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Chopra A, Gebran A, Khachfe H, Asmar RE, Nassour I, Narayanan S, AlMasri S, Singhi A, Lee K, Zureikat A, Paniccia A. Impact of Neoadjuvant Therapy on Oncological Outcomes of Patients With Distal Pancreatic Adenocarcinoma. J Surg Oncol 2024. [PMID: 39348461 DOI: 10.1002/jso.27856] [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: 02/04/2024] [Revised: 07/27/2024] [Accepted: 08/18/2024] [Indexed: 10/02/2024]
Abstract
BACKGROUND Distal pancreatic ductal adenocarcinoma (D-PDAC) often presents at an advanced stage. The efficacy of neoadjuvant therapy (NAT) in improving outcomes for D-PDAC is not well-established. This study evaluates the impact of NAT on the oncological outcomes of patients with D-PDAC. METHODS A retrospective cohort study of consecutive patients with resectable and borderline-resectable D-PDAC treated at a single center from 2012 to 2020 was performed. Stratification was based on initial treatment-NAT or surgery first (SF). Survival analysis, following intention-to-treat framework, used Kaplan-Meier and Cox regression to assess NAT's impact on progression-free survival (PFS) and overall survival (OS) of D-PDAC. RESULTS Among 141 patients (median age 69.8 years, 51.8% females) included in the study, 71 (50.4%) received NAT and 70 (49.6%) were planned for SF. Patients receiving NAT were younger (65.9 vs. 72.6 years) and had higher incidence of borderline-resectable disease (31% vs. 4.3%) (both p < 0.05) than those undergoing SF. Thirteen patients (18.3%) undergoing NAT and five (7.1%) in SF group, failed to undergo resection. Univariate comparison showed no difference in the PFS (SF:13.97 vs. NAT:17.00 months, p = 0.6), and OS (SF:23.73 vs. NAT:32.53 months, p = 0.35). Multivariate Cox regression analysis noted significantly improved PFS (HR = 0.64, 95%CI = 0.42-0.96, p = 0.031) and OS (HR = 0.60, 95%CI = 0.39-0.93, p = 0.021) with NAT. CONCLUSION NAT is associated with improved PFS and OS in patients with -D-PDAC. Further randomized controlled trials are warranted to confirm these findings.
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Affiliation(s)
- Asmita Chopra
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony Gebran
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hussein Khachfe
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rudy El Asmar
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Nassour
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sowmya Narayanan
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samer AlMasri
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aatur Singhi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth Lee
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amer Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Zhou L, Zhang L. Effect of postsurgical adjuvant chemotherapy timing on outcomes in patients with pancreatic cancer - a systematic review and meta-analysis. J Chemother 2024:1-11. [PMID: 39289876 DOI: 10.1080/1120009x.2024.2402175] [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: 06/07/2024] [Revised: 08/12/2024] [Accepted: 09/03/2024] [Indexed: 09/19/2024]
Abstract
To assess the association between the timing of postsurgical adjuvant chemotherapy and overall survival (OS) and disease-free survival (DFS) in patients with pancreatic cancer (PC). Literature search of PubMed, EMBASE, and Scopus databases was done for randomized controlled trials (RCTs) or observational studies (cohort studies, case-control studies), reporting outcomes of adult PC patients (aged 18 and above) who underwent surgery and received adjuvant chemotherapy at different time points after the operation. Pooled effect sizes were quantified and reported as hazard ratio (HR). The primary outcomes were OS and DFS. A random effects model to was used account for potential variability across studies. Sixteen studies were included. There was no significant difference between early and delayed initiation of adjuvant chemotherapy in terms of OS (HR 1.03, 95% CI: 0.98, 1.08) and DFS (HR 1.09, 95% CI: 0.91, 1.31). Subgroup analyses based on tumour stage, sample size, and the number of chemotherapeutic agents used did not reveal significant associations. Delayed initiation was associated with reduced OS in patients with well- to moderately differentiated tumours, with the confidence intervals approaching statistical significance (HR 1.12, 95% CI: 1.00,1.25). There was no significant association between the timing of postoperative adjuvant chemotherapy initiation and OS and DFS in patients with pancreatic cancer. These findings underscore the importance of optimizing treatment strategies and suggest that clinicians need to focus on other critical aspects such as drug selection, dosage, and patient-specific factors that might substantially impact treatment efficacy.
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Affiliation(s)
- Longlan Zhou
- Department of Oncology, Affiliated Banan Hospital of Chongqing Medical University, Chongqing, China
| | - Lin Zhang
- Department of Anesthesiology, Affiliated Banan Hospital of Chongqing Medical University, Chongqing, China
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Schütz ŠO, Rousek M, Záruba P, Husárová T, Pohnán R. Indocyanine green fluorescence in the evaluation of post-resection pancreatic remnant perfusion after a pancreaticoduodenectomy: a clinical study protocol. BMC Surg 2024; 24:261. [PMID: 39272087 PMCID: PMC11401333 DOI: 10.1186/s12893-024-02559-0] [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: 05/16/2024] [Accepted: 09/03/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Pancreaticoduodenectomy is associated with an incidence of postoperative complications of approximately 41%. One of the most severe complications is a postoperative pancreatic fistula. The exact cause of postoperative fistula development is still unknown, but it appears to be multifactorial. Proper perfusion of pancreatic remnant is essential for the healing of pancreaticojejunostomy. To date, there is no method to reliably evaluate the vascular supply of the remnant. One of the methods for the assessment of organ perfusion is the indocyanine green fluorescence. This study aims to determine if indocyanine green fluorescence is a reliable method to measure the perfusion of the post-resection pancreatic remnant. The secondary outcome is to determine if intraoperative evaluation of the vascular supply of the post-resection remnant may predict the increased risk of postoperative pancreatic fistula development. METHODS This study is designed as a prospective, observational study. All consecutive patients undergoing open or robotic pancreaticoduodenectomies at our department during the 1st May 2024-31st December 2026 period will be enrolled. The exclusion criteria are an allergy to indocyanine green and refusal by the patient. The adequacy of the vascular supply of the post-resection pancreatic remnant will be intraoperatively evaluated using a fluorescence detector. Patients will be divided into two groups: Those with high risk of pancreatic fistula development and those with low risk. The incidence of pancreatic fistulas in both groups is to be compared. Postoperative data including morbidity, mortality, hospital stay, intensive care unit stay and postoperative fistula development will be collected. DISCUSSION If an intraoperative assessment of the perfusion of post-resection pancreatic remnant using indocyanine green is proven to be a suitable method to estimate the increased risk of the pancreatic fistula, the list of the existing known risk factors could be expanded. In the most high-risk patients the modification of the surgical procedure could be considered. TRIAL REGISTRATION Number: NCT06198400 ClinicalTrials.Gov. Date 08.01.2024.
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Affiliation(s)
- Štěpán-Ota Schütz
- Department of Surgery, Second Faculty of Medicine of Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200/1, Prague, 16902, Czech Republic.
| | - Michael Rousek
- Department of Surgery, Second Faculty of Medicine of Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200/1, Prague, 16902, Czech Republic
| | - Pavel Záruba
- Department of Surgery, Second Faculty of Medicine of Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200/1, Prague, 16902, Czech Republic
| | - Tereza Husárová
- Department of Surgery, Second Faculty of Medicine of Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200/1, Prague, 16902, Czech Republic
| | - Radek Pohnán
- Department of Surgery, Second Faculty of Medicine of Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200/1, Prague, 16902, Czech Republic
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Patel A, Morocho B, Ritter J, Bertsch D, Cagir B, Macfie R. Preoperative Chemotherapy Does Not Impact Failure to Rescue in Patients Undergoing Pancreatectomy. J Surg Res 2024; 302:865-875. [PMID: 39255687 DOI: 10.1016/j.jss.2024.07.060] [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: 02/28/2024] [Revised: 06/26/2024] [Accepted: 07/17/2024] [Indexed: 09/12/2024]
Abstract
INTRODUCTION The role and impact of preoperative chemotherapy (PC) in pancreatic adenocarcinoma are questions under active investigation. Here we investigate the rate of failure to rescue (FTR) and surgical outcomes in patients undergoing pancreatectomy, with PC within 90 days (d) prior to surgery and without PC. MATERIALS AND METHODS The National Surgical Quality Improvement Program Targeted Dataset for Pancreatectomy (2014-2020) was queried to identify patients who underwent pancreatectomy for malignant non-neuroendocrine pancreatic tumors. The cohort was divided into those who underwent PC within 90 d and those without. Propensity score analysis was employed to match patients 1:1 based on age, sex, body mass index, hypertension, smoking status, ascites, diabetes, and American Society of Anesthesiology (ASA) score. The primary outcome of interest was FTR, defined as mortality following a major complication (Clavien-Dindo Class III-V). RESULTS After propensity score matching, 7895 patients with PC were matched to 7895 patients without PC. PC patients exhibited a significantly lower rate of FTR (P = 0.002) despite having higher ASA scores. This benefit was most pronounced in the pancreaticoduodenectomy subgroup (P < 0.009). PC patients demonstrated a lower rate of overall complications compared to those without PC (P < 0.001). Overall, the PC group was more likely to require vascular resection (P < 0.001). CONCLUSIONS Patients who received chemotherapy within 90 d prior to surgery experienced a lower rate of FTR and overall complications despite higher ASA scores and incidence of vascular resection. This suggests that, when appropriate, the receipt of PC does not negatively impact surgical outcomes.
