductal adenocarcinoma is the third leading cause of cancer-related death in the United States. As one of the most lethal cancer types, the prognosis for patients diagnosed with pancreatic cancer remains dismal and novel investigations are urgently needed. Evidence for an association of microbes with pancreatic cancer risk, development, treatment response, and post-treatment survivorship is rapidly developing. Herein, we provide an overview on the role of the microbiome as it relates to the natural history of pancreatic cancer, including host immune interactions, alterations in metabolism, direct carcinogenic effect, and its role in treatment response.
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Affiliation(s)
- Qin Yu
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christian Jobin
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA; Department of Infectious Diseases and Immunology, University of Florida College of Medicine, Gainesville, FL, USA; Department of Anatomy and Cell Biology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Ryan M Thomas
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA; Department of Molecular Genetics and Microbiology, University of Florida College of Medicine, Gainesville, FL, USA.
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14
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Shao Y, Feng J, Jiang Y, Hu Z, Wu J, Zhang M, Shen Y, Zheng S. Feasibility of mesentericoportal vein reconstruction by autologous falciform ligament during pancreaticoduodenectomy-cohort study. BMC Surg 2021; 21:4. [PMID: 33397346 PMCID: PMC7783990 DOI: 10.1186/s12893-020-01019-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 12/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mesentericoportal vein (MPV) resection in pancreatic ductal adenocarcinoma (PDAC) surgery has become a common procedure. A few studies had described the use of falciform ligament (FL) for MPV reconstruction and received encouraging preliminary effects. AIMS This study was designed to explore the feasibility and efficacy of this technique compared with others. METHODS Patients who underwent pancreaticoduodenectomy (PD) with MPV resection for PDAC from 2009 to 2018 were enrolled. Medical records were retrospectively reviewed, MPV reconstructions using FL were distinguished and compared with other techniques. RESULTS 146 patients underwent MPV reconstruction, and 13 received FL venoplasty. Other reconstruction techniques included primary end-to-end anastomosis (primary, n = 30), lateral venorrhaphy (LV, n = 19), polytetrafluoroethylene conduit interposition (PTFE, n = 24), iliac artery (IA) allografts interposition (n = 47), and portal vein (PV) allografts interposition (n = 13). FL group holds the advantages of shortest operation time (p = 0.023), lowest blood loss (p = 0.109), and shortest postoperative hospital stay (p = 0.125). The grouped patency rates of FL, primary, LV, PTFE, IA, and PV were 100%, 90%, 68%, 54%, 68%, and 85% respectively. Comparison displayed that FL had the highest patency rate (p = 0.008) and lowest antiplatelet/anticoagulation proportion (p = 0.000). Complications and long-term survival were similar among different techniques. The median survival time of patent group (24.0 months, 95% CI: 22.0-26.0) was much longer than that of the thrombosed (17.0 months, 95% CI: 13.7-20.3), though without significant difference (P = 0.148). CONCLUSIONS PD with MPV resection and reconstruction by FL is safe, feasible, and efficacious, it might provide a potential benefit for patients.
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Affiliation(s)
- Yi Shao
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Jiaojiao Feng
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, 310006, China
| | - Yuancong Jiang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Zhenhua Hu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Jian Wu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Min Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Yan Shen
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China. .,Key Laboratory of Organ Transplantation, Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, No. 79 QingChun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.
