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Abstract
Palliation is a term that is used in the literature to identify very different concepts. It is often used interchangeably with palliative care, symptom management, and hospice. While these concepts are indeed related, the distinctions are valuable to identify to impact patient care. A concept analysis of palliation was undertaken via Wilson’s method to define, identify core attributes and suggest areas for further research related to palliation. The analysis resulted in the following definition of palliation: patient goal directed symptom relief from a non-curative intervention, administered via human presence. Clarification of the definition and attributes will facilitate continued efforts to design valid measures of palliation as a patient-centered outcome.
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Martin RCG, McFarland K, Ellis S, Velanovich V. Irreversible electroporation therapy in the management of locally advanced pancreatic adenocarcinoma. J Am Coll Surg 2012; 215:361-9. [PMID: 22726894 DOI: 10.1016/j.jamcollsurg.2012.05.021] [Citation(s) in RCA: 184] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 05/02/2012] [Accepted: 05/02/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Locally advanced pancreatic cancer patients have limited options for disease control. Local ablation technologies based on thermal damage have been used but are associated with major complications in this region of the pancreas. Irreversible electroporation (IRE) is a nonthermal ablation technology that we have shown is safe near vital vascular and ductal structures. The aim of this study was to evaluate the safety and efficacy of IRE as a therapy in the treatment of locally advanced pancreatic cancer. STUDY DESIGN We performed a prospective multi-institutional pilot evaluation of patients undergoing IRE for locally advanced pancreatic cancer from December 2009 to March 2011. These patients were evaluated for 90-day morbidity, mortality, and local disease control. RESULTS Twenty-seven patients (13 women and 14 men) underwent IRE, with median age of 61 years (range 45 to 80 years). Eight patients underwent margin accentuation with IRE in combination with left-sided resection (n = 4) or pancreatic head resection (n = 4). Nineteen patients had in situ IRE. All patients underwent successful IRE, with intraoperative imaging confirming effective delivery of therapy. All 27 patients demonstrated nonclinically relevant elevation of their amylase and lipase, which peaked at 48 hours and returned to normal at 72 hour postprocedure. There has been one 90-day mortality. No patient has shown evidence of clinical pancreatitis or fistula formation. After all patients have completed 90-day follow-up, there has been 100% ablation success. CONCLUSIONS IRE ablation of locally advanced pancreatic cancer tumors is a safe and feasible primary local treatment in unresectable, locally advanced disease. Confirming these early results must occur in a planned phase II investigational device exemption (IDE) study to be initiated in 2012.
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Affiliation(s)
- Robert C G Martin
- Division of Surgical Oncology, Department of Surgery and James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY 40202, USA.
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Kneuertz PJ, Cunningham SC, Cameron JL, Torrez S, Tapazoglou N, Herman JM, Makary MA, Eckhauser F, Wang J, Hirose K, Edil BH, Choti MA, Schulick RD, Wolfgang CL, Pawlik TM. Palliative surgical management of patients with unresectable pancreatic adenocarcinoma: trends and lessons learned from a large, single institution experience. J Gastrointest Surg 2011; 15:1917-27. [PMID: 21913044 PMCID: PMC3578347 DOI: 10.1007/s11605-011-1665-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 08/09/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Routine palliative bypass has been advocated for palliation of patients with pancreatic adenocarcinoma who have inoperable disease discovered at the time of surgery. We examined trends in the relative use of palliative bypass over time with an emphasis on identifying changes in surgical indications, type of bypass performed, as well as perioperative outcomes associated with surgical palliation. METHODS Between 1996 and 2010, 1,913 patients with pancreatic adenocarcinoma in the head of the pancreas were surgically explored. Data regarding preoperative symptoms, intraoperative findings, type of surgical procedure performed, as well as perioperative and long-term outcomes were collected and analyzed. RESULTS Of the 1,913 patients, 583 (30.5%) underwent a palliative procedure. Most patients presented with jaundice (72.2%). The majority of patients were evaluated by CT scan (97.4%), which revealed a median tumor size of 3.2 cm. Most patients who underwent surgical palliation (64.5%) had a double bypass, while a minority had either gastrojejunostomy (28.2%) or hepaticojejunostomy (7.2%) alone. While the number of pancreaticoduodenectomies remained relatively stable over time, there was a temporal decrease in the utilization of palliative bypass (P < 0.001). Unanticipated locally advanced disease vs. liver/peritoneal metastasis as the indication for palliative surgery also changed over time (1996-2001: 47.8% vs. 52.2%; 2002-2007: 49.2% vs. 50.8%; 2008-2010: 17.2% vs. 82.7%) (P = 0.005). Palliative failure rates were 2.3% after hepaticojejunostomy and 3.1% after grastrojejunostomy. Patients with unsuspected metastatic disease had a worse survival compared with patients who had locally unresectable disease (median survival: 5 vs. 8 months, respectively; HR = 1.43, P = 0.001). CONCLUSION Palliative bypass procedures were less frequently performed over time, probably due to a significant decrease in the rate of unanticipated advanced locoregional disease at the time of exploration. While palliative bypass was effective, survival in the setting of metastatic disease was extremely short.
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Affiliation(s)
- Peter J. Kneuertz
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - John L. Cameron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sergio Torrez
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Joseph M. Herman
- Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Martin A. Makary
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frederic Eckhauser
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jingya Wang
- Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenzo Hirose
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Barish H. Edil
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael A. Choti
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D. Schulick
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Timothy M. Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA,Johns Hopkins Medicine Liver Tumor Center Multi-Disciplinary Clinic, Johns Hopkins Hospital, 600 N. Wolfe Street, Harvey 611, Baltimore, MD 21287, USA
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