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Affiliation(s)
- Apar Patel
- Department of Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | - Bryant Morocho
- Department of Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | - Jesse Ritter
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - David Bertsch
- Department of Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | - Burt Cagir
- Department of Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | - Rebekah Macfie
- Department of Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania.
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Yasrab M, Thakker S, Wright MJ, Ahmed T, He J, Wolfgang CL, Chu LC, Weiss MJ, Kawamoto S, Johnson PT, Fishman EK, Javed AA. Factors associated with radiological misstaging of pancreatic ductal adenocarcinoma: A retrospective observational study. Curr Probl Diagn Radiol 2024; 53:458-463. [PMID: 38522966 DOI: 10.1067/j.cpradiol.2024.03.001] [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: 11/18/2023] [Accepted: 03/06/2024] [Indexed: 03/26/2024]
Abstract
PURPOSE Accurate staging of disease is vital in determining appropriate care for patients with pancreatic ductal adenocarcinoma (PDAC). It has been shown that the quality of scans and the experience of a radiologist can impact computed tomography (CT) based assessment of disease. The aim of the current study was to evaluate the impact of the rereading of outside hospital (OH) CT by an expert radiologist and a repeat pancreatic protocol CT (PPCT) on staging of disease. METHODS Patients evaluated at the our institute's pancreatic multidisciplinary clinic (2006 to 2014) with OH scan and repeat PPCT performed within 30 days were included. In-house radiologists staged disease using OH scans and repeat PPCT, and factors associated with misstaging were determined. RESULTS The study included 100 patients, with a median time between OH scan and PPCT of 19 days (IQR: 13-23 days.) Stage migration was mostly accounted for by upstaging of disease (58.8 % to 83.3 %) in all comparison groups. When OH scans were rereviewed, 21.5 % of the misstaging was due to missed metastases, however, when rereads were compared to the PPCT, occult metastases accounted for the majority of misstaged patients (62.5 %). Potential factors associated with misstaging were primarily related to imaging technique. CONCLUSION A repeat PPCT results in increased detection of metastatic disease that rereviews of OH scans may otherwise miss. Accessible insurance coverage for repeat PPCT imaging even within 30 days of an OH scan could help optimize delivery of care and alleviate burdens associated with misstaging.
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Affiliation(s)
- Mohammad Yasrab
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sameer Thakker
- Department of Surgery, New York University Langone Hospital, NYU Langone Health, New York City, NY, USA
| | - Michael J Wright
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Taha Ahmed
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, New York University Langone Hospital, NYU Langone Health, New York City, NY, USA
| | - Linda C Chu
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Weiss
- Department of Surgery, Northwell Health, Lake Success, NY, USA
| | - Satomi Kawamoto
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pamela T Johnson
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ammar A Javed
- Department of Surgery, New York University Langone Hospital, NYU Langone Health, New York City, NY, USA.
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Shimane G, Nakano Y, Kitago M, Yagi H, Abe Y, Hasegawa Y, Soga S, Okuda S, Ishii R, Kitagawa Y. Preoperative predictive factors for positive peritoneal cytology results in patients with pancreatic ductal adenocarcinomas: a retrospective study. Int J Clin Oncol 2024; 29:985-993. [PMID: 38598039 DOI: 10.1007/s10147-024-02523-1] [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: 01/03/2024] [Accepted: 03/24/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND The clinical importance of positive peritoneal cytology results in patients with pancreatic ductal adenocarcinomas remains controversial. We evaluated the prognosis of these patients and the predictive preoperative risk factors for positive peritoneal cytology results. METHODS We retrospectively reviewed patients who underwent curative-intent surgery at our institution between May 2010 and June 2020. Preoperative risk factors for positive peritoneal cytology results were identified using logistic regression analysis. A scoring model was constructed using the total number of significant independent predictors for positive peritoneal cytology results. RESULTS Of 233 patients, 18 (7.7%) had positive peritoneal cytology results. The recurrence-free survival and cancer-specific survival were markedly worse in patients with positive peritoneal cytology results than in those with negative peritoneal cytology results (recurrence-free survival: 6.0 months vs. 16.6 months, p = 0.050; cancer-specific survival: 19.4 months vs. 47.5 months, p = 0.034). Tumor location (odds ratio: 3.760, 95% confidence interval: 1.099-11.818, p = 0.023), tumor size > 25 mm (odds ratio: 3.410, 95% confidence interval: 1.031-11.277, p = 0.046), preoperative serosal invasion (odds ratio: 5.193, 95% confidence interval: 1.099-24.531, p = 0.038), and preoperative carcinoembryonic antigen level > 5.6 ng/mL (odds ratio: 3.816, 95% confidence interval: 1.248-10.667, p = 0.019) were identified as significant independent predictive factors. Our predictive model's optimal cutoff and positive predictive values for positive peritoneal cytology results were 3 and 27.9%, respectively. CONCLUSIONS The indications for curative-intent surgery should be considered carefully in patients with high-risk factors for positive peritoneal cytology results.
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Affiliation(s)
- Gaku Shimane
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yutaka Nakano
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582, Japan.
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Shigeyoshi Soga
- Department of Radiology, Dokkyo Medical University School of Medicine, 880 Kita-Kobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Shigeo Okuda
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Ryota Ishii
- Department of Biostatistics, Institute of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582, Japan
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Saúde-Conde R, El Ghali B, Navez J, Bouchart C, Van Laethem JL. Total Neoadjuvant Therapy in Localized Pancreatic Cancer: Is More Better? Cancers (Basel) 2024; 16:2423. [PMID: 39001485 PMCID: PMC11240662 DOI: 10.3390/cancers16132423] [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: 05/15/2024] [Revised: 06/24/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) poses a significant challenge in oncology due to its advanced stage upon diagnosis and limited treatment options. Surgical resection, the primary curative approach, often results in poor long-term survival rates, leading to the exploration of alternative strategies like neoadjuvant therapy (NAT) and total neoadjuvant therapy (TNT). While NAT aims to enhance resectability and overall survival, there appears to be potential for improvement, prompting consideration of alternative neoadjuvant strategies integrating full-dose chemotherapy (CT) and radiotherapy (RT) in TNT approaches. TNT integrates chemotherapy and radiotherapy prior to surgery, potentially improving margin-negative resection rates and enabling curative resection for locally advanced cases. The lingering question: is more always better? This article categorizes TNT strategies into six main groups based on radiotherapy (RT) techniques: (1) conventional chemoradiotherapy (CRT), (2) the Dutch PREOPANC approach, (3) hypofractionated ablative intensity-modulated radiotherapy (HFA-IMRT), and stereotactic body radiotherapy (SBRT) techniques, which further divide into (4) non-ablative SBRT, (5) nearly ablative SBRT, and (6) adaptive ablative SBRT. A comprehensive analysis of the literature on TNT is provided for both borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), with detailed sections for each.
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Affiliation(s)
- Rita Saúde-Conde
- Digestive Oncology Department, Hôpitaux Universitaires de Bruxelles (HUB), Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Benjelloun El Ghali
- Department of Radiation Oncology, Hôpitaux Universitaires de Bruxelles (HUB), Institut Jules Bordet, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (B.E.G.); (C.B.)
| | - Julie Navez
- Department of Abdominal Surgery and Transplantation, Hôpitaux Universitaires de Bruxelles (HUB), Hopital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Christelle Bouchart
- Department of Radiation Oncology, Hôpitaux Universitaires de Bruxelles (HUB), Institut Jules Bordet, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (B.E.G.); (C.B.)
| | - Jean-Luc Van Laethem
- Digestive Oncology Department, Hôpitaux Universitaires de Bruxelles (HUB), Université Libre de Bruxelles, 1070 Brussels, Belgium;
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Napoli N, Kauffmann EF, Ginesini M, Di Dato A, Viti V, Gianfaldoni C, Lami L, Cappelli C, Rotondo MI, Campani D, Amorese G, Vivaldi C, Cesario S, Bernardini L, Vasile E, Vistoli F, Boggi U. Robotic Versus Open Pancreatoduodenectomy With Vein Resection and Reconstruction: A Propensity Score-Matched Analysis. ANNALS OF SURGERY OPEN 2024; 5:e409. [PMID: 38911629 PMCID: PMC11191888 DOI: 10.1097/as9.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 06/25/2024] Open
Abstract
Objective This study aimed to compare robotic pancreatoduodenectomy with vein resection (PD-VR) based on the incidence of severe postoperative complications (SPC). Background Robotic pancreatoduodenectomy has been gaining momentum in recent years. Vein resection is frequently required in this operation, but no study has compared robotic and open PD-VR using a matched analysis. Methods This was an intention-to-treat study designed to demonstrate the noninferiority of robotic to open PD-VR (2011-2021) based on SPC. To achieve a power of 80% (noninferiority margin:10%; α error: 0.05; ß error: 0.20), a 1:1 propensity score-matched analysis required 35 pairs. Results Of the 151 patients with PD-VR (open = 115, robotic = 36), 35 procedures per group were compared. Elective conversion to open surgery was required in 1 patient with robotic PD-VR (2.9%). One patient in both groups experienced partial vein thrombosis. SPC occurred in 7 (20.0%) and 6 patients (17.1%) in the robotic and open PD-VR groups, respectively (P = 0.759; OR: 1.21 [0.36-4.04]). Three patients died after robotic PD-VR (8.6%) and none died after open PD-VR (P = 0.239). Robotic PD-VR was associated with longer operative time (611.1 ± 13.9 minutes vs 529.0 ± 13.0 minutes; P < 0.0001), more type 2 vein resection (28.6% vs 5.7%; P = 0.0234) and less type 3 vein resection (31.4% vs 71.4%; P = 0.0008), longer vein occlusion time (30 [25.3-78.3] minutes vs 15 [8-19.5] minutes; P = 0.0098), less blood loss (450 [200-750] mL vs 733 [500-1070.3] mL; P = 0.0075), and fewer blood transfusions (intraoperative: 14.3% vs 48.6%; P = 0.0041) (perioperative: 14.3% vs 60.0%; P = 0.0001). Conclusions In this study, robotic PD-VR was noninferior to open PD-VR for SPC. Robotic and open PD-VR need to be compared in randomized controlled trials.