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15
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Tarvainen T, Sirén J, Kokkola A, Sallinen V. Effect of Hydrocortisone vs Pasireotide on Pancreatic Surgery Complications in Patients With High Risk of Pancreatic Fistula: A Randomized Clinical Trial. JAMA Surg 2020; 155:291-298. [PMID: 32022887 PMCID: PMC7042940 DOI: 10.1001/jamasurg.2019.6019] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Question Is hydrocortisone noninferior compared with pasireotide in reducing pancreatic surgery complications? Findings In this randomized clinical trial that included 126 patients undergoing partial pancreatectomy, the mean Comprehensive Complication Index score (a measurement of overall postoperative morbidity) was –6.16 points lower in patients receiving pasireotide and the lower limit of the 90% CI crossed the prespecified noninferiority margin (–9). In subgroup analyses of patients undergoing distal pancreatectomy, the mean Comprehensive Complication Index score was significantly lower (10.3 points) in the pasireotide vs hydrocortisone group. Meaning In this study, hydrocortisone is not noninferior compared with pasireotide, and pasireotide may be more effective in reducing postoperative complications in patients undergoing distal pancreatectomy. Importance Both hydrocortisone and pasireotide have been shown in randomized clinical trials to be effective in reducing postoperative complications of pancreatic surgery, but to date no randomized clinical trial has evaluated the effectiveness of pasireotide compared with hydrocortisone. Objective To assess the noninferiority of hydrocortisone compared with pasireotide in reducing complications after partial pancreatectomy. Design, Setting, and Participants A noninferiority, parallel-group, individually randomized clinical trial was conducted at a single academic center between May 19, 2016, and December 17, 2018. Outcome collectors and analyzers were blinded. A total of 281 patients undergoing partial pancreatectomy were assessed for inclusion. Patients younger than 18 years, those allergic to hydrocortisone or pasireotide, patients undergoing pancreaticoduodenectomy with hard pancreas or dilated pancreatic duct, and patients not eventually undergoing partial pancreatectomy were excluded. Modified intention-to-treat analysis was used in determination of the results. Interventions Treatment included pasireotide, 900 μg, subcutaneously twice a day for 7 days or hydrocortisone, 100 mg, intravenously 3 times a day for 3 days. Main Outcomes and Measures The primary outcome was the Comprehensive Complication Index (CCI) score within 30 days. The noninferiority limit was set to 9 CCI points. Results Of the 281 patients (mean [SD] age, 63.8 years) assessed for eligibility, 168 patients (mean [SD] age, 63.6 years) were randomized and 126 were included in the modified intention-to-treat analyses. Sixty-three patients received pasireotide (35 men [56%]; median [interquartile range] age, 64 [56-70] years) and 63 patients received hydrocortisone (25 men [40%]; median [interquartile range] age, 67 [56-73] years). The mean (SD) CCI score was 23.94 (17.06) in the pasireotide group and 30.11 (20.47) in the hydrocortisone group (mean difference, –6.16; 2-sided 90% CI, –11.73 to –0.60), indicating that hydrocortisone was not noninferior. Postoperative pancreatic fistula was detected in 34 patients (54%) in the pasireotide group and 39 patients (62%) in the hydrocortisone group (odds ratio, 1.39; 95% CI, 0.68-2.82; P = .37). One patient in the pasireotide group and 2 patients in the hydrocortisone group died within 30 days. In subgroup analyses of patients undergoing distal pancreatectomy, the CCI score was a mean of 10.3 points lower (mean [SD], 16.03 [11.94] vs 26.28 [21.76]; 2-sided 95% CI, −19.34 to −2.12; P = .03) and postoperative pancreatic fistula rate was lower (37% vs 67%; P = .02) in the pasireotide group compared with the hydrocortisone group. Conclusions and Relevance In this study, hydrocortisone was not noninferior compared with pasireotide in patients undergoing partial pancreatectomy. Pasireotide may be more effective than hydrocortisone in patients undergoing distal pancreatectomy. Trial Registration ClinicalTrials.gov identifier: NCT02775227; EudraCT identifier: 2016-000212-16
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Affiliation(s)
- Timo Tarvainen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jukka Sirén
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arto Kokkola
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Sallinen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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16
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Fong Y, Buell JF, Collins J, Martinie J, Bruns C, Tsung A, Clavien PA, Nachmany I, Edwin B, Pratschke J, Solomonov E, Koenigsrainer A, Giulianotti PC. Applying the Delphi process for development of a hepatopancreaticobiliary robotic surgery training curriculum. Surg Endosc 2020; 34:4233-4244. [PMID: 32767146 DOI: 10.1007/s00464-020-07836-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/21/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Robotic hepatopancreaticobiliary (HPB) procedures are performed worldwide and establishing processes for safe adoption of this technology is essential for patient benefit. We report results of the Delphi process to define and optimize robotic training procedures for HPB surgeons. METHODS In 2019, a robotic HPB surgery panel with an