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Affiliation(s)
- Niccolò Napoli
- From the Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | | | - Michael Ginesini
- From the Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Armando Di Dato
- From the Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Virginia Viti
- From the Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Cesare Gianfaldoni
- From the Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Lucrezia Lami
- From the Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Carla Cappelli
- Division of Radiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | | | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Caterina Vivaldi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Silvia Cesario
- Division of Medical Oncology 2, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Laura Bernardini
- Division of Medical Oncology 2, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Enrico Vasile
- Division of Medical Oncology 2, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Fabio Vistoli
- From the Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Ugo Boggi
- From the Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
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9
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Poiraud C, Lenne X, Bruandet A, Theis D, Bertrand N, Turpin A, Truant S, El Amrani M. Adjuvant chemotherapy omission after pancreatic cancer resection: a French nationwide study. World J Surg Oncol 2024; 22:123. [PMID: 38711136 DOI: 10.1186/s12957-024-03393-7] [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: 01/30/2024] [Accepted: 04/17/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Adjuvant chemotherapy (AC) improves the prognosis after pancreatic ductal adenocarcinoma (PDAC) resection. However, previous studies have shown that a large proportion of patients do not receive or complete AC. This national study examined the risk factors for the omission or interruption of AC. METHODS Data of all patients who underwent pancreatic surgery for PDAC in France between January 2012 and December 2017 were extracted from the French National Administrative Database. We considered "omission of adjuvant chemotherapy" (OAC) all patients who failed to receive any course of gemcitabine within 12 postoperative weeks and "interruption of AC" (IAC) was defined as less than 18 courses of AC. RESULTS A total of 11 599 patients were included in this study. Pancreaticoduodenectomy was the most common procedure (76.3%), and 31% of the patients experienced major postoperative complications. OACs and IACs affected 42% and 68% of the patients, respectively. Ultimately, only 18.6% of the cohort completed AC. Patients who underwent surgery in a high-volume centers were less affected by postoperative complications, with no impact on the likelihood of receiving AC. Multivariate analysis showed that age ≥ 80 years, Charlson comorbidity index (CCI) ≥ 4, and major complications were associated with OAC (OR = 2.19; CI95%[1.79-2.68]; OR = 1.75; CI95%[1.41-2.18] and OR = 2.37; CI95%[2.15-2.62] respectively). Moreover, age ≥ 80 years and CCI 2-3 or ≥ 4 were also independent risk factors for IAC (OR = 1.54, CI95%[1.1-2.15]; OR = 1.43, CI95%[1.21-1.68]; OR = 1.47, CI95%[1.02-2.12], respectively). CONCLUSION Sequence surgery followed by chemotherapy is associated with a high dropout rate, especially in octogenarian and comorbid patients.
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Affiliation(s)
- Charles Poiraud
- Digestive Surgery and Transplantation Department, CHU de Lille, 59000, Lille, France
- University of Lille, 59000, Lille, France
| | - Xavier Lenne
- Department of Medical Information, CHRU de Lille, 59000, Lille, France
- University of Lille, 59000, Lille, France
| | - Amélie Bruandet
- Department of Medical Information, CHRU de Lille, 59000, Lille, France
- University of Lille, 59000, Lille, France
| | - Didier Theis
- Department of Medical Information, CHRU de Lille, 59000, Lille, France
- University of Lille, 59000, Lille, France
| | - Nicolas Bertrand
- Medical Oncology Department, CHU de Lille, 59000, Lille, France
- University of Lille, 59000, Lille, France
| | - Anthony Turpin
- Medical Oncology Department, CHU de Lille, 59000, Lille, France
- University of Lille, 59000, Lille, France
| | - Stephanie Truant
- Digestive Surgery and Transplantation Department, CHU de Lille, 59000, Lille, France
- University of Lille, 59000, Lille, France
| | - Mehdi El Amrani
- Digestive Surgery and Transplantation Department, CHU de Lille, 59000, Lille, France.
- University of Lille, 59000, Lille, France.
- Service de Chirurgie Digestive Et Transplantation, Hôpital CLAUDE HURIEZ, Rue Michel Polonovski LILLE CEDEX, 59037, Lille, France.
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10
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Zhao X, Kolbinger FR, Distler M, Weitz J, Makarov D, Bachmann M, Baraban L. Portable droplet-based real-time monitoring of pancreatic α-amylase in postoperative patients. Biosens Bioelectron 2024; 251:116034. [PMID: 38359666 DOI: 10.1016/j.bios.2024.116034] [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: 10/23/2023] [Revised: 12/21/2023] [Accepted: 01/11/2024] [Indexed: 02/17/2024]
Abstract
Postoperative complications after pancreatic surgery are frequent and can be life-threatening. Current clinical diagnostic strategies involve time-consuming quantification of α-amylase activity in abdominal drain fluid, which is performed on the first and third postoperative day. The lack of real-time monitoring may delay adjustment of medical treatment upon complications and worsen prognosis for patients. We report a bedside portable droplet-based millifluidic device enabling real-time sensing of drain α-amylase activity for postoperative monitoring of patients undergoing pancreatic surgery. Here, a tiny amount of drain liquid of patient samples is continuously collected and co-encapsulated with a starch reagent in nanoliter-sized droplets to track the fluorescence intensity released upon reaction with α-amylase. Comparing the α-amylase levels of 32 patients, 97 % of the results of the droplet-based millifluidic system matched the clinical data. Our method reduces the α-amylase assay duration to approximately 3 min with the limit of detection 7 nmol/s·L, enabling amylase activity monitoring at the bedside in clinical real-time. The presented droplet-based platform can be extended for analysis of different body fluids, diseases, and towards a broader range of biomarkers, including lipase, bilirubin, lactate, inflammation, or liquid biopsy markers, paving the way towards new standards in postoperative patient monitoring.
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Affiliation(s)
- Xinne Zhao
- Institute of Radiopharmaceutical Cancer Research, Helmholtz-Zentrum Dresden-Rossendorf e. V, 01328, Dresden, Germany.
| | - Fiona R Kolbinger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav. Carus, TUD Dresden University of Technology, Germany; Else Kröner Fresenius Center for Digital Health (EKFZ), TUD Dresden University of Technology, Germany.
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav. Carus, TUD Dresden University of Technology, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav. Carus, TUD Dresden University of Technology, Germany; Else Kröner Fresenius Center for Digital Health (EKFZ), TUD Dresden University of Technology, Germany
| | - Denys Makarov
- Institute of Ion Beam Physics and Materials Research, Helmholtz-Zentrum Dresden-Rossendorf e. V, 01328, Dresden, Germany.
| | - Michael Bachmann
- Institute of Radiopharmaceutical Cancer Research, Helmholtz-Zentrum Dresden-Rossendorf e. V, 01328, Dresden, Germany.
| | - Larysa Baraban
- Institute of Radiopharmaceutical Cancer Research, Helmholtz-Zentrum Dresden-Rossendorf e. V, 01328, Dresden, Germany; Else Kröner Fresenius Center for Digital Health (EKFZ), TUD Dresden University of Technology, Germany.
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11
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Paiella S, Malleo G, Lionetto G, Cattelani A, Casciani F, Secchettin E, De Pastena M, Bassi C, Salvia R. Adjuvant Therapy After Upfront Resection of Resectable Pancreatic Cancer: Patterns of Omission and Use-A Prospective Real-Life Study. Ann Surg Oncol 2024; 31:2892-2901. [PMID: 38286884 PMCID: PMC10997715 DOI: 10.1245/s10434-024-14951-4] [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: 08/22/2023] [Accepted: 01/05/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Little is known about adjuvant therapy (AT) omission and use outside of randomized trials. We aimed to assess the patterns of AT omission and use in a cohort of upfront resected pancreatic cancer patients in a real-life scenario. METHODS From January 2019 to July 2022, 317 patients with resected pancreatic cancer and operated upfront were prospectively enrolled in this prospective observational trial according to the previously calculated sample size. The association between perioperative variables and the risk of AT omission and AT delay was analyzed using multivariable logistic regression. RESULTS Eighty patients (25.2%) did not receive AT. The main reasons for AT omission were postoperative complications (38.8%), oncologist's choice (21.2%), baseline comorbidities (20%), patient's choice (10%), and early recurrence (10%). At the multivariable analysis, the odds of not receiving AT increased significantly for older patients (odds ratio [OR] 1.1, p < 0.001), those having an American Society of Anesthesiologists score ≥II (OR 2.03, p = 0.015), or developing postoperative pancreatic fistula (OR 2.5, p = 0.019). The likelihood of not receiving FOLFIRINOX as AT increased for older patients (OR 1.1, p < 0.001), in the presence of early-stage disease (stage I-IIa vs. IIb-III, OR 2.82, p =0.031; N0 vs. N+, OR 3, p = 0.03), and for patients who experienced postoperative major complications (OR 4.7, p = 0.009). A twofold increased likelihood of delay in AT was found in patients experiencing postoperative complications (OR 3.86, p = 0.011). CONCLUSIONS AT is not delivered in about one-quarter of upfront resected pancreatic cancer patients. Age, comorbidities, and postoperative complications are the main drivers of AT omission and mFOLFIRINOX non-use. CLINICALTRIALS REGISTRATION NCT03788382.
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Affiliation(s)
- Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy.
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Gabriella Lionetto
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Alice Cattelani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Fabio Casciani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Erica Secchettin
- Department of Surgical Sciences, University of Verona, Verona, Italy
| | - Matteo De Pastena
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy.
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12
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Morris-Stiff G. Exocrine pancreatic insufficiency and fat malabsorption related to pancreatectomy and other gastrointestinal surgery: A narrative review. Nutr Clin Pract 2024; 39 Suppl 1:S35-S45. [PMID: 38429966 DOI: 10.1002/ncp.11123] [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: 08/30/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 03/03/2024] Open
Abstract
Surgical resection is the mainstay of treatment for patients with tumors of the pancreas. There are a number of well-recognized complications that account for the significant morbidity associated with the operation, including exocrine pancreatic insufficiency (EPI). Patients with pancreatic cancer commonly have evidence of EPI prior to surgery, and this is exacerbated by an operation, the extent of the insult being dependent on the indication for surgery and the operation performed. There are accumulating data to demonstrate that treatment of EPI with pancreatic enzyme replacement (PERT) enhances clinical outcomes after surgery by reducing critical complications; this in turn may enhance oncological outcomes. Data would indicate that quality of life (QoL) is also improved after surgery when enzymes are prescribed. To date, many surgeons and clinicians have not appreciated the need for PERT or the benefits it may bring to their patients; therefore, education of clinicians remains a significant opportunity. In turn, patient education about consumption of the correct dose of enzymes at the appropriate time is key to an optimal outcome. In addition, because of the complex nature of the regulation of pancreatic exocrine function, there is evidence to support the presence of EPI following operations performed on other gastrointestinal (GI) organs, including the esophagus, stomach, and small intestine. The aim of this review is to document the existing published evidence in relation to EPI and its treatment with PERT following GI surgery.
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13
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Rashid Z, Munir MM, Woldesenbet S, Khan MMM, Khalil M, Endo Y, Tsilimigras DI, Dillhoff M, Ejaz A, Pawlik TM. Association between social determinants of health and delayed postoperative adjuvant therapy among patients undergoing resection of pancreatic cancer. J Surg Oncol 2024; 129:850-859. [PMID: 38151795 DOI: 10.1002/jso.27571] [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: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Pancreatic cancer (PDAC) requires a multimodality approach. We sought to define the association between social determinants of health (SDOH) and delayed or nonreceipt of adjuvant chemotherapy (aCT) among patients undergoing PDAC resection. METHODS Data on patients who underwent PDAC resection between 2014 and 2020 were identified from Medicare Standard Analytic Files and merged with the county-level social vulnerability index (SVI). Mediation analysis defined the association between SVI subthemes and aCT receipt. RESULTS Among 24 078 patients, 47.7% received timely aCT, 17.7% received delayed aCT, and 34.6% did not receive any aCT. High SVI was associated with delay (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.10-1.34) and nonreceipt of aCT (OR 1.30, 95% CI 1.20-1.41) (both p < 0.05). 73.1% of the variation in timely aCT receipt was directly attributable to SVI, whereas 26.9% of the effect was due to indirect mediators including hospital volume (6.4%), length-of-stay (7.9%) and postoperative complications (12.6%). Socioeconomic status (delayed aCT: OR 1.25, 95% CI 1.13-1.38; nonreceipt aCT: OR 1.25, 95% CI 1.15-1.36) and household composition and disability (delayed aCT: OR 1.30, 95% CI 1.17-1.43; nonreceipt aCT: OR 1.19, 95% CI 1.09-1.29) were associated with receipt of aCT (both p < 0.001). CONCLUSIONS Most of the disparities in receipt of aCT after PDAC surgery are driven by underlying SDOH such as SVI.
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Affiliation(s)
- Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad M Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad M M Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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14
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Marchese U, Desbiens JF, Lenne X, Naveendran G, Tzedakis S, Gaillard M, Bruandet A, Theis D, Boyer L, Truant S, Fuks D, El Amrani M. Study of Risk Factors for Readmission After Pancreatectomy for Cancer: Analysis of Nationwide Cohort. Ann Surg 2024; 279:486-492. [PMID: 37254769 DOI: 10.1097/sla.0000000000005929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To identify the factors associated with readmission after pancreatectomy for cancer and to assess their impact on the 1-year mortality in a French multicentric population. BACKGROUND Pancreatectomy is a complex procedure with high morbidity that increases the length of hospital stay and jeopardizes survival. Hospital readmissions lead to increased health system costs, making this a topic of great interest. METHODS Data collected from patients who underwent pancreatectomy for cancer between 2011 and 2019 were extracted from a French national medico-administrative database. A descriptive analysis was conducted to evaluate the association of baseline variables, including age, sex, liver-related comorbidities, Charlson Comorbidity Index, tumor localization, and use of neoadjuvant therapy, along with hospital type and volume, with readmission status. Centers were divided into low and high volumes according to the cutoff of 26 cases/year. Logistic regression models were developed to determine whether the identified bivariate associations persisted after adjusting for the patient characteristics. The mortality rates during readmission and at 1 year postoperatively were also determined. RESULTS Of 22,935 patients who underwent pancreatectomy, 9129 (39.3%) were readmitted within 6 months. Readmission rates by year did not vary over the study period, and mean readmissions occurred within 20 days after discharge. Multivariate analysis showed that male sex [odds ratio (OR) = 1.12], age >70 years (OR = 1.16), comorbidities (OR = 1.21), distal pancreatectomy (OR = 1.11), and major postoperative complications (OR = 1.37) were predictors of readmission. Interestingly, readmission and surgery in low-volume centers increased the risk of death at 1 year by a factor of 2.15 [(2.01-2.31), P < 0.001] and 1.31 [(1.17-1.47), P < 0.001], respectively. CONCLUSIONS Readmission after pancreatectomy for cancer is high with an increased rate of 1-year mortality.
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Affiliation(s)
- Ugo Marchese
- Department of Digestive, HPB and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris
- Paris University - 15 rue de l'école de médecine, Paris
| | - Jean-François Desbiens
- Department of digestive surgery and Transplantation, CHRU de Lille, Lille
- Lille university, Lille
| | - Xavier Lenne
- Lille university, Lille
- Department of Medical Information, CHRU de Lille, Lille
| | - Gaanan Naveendran
- Department of Digestive, HPB and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris
- Paris University - 15 rue de l'école de médecine, Paris
| | - Stylianos Tzedakis
- Department of Digestive, HPB and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris
- Paris University - 15 rue de l'école de médecine, Paris
| | - Martin Gaillard
- Department of Digestive, HPB and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris
- Paris University - 15 rue de l'école de médecine, Paris
| | - Amelie Bruandet
- Lille university, Lille
- Department of Medical Information, CHRU de Lille, Lille
| | - Didier Theis
- Lille university, Lille
- Department of Medical Information, CHRU de Lille, Lille
| | - Laurent Boyer
- Department of Medical Information La Timone Hospital, Marseille
- Aix-Marseille University, Jardin du Pharo, Marseille
| | - Stephanie Truant
- Department of digestive surgery and Transplantation, CHRU de Lille, Lille
- Lille university, Lille
| | - David Fuks
- Department of Digestive, HPB and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris
- Paris University - 15 rue de l'école de médecine, Paris
| | - Mehdi El Amrani
- Department of digestive surgery and Transplantation, CHRU de Lille, Lille
- Lille university, Lille
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15
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Sok C, Sandhu S, Shah H, Ajay PS, Russell MC, Cardona K, Maegawa F, Maithel SK, Sarmiento J, Goyal S, Kooby DA, Shah MM. Simple Preoperative Imaging Measurements Predict Postoperative Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg Oncol 2024; 31:1898-1905. [PMID: 37968411 PMCID: PMC10922305 DOI: 10.1245/s10434-023-14564-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/22/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Postoperative pancreatic fistula is a potentially devastating complication after pancreatoduodenectomy (PD). The purpose of this study was to identify features on preoperative computed tomography (CT) imaging that correlate with an increased risk of postoperative pancreatic fistula (POPF). METHODS Patients who underwent PD at our high-volume pancreatic surgery center from 2019 to 2021 were included if CT imaging was available within 8 weeks of surgical intervention. Pancreatic neck thickness (PNT), abdominal wall thickness (AWT), and intra-abdominal distance from pancreas to peritoneum (PTP) were measured by two board-certified radiologists who were blinded to the clinical outcomes. Radiographic measurements, as well as preoperative patient characteristics and intraoperative data, were assessed with univariate and multivariable analysis (MVA) to determine risk for clinically relevant POPF (CR-POPF, grades B and C). RESULTS A total of 204 patients met inclusion criteria. Median PTP was 5.8 cm, AWT 1.9 cm, and PNT 1.3 cm. CR-POPF occurred in 33 of 204 (16.2%) patients. MVA revealed PTP > 5.8 cm (odds ratio [OR] 2.86, p = 0.023), PNT > 1.3 cm (OR 2.43, p = 0.047), soft pancreas consistency (OR 3.47, p = 0.012), and pancreatic duct size ≤ 3.0 mm (OR 4.55, p = 0.01) as independent risk factors for CR-POPF after PD. AWT and obesity were not associated with increased risk of CR-POPF. Patients with PTP > 5.8 cm or PNT > 1.3 cm were significantly more likely to suffer a major complication after PD (39.6% vs. 22.3% and 40% vs. 22.1%, p < 0.008). CONCLUSIONS Patients with a thick pancreatic neck and increased intra-abdominal girth have a heightened risk of CR-POPF after pancreatoduodenectomy, and they experience more serious postoperative complications. We defined a simple CT scan-based measurement tool to identify patients at increased risk of CR-POPF.