interest in surgical training from the Americas and Europe was created and met. An e-consensus-finding exercise using the Delphi process was applied and consensus was defined as 80% agreement on each question. Iterations of anonymous voting continued over three rounds. RESULTS Members agreed on several points: there was need for a standardized robotic training curriculum for HPB surgery that considers experience of surgeons and based on a robotic hepatectomy includes a common approach for "basic robotic skills" training (e-learning module, including hardware description, patient selection, port placement, docking, troubleshooting, fundamentals of robotic surgery, team training and efficiency, and emergencies) and an "advanced technical skills curriculum" (e-learning, including patient selection information, cognitive skills, and recommended operative equipment lists). A modular approach to index procedures should be used with video demonstrations, port placement for index procedure, troubleshooting, and emergency scenario management information. Inexperienced surgeons should undergo training in basic robotic skills and console proficiency, transitioning to full procedure training of e-learning (video demonstration, simulation training, case observation, and final evaluation). Experienced surgeons should undergo basic training when using a new system (e-learning, dry lab, and operating room (OR) team training, virtual reality modules, and wet lab; case observations were unnecessary for basic training) and should complete the advanced index procedural robotic curriculum with assessment by wet lab, case observation, and OR team training. CONCLUSIONS Optimization and standardization of training and education of HPB surgeons in robotic procedures was agreed upon. Results are being incorporated into future curriculum for education in robotic surgery.
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Affiliation(s)
- Yuman Fong
- Department of Surgery, City of Hope Medical Center, 1500 East Duarte Road, Duarte, CA, 91011, USA.
| | - Joseph F Buell
- Department of Surgery, Mission Healthcare, HCA Healthcare, North Carolina Division, MAHEC University of North Carolina, Asheville, NC, USA
| | - Justin Collins
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - John Martinie
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Christiane Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Allan Tsung
- Department of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Ido Nachmany
- Department of "Surgery B". Tel Aviv Sourasky Medical Center, Tel Aviv & The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Evgeny Solomonov
- Department of General and Hepato-Pancreatico-Biliary and Transplant Surgery, Ziv Medical Centre, Zefat (Safed), Israel
| | - Alfred Koenigsrainer
- Department of General, Visceral, Cancer and Surgery, University of Tuebingen, Tuebingen, Germany
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17
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Gasteiger S, Primavesi F, Göbel G, Braunwarth E, Cardini B, Maglione M, Sopper S, Öfner D, Stättner S. Early Post-Operative Pancreatitis and Systemic Inflammatory Response Assessed by Serum Lipase and IL-6 Predict Pancreatic Fistula. World J Surg 2020; 44:4236-4244. [PMID: 32901324 PMCID: PMC7599180 DOI: 10.1007/s00268-020-05768-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2020] [Indexed: 02/06/2023]
Abstract
Background Post-operative pancreatic fistula (POPF) remains a critical complication after pancreatic resection. This prospective pilot study evaluates perioperative markers of pancreatitis and systemic inflammation to predict clinically relevant grade B/C-POPF (CR-POPF). Methods All patients undergoing pancreatic resection from December 2017 to April 2019 were prospectively enrolled. Surgical procedures and outcomes were correlated with perioperative blood markers. ROC analysis was performed to assess their predictive value for CR-POPF. Cut-offs were calculated with the Youden index. Results In total, 70 patients were analysed (43 pancreatoduodenectomies and 27 distal pancreatectomies). In-hospital/90-d mortality and morbidity were 5.7/7.1% (n = 4/n = 5) and 75.7% (n = 53). Major complications (Clavien–Dindo ≥ 3a) occurred in 28 (40.0%) patients, CR-POPF in 20 (28.6%) patients. Serum lipase (cut-off > 51U/L) and IL-6 (> 56.5 ng/l) on POD3 were significant predictors for CR-POPF (AUC = 0.799, 95%-CI 0.686–0.912 and AUC = 0.784, 95%-CI 0.668–0.900; combined AUC = 0.858, 95%-CI 0.758–0.958; all p < 0.001). Patients with both or one factor(s) above cut-off more frequently developed CR-POPF than cases without (100 vs. 50% vs. 7.5%, p < 0.001). This also applied for overall and severe complications (p = 0.013 and p = 0.009). Conclusions Post-operative pancreatitis and inflammatory response are major determinants for development of POPF. A combination of serum lipase and IL-6 on POD3 is a highly significant early predictor of CR-POPF and overall complications, potentially guiding patient management. Clinical trial registration The study protocol was registered at clinicaltrials.gov (NCT04294797) Electronic supplementary material The online version of this article (10.1007/s00268-020-05768-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Gasteiger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - F Primavesi
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria. .,Department of General, Vascular and Visceral Surgery, Salzkammergut Klinikum, Dr.-Wilhelm-Bock-Straße 1, 4840, Vöcklabruck, Austria.
| | - G Göbel
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Schoepfstrasse 41, 6020, Innsbruck, Austria
| | - E Braunwarth
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - B Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - M Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - S Sopper
- Department of Haematology and Oncology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - D Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - S Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Department of General, Vascular and Visceral Surgery, Salzkammergut Klinikum, Dr.-Wilhelm-Bock-Straße 1, 4840, Vöcklabruck, Austria
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18
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Canto MI, Kerdsirichairat T, Yeo CJ, Hruban RH, Shin EJ, Almario JA, Blackford A, Ford M, Klein AP, Javed AA, Lennon AM, Zaheer A, Kamel IR, Fishman EK, Burkhart R, He J, Makary M, Weiss MJ, Schulick RD, Goggins MG, Wolfgang CL. Surgical Outcomes After Pancreatic Resection of Screening-Detected Lesions in Individuals at High Risk for Developing Pancreatic Cancer. J Gastrointest Surg 2020; 24:1101-1110. [PMID: 31197699 PMCID: PMC6908777 DOI: 10.1007/s11605-019-04230-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/10/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Screening high-risk individuals (HRI) can detect potentially curable pancreatic ductal adenocarcinoma (PDAC) and its precursors. We describe the outcomes of high-risk individuals (HRI) after pancreatic resection of screen-detected neoplasms. METHODS Asymptomatic HRI enrolled in the prospective Cancer of the Pancreas Screening (CAPS) studies from 1998 to 2014 based on family history or germline mutations undergoing surveillance for at least 6 months were included. Pathologic diagnoses, hospital length of stay, incidence of diabetes mellitus, operative morbidity, need for repeat operation, and disease-specific mortality were determined. RESULTS Among 354 HRI, 48 (13.6%) had 57 operations (distal pancreatectomy (31), Whipple (20), and total pancreatectomy (6)) for suspected pancreatic neoplasms presenting as a solid mass (22), cystic lesion(s) (25), or duct stricture (1). The median length of stay was 7 days (IQR 5-11). Nine of the 42 HRI underwent completion pancreatectomy for a new lesion after a median of 3.8 years (IQR 2.5-7.6). Postoperative complications developed in 17 HRI (35%); there were no perioperative deaths. New-onset diabetes mellitus after partial resection developed in 20% of HRI. Fourteen PDACs were diagnosed, 11 were screen-detected, 10 were resectable, and 9 had an R0 resection. Metachronous PDAC developed in remnant pancreata of 2 HRI. PDAC-related mortality was 4/10 (40%), with 90% 1-year survival and 60% 5-year survival, respectively. CONCLUSIONS Screening HRI can detect PDAC with a high resectability rate. Surgical treatment is associated with a relatively short length of stay and low readmission rate, acceptable morbidity, zero 90-day mortality, and significant long-term survival. CLINICAL TRIAL REGISTRATION NUMBER NCT2000089.