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Affiliation(s)
- Caitlin Sok
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Sameer Sandhu
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Hardik Shah
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Pranay S Ajay
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Felipe Maegawa
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Juan Sarmiento
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Subir Goyal
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Mihir M Shah
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA.
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16
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Zhang J, Cai H, Zhang M, Wang X, Cai Y, Peng B. Textbook oncologic outcomes are associated with increased overall survival in patients with pancreatic head cancer after undergoing laparoscopic pancreaticoduodenectomy. World J Surg Oncol 2024; 22:43. [PMID: 38317188 PMCID: PMC10845781 DOI: 10.1186/s12957-024-03322-8] [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: 12/04/2023] [Accepted: 01/23/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Textbook oncologic outcomes (TOO) have been used to evaluate long-term oncologic outcomes for patients after pancreaticoduodenectomy (PD) but not laparoscopic pancreaticoduodenectomy (LPD). The aim of the study was to assess the prognostic value of TOO for patients with pancreatic head cancer undergoing LPD and discuss the risk factors associated with achieving TOO. METHODS Patients with pancreatic head cancer who underwent LPD in West China Hospital from January 2015 to May 2022 were consecutively enrolled. TOO was defined as achieving R0 resection, examination of ≥ 12 lymph nodes, no prolonged length of stay, no 30-day readmission/death, and receiving adjuvant chemotherapy. Survival analysis was used to determine the prognostic value of a TOO on overall survival (OS) and recurrence-free survival (RFS). Logistic regression was used to identify the risk factors of a TOO. The rates of a TOO and of each indicator were compared in patients who suffered or not from delayed gastric emptying (DGE). RESULTS A total of 44 (25.73%) patients achieved TOO which was associated with improved median OS (TOO 32 months vs. non-TOO 20 months, P = 0.034) and a better RFS (TOO 19 months vs. non-TOO 13 months, P = 0.053). Patients suffering from DGE [odds ratio (OR) 4.045, 95% CI 1.151-14.214, P = 0.029] were independent risk factors for TOO. In addition, patients with DGE after surgery had a significantly lower rate of TOO (P = 0.015) than patients without DGE. CONCLUSIONS As there were significant differences between patients who achieved TOO or not, TOO is a good indicator for long-term oncologic outcomes in patients with pancreatic head cancer after undergoing LPD. DGE is the risk factor for achieving TOO, so it is important to prevent the DGE after LPD to improve the rate of TOO.
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Affiliation(s)
- Jing Zhang
- Department of General Surgery, Division of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - He Cai
- Department of General Surgery, Division of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Man Zhang
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Xin Wang
- Department of General Surgery, Division of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yunqiang Cai
- Department of General Surgery, Division of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- The Health Management Center of West China Hospital, Sichuan University, Chengdu, China
| | - Bing Peng
- Department of General Surgery, Division of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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17
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Rompen IF, Habib JR, Wolfgang CL, Javed AA. Anatomical and Biological Considerations to Determine Resectability in Pancreatic Cancer. Cancers (Basel) 2024; 16:489. [PMID: 38339242 PMCID: PMC10854859 DOI: 10.3390/cancers16030489] [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: 11/14/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains associated with poor outcomes with a 5-year survival of 12% across all stages of the disease. These poor outcomes are driven by a delay in diagnosis and an early propensity for systemic dissemination of the disease. Recently, aggressive surgical approaches involving complex vascular resections and reconstructions have become more common, thus allowing more locally advanced tumors to be resected. Unfortunately, however, even after the completion of surgery and systemic therapy, approximately 40% of patients experience early recurrence of disease. To determine resectability, many institutions utilize anatomical staging systems based on the presence and extent of vascular involvement of major abdominal vessels around the pancreas. However, these classification systems are based on anatomical considerations only and do not factor in the burden of systemic disease. By integrating the biological criteria, we possibly could avoid futile resections often associated with significant morbidity. Especially patients with anatomically resectable disease who have a heavy burden of radiologically undetected systemic disease most likely do not derive a survival benefit from resection. On the contrary, we could offer complex resections to those who have locally advanced or oligometastatic disease but have favorable systemic biology and are most likely to benefit from resection. This review summarizes the current literature on defining anatomical and biological resectability in patients with pancreatic cancer.
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Affiliation(s)
- Ingmar F. Rompen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Joseph R. Habib
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Christopher L. Wolfgang
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Ammar A. Javed
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
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18
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Lim SY, Alramadhan HJ, Jeong H, Chae H, Kim HS, Yoon SJ, Shin SH, Han IW, Heo JS, Kim H. Survival Comparison of Different Operation Types for Middle Bile Duct Cancer: Bile Duct Resection versus Pancreaticoduodenectomy Considering Complications and Adjuvant Treatment Effects. Cancers (Basel) 2024; 16:297. [PMID: 38254787 PMCID: PMC10814212 DOI: 10.3390/cancers16020297] [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: 11/24/2023] [Revised: 12/30/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Margin status is one of the most significant prognostic factors after curative surgery for middle bile duct (MBD) cancer. Bile duct resection (BDR) is commonly converted to pancreaticoduodenectomy (PD) to achieve R0 resection. Additionally, adjuvant treatment is actively performed after surgery to improve survival. However, the wider the range of surgery, the higher the chance of complications; this, in turn, makes adjuvant treatment impossible. Nevertheless, no definitive surgical strategy considers the possible complication rates and subsequent adjuvant treatment. We aimed to investigate the appropriate surgical type considering the margin status, complications, and adjuvant treatment in MBD cancer. MATERIALS AND METHODS From 2008 to 2017, 520 patients diagnosed with MBD cancer at the Samsung Medical Center were analyzed retrospectively according to the operation type, margin status, complications, and adjuvant treatment. The R1 group was defined as having a carcinoma margin. RESULTS The 5-year survival rate for patients who underwent R0 and R1 resection was 54.4% and 33.3%, respectively (p = 0.131). Prognostic factors affecting the overall survival were the age, preoperative CA19-9 level, T stage, and N stage, but not the operation type, margin status, complications, or adjuvant treatment. The complication rates were 11.5% and 29.8% in the BDR and PD groups, respectively (p < 0.001). We observed no significant difference in the adjuvant treatment ratio according to complications (p = 0.675). Patients with PD who underwent R0 resection and could not undergo chemotherapy because of complications reported better survival rates than those with BDR who underwent R1 resection after adjuvant treatment (p = 0.003). CONCLUSION The survival outcome of patients with R1 margins who underwent BDR did not match those with R0 margins after PD, even after adjuvant treatment. Due to improvements in surgical techniques and the ability to resolve complications, surgical complications exert a marginal effect on survival. Therefore, surgeons should secure R0 margins to achieve the best survival outcomes.
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Affiliation(s)
- Soo Yeun Lim
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.Y.L.); (H.J.); (H.C.); (H.S.K.); (S.J.Y.); (I.W.H.); (J.S.H.)
| | | | - HyeJeong Jeong
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.Y.L.); (H.J.); (H.C.); (H.S.K.); (S.J.Y.); (I.W.H.); (J.S.H.)
| | - Hochang Chae
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.Y.L.); (H.J.); (H.C.); (H.S.K.); (S.J.Y.); (I.W.H.); (J.S.H.)
| | - Hyeong Seok Kim
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.Y.L.); (H.J.); (H.C.); (H.S.K.); (S.J.Y.); (I.W.H.); (J.S.H.)
| | - So Jeong Yoon
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.Y.L.); (H.J.); (H.C.); (H.S.K.); (S.J.Y.); (I.W.H.); (J.S.H.)
| | - Sang Hyun Shin
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.Y.L.); (H.J.); (H.C.); (H.S.K.); (S.J.Y.); (I.W.H.); (J.S.H.)
| | - In Woong Han
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.Y.L.); (H.J.); (H.C.); (H.S.K.); (S.J.Y.); (I.W.H.); (J.S.H.)
| | - Jin Seok Heo
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.Y.L.); (H.J.); (H.C.); (H.S.K.); (S.J.Y.); (I.W.H.); (J.S.H.)
| | - Hongbeom Kim
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.Y.L.); (H.J.); (H.C.); (H.S.K.); (S.J.Y.); (I.W.H.); (J.S.H.)