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Affiliation(s)
- Marcia Irene Canto
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Tossapol Kerdsirichairat
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Charles J. Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ralph H. Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Eun Ji Shin
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jose Alejandro Almario
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Amanda Blackford
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Madeline Ford
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Alison P. Klein
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ammar A. Javed
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne Marie Lennon
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Atif Zaheer
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ihab R. Kamel
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Elliot K. Fishman
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Richard Burkhart
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Martin Makary
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Matthew J. Weiss
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | - Michael G. Goggins
- Departments of Medicine (Gastroenterology), The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland,Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Christopher L. Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
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19
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Bacalbasa N, Balescu I, Dima S, Croitoru A, Brasoveanu V, Vilcu M, Brezean I. Pancreatoduodenectomy En Bloc With Vascular Resections in Borderline Resectable Pancreatic Cancer. In Vivo 2020; 33:2303-2308. [PMID: 31662572 DOI: 10.21873/invivo.11738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIM Pancreatic cancer remains asymptomatic for a long period of time, being frequently diagnosed when vascular invasion is already present. Such cases are widely known as borderline lesions. The aim of this study was to identify the effectiveness of vascular resection in this subgroup of patients. PATIENTS AND METHODS Fifteen such cases were submitted to surgery with curative intent. RESULTS Eight cases were diagnosed with borderline resectable lesions with portal vein invasion and were submitted to per primam resection and seven cases were initially diagnosed with arterial invasion and had been initially submitted to neoadjuvant chemotherapy followed by resection. In all cases portal vein resection was needed while in other four cases association of superior mesenteric artery resection was performed. Postoperatively, five patients developed complications requiring reoperation, three of whom died at the end of the first postoperative month. The histopathological studies confirmed the completeness of resection in all cases. CONCLUSION Vascular resections in pancreatic cancer resections remain demanding procedures, and are reserved for cases in which a radical resection is feasible.
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Affiliation(s)
- Nicolae Bacalbasa
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania.,"Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
| | | | - Simona Dima
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
| | - Adina Croitoru
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania.,"Titu Maiorescu" University, Bucharest, Romania
| | - Vladislav Brasoveanu
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania.,"Titu Maiorescu" University, Bucharest, Romania
| | - Mihaela Vilcu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania
| | - Iulian Brezean
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania
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20
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Weilin M, Xu H, Yang L, Wenqi C, Huanyu W, Wentao Z, Dayong J, Wenchuan W, Dansong W, Tiantao K, Lei Z, Wenhui L, Xuefeng X. Propensity score-matched analysis of clinical outcome after enucleation versus regular pancreatectomy in patients with small non-functional pancreatic neuroendocrine tumors. Pancreatology 2020; 20:169-176. [PMID: 31941586 DOI: 10.1016/j.pan.2019.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/19/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The effectiveness of enucleation in treatment for low-grade (G1, G2) small (≤2 cm) non-functional pancreatic neuroendocrine tumors (sNF-pNETs) remains controversial. This study investigated short- and long-term outcome of enucleation comparing with regular pancreatectomy in patients with sNF-pNETs. METHODS The clinical data of patients with sNF-pNETs who underwent surgery in our hospital from January 2000 to December 2017 were retrospectively collected. Short- and long-term outcomes of two operations were analyzed. The propensity score matching (PSM) was performed to reduce potential selection bias. RESULTS A total of 123 patients with sNF-pNETs were enrolled with 62 males, 69 G1, and median age was 56.91 ± 10.04 years old. During the follow-up period (mean 87 ± 58.1 months), 9(7.32%) disease progressed (recurrence or metastasis) and 2 died (1.62%), 5-years OS was 100%, 5-years DFS was 91.4%. Both lymph node metastasis (p = 0.117) and pathological grade (p = 0.050) were not prognostic factors for sNF-pNETs. The propensity score-matched cohort comprised 27 patients with enucleation and 44 patients with regular pancreatectomy. Enucleation was noninferior to regular pancreatectomy in terms of DFS, before or after PSM. The surgical duration (P < 0.01) and blood loss (P < 0.01) significantly decreased in enucleation compared with regular pancreatectomy. The other postoperative complications tended to occur in regular pancreatectomy than in enucleation, but no statistically significant difference (all p > 0.05). CONCLUSION Enucleation seems to be an effective option for the treatment of sNF-pNETs with a lower total rate of postoperative complications and similar long-term prognosis, compared with regular pancreatectomy.