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19
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Barrios P, Chawla A. Gastrointestinal Malignancies: Pancreatic Cancer Clinical Trials in Neoadjuvant Chemotherapy. Cancer Treat Res 2024; 192:119-129. [PMID: 39212918 DOI: 10.1007/978-3-031-61238-1_6] [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: 09/04/2024]
Abstract
Surgical resection is the only known treatment associated with long-term survival in pancreatic adenocarcinoma. While adjuvant therapy has shown a clear survival benefit, neoadjuvant chemotherapy has gained interest due to its ability to prioritize the treatment of micrometastatic disease prior to resection and improve chemotherapy tolerance prior to a major operation. Investigations have focused on evaluating the survival benefit of neoadjuvant therapy using single and combination chemotherapy as well as radiation therapy. Landmark trials in localized pancreatic cancer have paved the way for the standard use of neoadjuvant therapy for pancreatic adenocarcinoma.
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Affiliation(s)
- Paola Barrios
- Division of Surgical Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Akhil Chawla
- Division of Surgical Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA.
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20
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Brajcich BC, Ko CY, Liu JB, Ellis RJ, D'Angelica MI. A NSQIP-Based Randomized Clinical Trial Evaluating Choice of Prophylactic Antibiotics for Pancreaticoduodenectomy. Cancer Treat Res 2024; 192:131-145. [PMID: 39212919 DOI: 10.1007/978-3-031-61238-1_7] [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: 09/04/2024]
Abstract
Surgical site infection is a common complication following pancreaticoduodenectomy and is a major source of postoperative morbidity. Surgical site infection is more common among patients who undergo preoperative biliary instrumentation, likely because of the introduction of intestinal flora into the normally sterile biliary tree. Frequently, bacterial isolates from surgical site infections after pancreaticoduodenectomy demonstrate resistance to the antibiotic agents typically used for surgical prophylaxis, suggesting that broad-spectrum coverage may be beneficial. This chapter summarizes the current evidence regarding surgical site infection following pancreatic surgery and describes the rationale and methodology underlying a multicenter randomized trial evaluating piperacillin-tazobactam compared with cefoxitin for surgical site infection prevention following pancreaticoduodenectomy. As the first U.S. randomized surgical trial to utilize a clinical registry for data collection, this study serves as proof of concept for registry-based clinical trials. The trial has successfully completed patient accrual, and study results are forthcoming.
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Affiliation(s)
- Brian C Brajcich
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
- Department of Surgery, Northwestern Medicine, Northwestern Quality Improvement, Research, and Education in Surgery (NQUIRES), Chicago, IL, USA
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Jason B Liu
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
- Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ryan J Ellis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Michael I D'Angelica
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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21
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Lima HA, Moazzam Z, Endo Y, Alaimo L, Woldesenbet S, Munir MM, Shaikh C, Resende V, Pawlik TM. The Impact of Medicaid Expansion on Early-Stage Pancreatic Adenocarcinoma at High- Versus Low-Volume Facilities. Ann Surg Oncol 2023; 30:7263-7274. [PMID: 37368099 DOI: 10.1245/s10434-023-13810-y] [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: 03/20/2023] [Accepted: 05/10/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION While Medicaid Expansion (ME) has improved healthcare access, disparities in outcomes after volume-dependent surgical care persist. We sought to characterize the impact of ME on postoperative outcomes among patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) at high-volume (HVF) versus low-volume (LVF) facilities. METHODS Patients who underwent resection for PDAC were identified from the National Cancer Database (NCDB; 2011-2018). HVF was defined as ≥20 resections/year. Patients were divided into pre- and post-ME cohorts, and the primary outcome was textbook oncologic outcomes (TOO). Difference-in-difference (DID) analysis was used to assess changes in TOO achievement among patients living in ME versus non-ME states. RESULTS Among 33,764 patients who underwent resection of PDAC, 19.1% (n = 6461) were treated at HVF. Rates of TOO achievement were higher at HVF (HVF: 45.7% vs. LVF: 32.8%; p < 0.001). On multivariable analysis, undergoing surgery at HVF was associated with higher odds of achieving TOO (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.49-1.72) and improved overall survival (OS) [hazard ratio (HR) 0.96, 95% CI 0.92-0.99]. Compared with patients living in non-ME states, individuals living in ME states were more likely to achieve TOO on adjusted DID analysis (5.4%, p = 0.041). Although rates of TOO achievement did not improve after ME at HVF (3.7%, p = 0.574), ME contributed to markedly higher rates of TOO among patients treated at LVF (6.7%, p = 0.022). CONCLUSIONS Although outcomes for PDAC remain volume-dependent, ME has contributed to significant improvement in TOO achievement among patients treated at LVF. These data highlight the impact of ME on reducing disparities in surgical outcomes relative to site of care.
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Affiliation(s)
- Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Chanza Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Vivian Resende
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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22
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Gibiino G, Cucchetti A, Mocchegiani F, Bocchino A, Gaudenzi F, Binda C, Raumer L, Fabbri C, Cristini F, Vivarelli M, Ercolani G. Alarming correlation between multidrug-resistant bacteriobilia and morbidity after pancreatic surgery. Dig Liver Dis 2023; 55:1502-1508. [PMID: 37263811 DOI: 10.1016/j.dld.2023.05.012] [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: 01/02/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Pancreatic surgery is characterized by high morbidity and mortality. Biliary colonization may affect clinical outcomes in these patients. AIMS This study aimed to verify whether bacteriobilia and multidrug resistance (MDR) detected during and after pancreatic surgery may have an impact on post-operative outcomes. METHODS Data from patients undergoing pancreatic surgery involving bile duct transection (2016-2022) in two high-volume centers were analyzed in relationship to overall morbidity, major morbidity and mortality after pancreato-duodenectomy (PD) or total pancreatectomy (TP). Simple and multivariable regressions were used. RESULTS 227 patients submitted to PD (n=129) or TP (n=98) were included. Of them, 133 had preoperative biliary drainage (BD; 56.6%), mostly with the employment of endoscopic stents (91.7%). Bacteriobilia was detected in 111 patients (48.9%), and remarkably, observed in patients with BD (p=0.001). In addition, 25 MDR pathogens were identified (22.5%), with a significant prevalence in patients with BD. Multivariable regression analysis showed BD was strongly related to MDR isolation (odds ratio [OR]: 5.61; p=0.010). MDR isolation was the main factor linked to a higher number of major complications (OR: 2.75; p=0.041), including major infection complications (OR: 2.94; p=0.031). CONCLUSIONS Isolation of MDR from biliary swab during PD or TP significantly increases the risk of a worse post-operative outcome. Pre-operative precautions could improve patient safety.
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Affiliation(s)
- Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, Forlì, Italy.
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum - University of Bologna, Bologna, Italy; Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Federico Mocchegiani
- Hepatopancreatobiliary and Transplant Unit, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Antonio Bocchino
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Federico Gaudenzi
- Hepatopancreatobiliary and Transplant Unit, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, Forlì, Italy
| | - Luigi Raumer
- Infectious Diseases Unit, Forlì-Cesena Hospitals, Ausl Romagna
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, Forlì, Italy
| | | | - Marco Vivarelli
- Hepatopancreatobiliary and Transplant Unit, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum - University of Bologna, Bologna, Italy; Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
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23
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Kaslow SR, Sacks GD, Berman RS, Lee AY, Correa-Gallego C. Natural History of Stage IV Pancreatic Cancer. Identifying Survival Benchmarks for Curative-intent Resection in Patients With Synchronous Liver-only Metastases. Ann Surg 2023; 278:e798-e804. [PMID: 36353987 DOI: 10.1097/sla.0000000000005753] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate long-term oncologic outcomes of patients with stage IV pancreatic ductal adenocarcinoma and to identify survival benchmarks for comparison when considering resection in these patients. BACKGROUND Highly selected cohorts of patients with liver-oligometastatic pancreas cancer have reported prolonged survival after resection. The long-term impact of surgery in this setting remains undefined because of a lack of appropriate control groups. METHODS We identified patients with clinical stage IV pancreatic ductal adenocarcinoma with synchronous liver metastases within our cancer registry. We estimated overall survival (OS) among various patient subgroups using the Kaplan-Meier method. To mitigate immortal time bias, we analyzed long-term outcomes of patients who survived beyond 12 months (landmark time) from diagnosis. RESULTS We identified 241 patients. Median OS was 7 months (95% CI, 5-9), both overall and for patients with liver-only metastasis (n=144). Ninety patients (38% of liver only; 40% of whole cohort) survived at least 12 months; those who received chemotherapy in this subgroup had a median OS of 26 months (95% CI, 17-39). Of these patients, those with resectable or borderline resectable primary tumors and resectable liver-only metastasis (n=9, 4%) had a median OS of 39 months (95% CI, 13-NR). CONCLUSIONS The 4% of our cohort that were potentially eligible for surgery experienced a prolonged survival compared with all-comers with stage IV disease. Oncologic outcomes of patients undergoing resection of metastatic pancreas cancer should be assessed in the context of the expected survival of patients potentially eligible for surgery and not relative to all patients with stage IV disease.