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Affiliation(s)
- Mao Weilin
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Han Xu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lv Yang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Wenqi
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wang Huanyu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhou Wentao
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jin Dayong
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wu Wenchuan
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wang Dansong
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kuang Tiantao
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhang Lei
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lou Wenhui
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Xu Xuefeng
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
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21
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Abstract
Gastrointestinal bleeding (GIB) can occur as a complicating issue in the postoperative course after visceral surgery. It can be of varying clinical extent ranging from mild anemia to fatal hemorrhagic shock. Symptomatic manifestations of a GIB are hematemesis, melena and hematochezia. The GIB are fundamentally differentiated into upper and lower GIB. While upper GIB is defined as the occurrence of endoluminal hemorrhage above the ligament of Treitz, correspondingly the definition of lower GIB is intraluminal bleeding distal to the duodenojejunal flexure. Knowledge of their procedure-related incidence during the postoperative course enables a better assessment of the necessary intervention.
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Affiliation(s)
- C Stier
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacherstr. 2, 97080, Würzburg, Deutschland.
- Medizinische Klinik und Poliklinik I, Universitätsklinik Würzburg, Würzburg, Deutschland.
| | - J May
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacherstr. 2, 97080, Würzburg, Deutschland
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22
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Adiamah A, Ranat R, Gomez D. Enteral versus parenteral nutrition following pancreaticoduodenectomy: a systematic review and meta-analysis. HPB (Oxford) 2019; 21:793-801. [PMID: 30773452 DOI: 10.1016/j.hpb.2019.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The need for nutritional support following pancreaticoduodenectomy is well recognised due to the high prevalence of malnutrition, but the optimal delivery route is still debated. This meta-analysis evaluated postoperative outcomes in patients receiving enteral or parenteral nutrition. METHODS EMBASE, MEDLINE and Cochrane databases were searched to identify randomised controlled trials comparing enteral and parenteral nutrition in patients undergoing pancreaticoduodenectomy. The primary outcome measure was delayed gastric emptying (DGE). Secondary outcome measures included length of hospital stay (LOS); postoperative pancreatic fistula (POPF); post-pancreaticoduodenectomy haemorrhage (PPH); and infective complications (IC). RESULTS Five randomised controlled trials met inclusion criteria and reported on 690 patients (enteral nutrition n = 383; and parenteral nutrition n = 307). Median age was 61.5 years (interquartile range 60.1-63.6). The pooled relative risk (RR) of the primary outcome, DGE, was 0.97 (95% confidence interval (CI) 0.52-1.81, p = 0.93). There were no statistically significant difference in the secondary outcome measures of POPF (RR 1.07, 95% CI 0.42-2.76, p = 0.88); PPH (RR 0.67, 95% CI 0.31-1.48, p = 0.33) and infectious complications (RR 0.76, 95% CI 0.50-1.17, p = 0.22). However, LOS favoured enteral nutrition, weighted mean difference -1.63 days (95% CI -2.80, -0.46, p = 0.006). CONCLUSIONS EN is associated with a significantly shorter LOS compared to PN in patients undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Alfred Adiamah
- Department of Hepatobiliary Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom
| | - Reesha Ranat
- Department of Hepatobiliary Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom
| | - Dhanwant Gomez
- Department of Hepatobiliary Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom.
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23
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Outcomes following pancreatic resections—results and challenges of an Austrian university hospital compared to nationwide data and international centres. Eur Surg 2019. [DOI: 10.1007/s10353-019-0585-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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