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Affiliation(s)
- Sarah R Kaslow
- Department of Surgery, New York University Grossman School of Medicine, New York City, NY
| | - Greg D Sacks
- Department of Surgery, New York University Grossman School of Medicine, New York City, NY
| | - Russell S Berman
- Department of Surgery, New York University Grossman School of Medicine, New York City, NY
| | - Ann Y Lee
- Department of Surgery, New York University Grossman School of Medicine, New York City, NY
| | - Camilo Correa-Gallego
- Department of Surgery, New York University Grossman School of Medicine, New York City, NY
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY
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24
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Rousek M, Kachlík D, Záruba P, Pudil J, Schütz ŠO, Balko J, Pohnán R. Vascular supply of postresection pancreatic remnant after pancreaticoduodenectomy: A cadaveric study. Medicine (Baltimore) 2023; 102:e35049. [PMID: 37682165 PMCID: PMC10489493 DOI: 10.1097/md.0000000000035049] [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: 07/12/2023] [Accepted: 08/11/2023] [Indexed: 09/09/2023] Open
Abstract
OBJECTIVES The vascular supply to the neck and body of the pancreas is highly variable. The dorsal pancreatic artery is the dominant artery feeding this area. The aim of this study was to describe the vascular supply of postresection pancreatic remnants after pancreaticoduodenectomy. Patients with hazardous anatomical arrangement may be at a higher risk of postresection remnant ischemia and postoperative pancreatic fistula development. METHODS The modified Whipple procedure was performed on 20 cadaveric donors. The macroscopic anatomical supply of the postresection pancreatic remnant of each donor was evaluated. RESULTS The arterial supply of the postresection remnant was highly variable. In 30% of cases (6/20), the dorsal pancreatic artery was cut during the pancreatoduodenectomy or it was missing. In these cases, the area of the pancreaticojejunostomy construction was fed only through anastomoses between the transverse pancreatic artery and the pancreatic branches of the splenic artery. CONCLUSIONS In 30% of cases, the arterial supply of the postresection pancreatic remnant was dependent on inconstant intraparenchymal arterial anastomoses. These patients may be at a higher risk of postoperative pancreatic fistula development.
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Affiliation(s)
- Michael Rousek
- Department of Surgery, Second Faculty of Medicine of Charles University and Military University Hospital Prague, Praha, Czech Republic
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - David Kachlík
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pavel Záruba
- Department of Surgery, Second Faculty of Medicine of Charles University and Military University Hospital Prague, Praha, Czech Republic
| | - Jiří Pudil
- Department of Surgery, Second Faculty of Medicine of Charles University and Military University Hospital Prague, Praha, Czech Republic
| | - Štěpán Ota Schütz
- Department of Surgery, Second Faculty of Medicine of Charles University and Military University Hospital Prague, Praha, Czech Republic
| | - Jan Balko
- Department of Pathology and Molecular Medicine, Second Faculty of Medicine, Charles University Prague and Faculty Hospital Motol, Prague, Czech Republic
| | - Radek Pohnán
- Department of Surgery, Second Faculty of Medicine of Charles University and Military University Hospital Prague, Praha, Czech Republic
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25
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Birgin E, Müller M, Woll C, Klompmaker A, Téoule P, Reißfelder C, Rahbari NN. Development of a conceptual framework to detect perioperative symptom burden following abdominal surgery for cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106933. [PMID: 37211468 DOI: 10.1016/j.ejso.2023.05.008] [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: 04/11/2023] [Revised: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Abdominal surgery for gastrointestinal malignancies has a significant impact on patients' health-related quality of life. However, there is so far no patient-reported outcome measures (PROM) in the immediate postoperative period to detect the perioperative symptom burden and patients' needs which may precede occult and severe complications. The aim of the study was to create a conceptual framework for the development of a PROM to measure perioperative symptom burden in abdominal cancer patients. METHODS This mixed method study was performed between March 2021, and July 2021 as part of a multiphase approach to develop a new PROM. A systematic review of the literature was performed health domains were identified. The relevance of the health domains was assessed in a two-round Delphi study with clinical experts. Qualitative interviews were performed in patients who underwent abdominal surgery for cancer. RESULTS The systematic literature review yielded 12 different PROM with 168 items and 55 health domains. The most common health domains involved the "digestive system" and "pain". In total, 30 patients (median age 66 years, 20 men [60%]) were included for qualitative patient interviews. Of 16 health domains identified by the Delphi study, a total 15 health domains were confirmed during patients' interviews. The final conceptual framework included 20 health domains. CONCLUSION This study provides the essential groundwork to develop and validate a new PROM for the immediate postoperative period of patients undergoing abdominal surgery for cancer.
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Affiliation(s)
- Emrullah Birgin
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Mitho Müller
- Department of Psychology, Ludwig Maximilian University, Munich, Germany
| | - Christian Woll
- Department of Psychology, Ludwig Maximilian University, Munich, Germany
| | - Annika Klompmaker
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Patrick Téoule
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reißfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nuh N Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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26
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Russell TB, Labib PL, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Croagh D, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh B, Serrablo A, Aroori S. Serious complications of pancreatoduodenectomy correlate with lower rates of adjuvant chemotherapy: Results from the recurrence after Whipple's (RAW) study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106919. [PMID: 37330348 DOI: 10.1016/j.ejso.2023.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/29/2023] [Accepted: 04/24/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Adjuvant chemotherapy (AC) can prolong overall survival (OS) after pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). However, fitness for AC may be influenced by postoperative recovery. We aimed to investigate if serious (Clavien-Dindo grade ≥ IIIa) postoperative complications affected AC rates, disease recurrence and OS. MATERIALS AND METHODS Data were extracted from the Recurrence After Whipple's (RAW) study (n = 1484), a retrospective study of PD outcomes (29 centres from eight countries). Patients who died within 90-days of PD were excluded. The Kaplan-Meier method was used to compare OS in those receiving or not receiving AC, and those with and without serious postoperative complications. The groups were then compared using univariable and multivariable tests. RESULTS Patients who commenced AC (vs no AC) had improved OS (median difference: (MD): 201 days), as did those who completed their planned course of AC (MD: 291 days, p < 0.0001). Those who commenced AC were younger (mean difference: 2.7 years, p = 0.0002), more often (preoperative) American Society of Anesthesiologists (ASA) grade I-II (74% vs 63%, p = 0.004) and had less often experienced a serious postoperative complication (10% vs 18%, p = 0.002). Patients who developed a serious postoperative complication were less often ASA grade I-II (52% vs 73%, p = 0.0004) and less often commenced AC (58% vs 74%, p = 0.002). CONCLUSION In our multicentre study of PD outcomes, PDAC patients who received AC had improved OS, and those who experienced a serious postoperative complication commenced AC less frequently. Selected high-risk patients may benefit from targeted preoperative optimisation and/or neoadjuvant chemotherapy.
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Affiliation(s)
- Thomas B Russell
- University Hospitals Plymouth NHS Trust, Plymouth, UK; University of Plymouth, Plymouth, UK
| | - Peter L Labib
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | | | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Vasileios K Mavroeidis
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | | | | | | | - Hassaan Bari
- Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | | | | | | | | | | | | | - Ismael Dominguez
- Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dhanny Gomez
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Andrea Mingoli
- Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Somaiah Aroori
- University Hospitals Plymouth NHS Trust, Plymouth, UK; University of Plymouth, Plymouth, UK.
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27
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Gaskill CE, Bold RJ. Impact on patient outcomes after regionalization of pancreatic surgery. J Gastrointest Oncol 2023; 14:1909-1912. [PMID: 37720435 PMCID: PMC10502541 DOI: 10.21037/jgo-2023-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/26/2023] [Indexed: 09/19/2023] Open
Affiliation(s)
- Cameron E Gaskill
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Medical Center, Sacramento, CA, USA
| | - Richard J Bold
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Medical Center, Sacramento, CA, USA
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28
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Lintern N, Smith AM, Jayne DG, Khaled YS. Photodynamic Stromal Depletion in Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2023; 15:4135. [PMID: 37627163 PMCID: PMC10453210 DOI: 10.3390/cancers15164135] [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: 07/05/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest solid malignancies, with a five-year survival of less than 10%. The resistance of the disease and the associated lack of therapeutic response is attributed primarily to its dense, fibrotic stroma, which acts as a barrier to drug perfusion and permits tumour survival and invasion. As clinical trials of chemotherapy (CT), radiotherapy (RT), and targeted agents have not been successful, improving the survival rate in unresectable PDAC remains an urgent clinical need. Photodynamic stromal depletion (PSD) is a recent approach that uses visible or near-infrared light to destroy the desmoplastic tissue. Preclinical evidence suggests this can resensitise tumour cells to subsequent therapies whilst averting the tumorigenic effects of tumour-stromal cell interactions. So far, the pre-clinical studies have suggested that PDT can successfully mediate the destruction of various stromal elements without increasing the aggressiveness of the tumour. However, the complexity of this interplay, including the combined tumour promoting and suppressing effects, poses unknowns for the clinical application of photodynamic stromal depletion in PDAC.
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Affiliation(s)
- Nicole Lintern
- School of Biomedical Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Andrew M. Smith
- Leeds Institute of Medical Research, St James’s University Hospital, Leeds LS9 7TF, UK
| | - David G. Jayne
- Leeds Institute of Medical Research, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Yazan S. Khaled
- Leeds Institute of Medical Research, St James’s University Hospital, Leeds LS9 7TF, UK
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Macfie R, Cohen N. ASO Author Reflections: Timing of Systemic Therapy and Postoperative Morbidity in Resectable Pancreatic Ductal Adenocarcinoma and Distal Cholangiocarcinoma. Ann Surg Oncol 2023; 30:5035. [PMID: 37179272 DOI: 10.1245/s10434-023-13581-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Rebekah Macfie
- Department of Surgery, The Mount Sinai Hospital, New York City, USA.
| | - Noah Cohen
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York City, USA
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Macfie R, Berger Y, Liu H, Li T, Imtiaz S, Ang C, Sarpel U, Hiotis S, Labow D, Golas B, Cohen NA. Major Postoperative Complications Limit Adjuvant Therapy Administration in Patients Undergoing Pancreatoduodenectomy for Distal Cholangiocarcinoma or Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2023; 30:5027-5034. [PMID: 37210446 DOI: 10.1245/s10434-023-13533-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/03/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Guidelines for perioperative systemic therapy administration in patients undergoing pancreatoduodenectomy for pancreatic adenocarcinoma (PDAC) and distal cholangiocarcinoma (dCCA) are evolving. Decisions regarding adjuvant therapy are influenced by postoperative morbidity, which is common after pancreatoduodenectomy. We evaluated whether postoperative complications are associated with receipt of adjuvant therapy after pancreatoduodenectomy. METHODS A retrospective analysis of patients undergoing pancreatoduodenectomy for PDAC or dCCA from 2015 to 2020 was conducted. Demographic, clinicopathologic, and postoperative variables were analyzed. RESULTS Overall, 186 patients were included-145 with PDAC and 41 with dCCA. Postoperative complication rates were similar for both pathologies (61% and 66% for PDAC and dCCA, respectively). Major postoperative complications (MPCs), defined as Clavien-Dindo >3, occurred in 15% and 24% of PDAC and dCCA patients, respectively. Patients with MPCs received lower rates of adjuvant therapy administration, irrespective of primary tumor (PDAC: 21 vs. 72%, p = 0.008; dCCA: 20 vs. 58%, p = 0.065). Recurrence-free survival (RFS) was worse for patients with PDAC who experienced an MPC [8 months (interquartile range [IQR] 1-15) vs. 23 months (IQR 19-27), p < 0.001] or who did not receive any perioperative systemic therapy [11 months (IQR 7-15) vs. 23 months (IQR 18-29), p = 0.038]. In patients with dCCA, 1-year RFS was worse for patients who did not receive adjuvant therapy (55 vs. 77%, p = 0.038). CONCLUSION Patients who underwent pancreatoduodenectomy for either PDAC or dCCA and who experienced an MPC had lower rates of adjuvant therapy and worse RFS, suggesting that clinicians adopt a standard neoadjuvant systemic therapy strategy in patients with PDAC. Our results propose a paradigm shift towards preoperative systemic therapy in patients with dCCA.
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Affiliation(s)
- Rebekah Macfie
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA.
| | - Yael Berger
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Hongdau Liu
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Thomas Li
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Sayed Imtiaz
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Celina Ang
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Umut Sarpel
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Spiros Hiotis
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Daniel Labow
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Benjamin Golas
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Noah A Cohen
- Division of Surgical Oncology, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
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31
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Javed AA, Floortje van Oosten A, Habib JR, Hasanain A, Kinny-Köster B, Gemenetzis G, Groot VP, Ding D, Cameron JL, Lafaro KJ, Burns WR, Burkhart RA, Yu J, He J, Wolfgang CL. A Delay in Adjuvant Therapy Is Associated With Worse Prognosis Only in Patients With Transitional Circulating Tumor Cells After Resection of Pancreatic Ductal Adenocarcinoma. Ann Surg 2023; 277:866-872. [PMID: 36111839 DOI: 10.1097/sla.0000000000005710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of the study was to assess the association of circulating tumor cells (CTCs) with survival as a biomarker in pancreatic ductal adenocarcinoma (PDAC) within the context of a delay in the initiation of adjuvant therapy. BACKGROUND Outcomes in patients with PDAC remain poor and are driven by aggressive systemic disease. Although systemic therapies improve survival in resected patients, factors such as a delay in the initiation of adjuvant therapy are associated with worse outcomes. CTCs have previously been shown to be predictive of survival. METHODS A retrospective study was performed on PDAC patients enrolled in the prospective CircuLating tUmor cellS in pancreaTic cancER trial (NCT02974764) on CTC-dynamics at the Johns Hopkins Hospital. CTCs were isolated based on size (isolation by size of epithelial tumor cells; Rarecells) and counted and characterized by subtype using immunofluorescence. The preoperative and postoperative blood samples were used to identify 2 CTC types: epithelial CTCs (eCTCs), expressing pancytokeratin, and transitional CTCs (trCTCs), expressing both pancytokeratin and vimentin. Patients who received adjuvant therapy were compared with those who did not. A delay in the receipt of adjuvant therapy was defined as the initiation of therapy ≥8 weeks after surgical resection. Clinicopathologic features, CTCs characteristics, and outcomes were analyzed. RESULTS Of 101 patients included in the study, 43 (42.5%) experienced a delay in initiation and 20 (19.8%) did not receive adjuvant therapy. On multivariable analysis, the presence of trCTCs ( P =0.002) and the absence of adjuvant therapy ( P =0.032) were associated with worse recurrence-free survival (RFS). Postoperative trCTC were associated with poorer RFS, both in patients with a delay in initiation (12.4 vs 17.9 mo, P =0.004) or no administration of adjuvant chemotherapy (3.4 vs NR, P =0.016). However, it was not associated with RFS in patients with timely initiation of adjuvant chemotherapy ( P =0.293). CONCLUSIONS Postoperative trCTCs positivity is associated with poorer RFS only in patients who either experience a delay in initiation or no receipt of adjuvant therapy. This study suggests that a delay in the initiation of adjuvant therapy could potentially provide residual systemic disease (trCTCs) a window of opportunity to recover from the surgical insult. Future studies are required to validate these findings and explore the underlying mechanisms involved.
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Affiliation(s)
- Ammar A Javed
- Department of Surgery, New York University Langone Hospital, New York City, NY
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anne Floortje van Oosten
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, The Netherlands
| | - Joseph R Habib
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alina Hasanain
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benedict Kinny-Köster
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Georgios Gemenetzis
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Vincent P Groot
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ding Ding
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, Manhasset, NY
| | - John L Cameron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kelly J Lafaro
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - William R Burns
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard A Burkhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jun Yu
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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de Scordilli M, Michelotti A, Zara D, Palmero L, Alberti M, Noto C, Totaro F, Foltran L, Guardascione M, Iacono D, Ongaro E, Fasola G, Puglisi F. Preoperative treatments in borderline resectable and locally advanced pancreatic cancer: current evidence and new perspectives. Crit Rev Oncol Hematol 2023; 186:104013. [PMID: 37116817 DOI: 10.1016/j.critrevonc.2023.104013] [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: 12/03/2022] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 04/30/2023] Open
Abstract
Surgery is the only curative treatment for non-metastatic pancreatic adenocarcinoma, but less than 20% of patients present a resectable disease at diagnosis. Treatment strategies and disease definition for borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC) vary in the different cancer centres. Preoperative chemotherapy (CT) is the standard of care for both BRPC and LAPC patients, however literature data are still controversial concerning the type, dose and duration of the different CT regimens, as well as regarding the integration of radiotherapy (RT) or chemoradiation (CRT) in the therapeutic algorithm. In this unsettled debate, we aimed at focusing on the therapeutic regimens currently in use and relative literature data, to report international trials comparing the available therapeutic options or explore the introduction of new pharmacological agents, and to analyse possible new scenarios in microenvironment evaluation before and after neoadjuvant therapies or in patients' selection at a molecular level.
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Affiliation(s)
- Marco de Scordilli
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Anna Michelotti
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.
| | - Diego Zara
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Lorenza Palmero
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Martina Alberti
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.
| | - Claudia Noto
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Fabiana Totaro
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Luisa Foltran
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Michela Guardascione
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Donatella Iacono
- Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.
| | - Elena Ongaro
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Gianpiero Fasola
- Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.
| | - Fabio Puglisi
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
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Ghabi EM, Shoucair S, Ding D, Javed AA, Thompson ED, Zheng L, Cameron JL, Wolfgang CL, Shubert CR, Lafaro KJ, Burkhart RA, Burns WR, He J. Tailoring Adjuvant Chemotherapy to Biologic Response Following Neoadjuvant Chemotherapy Impacts Overall Survival in Pancreatic Cancer. J Gastrointest Surg 2023; 27:691-700. [PMID: 36280632 PMCID: PMC10079604 DOI: 10.1007/s11605-022-05476-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/16/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The role of postoperative chemotherapy in patients with resected pancreatic cancer who receive neoadjuvant treatment is unknown. Clinicians use changes in CA19-9 and histopathologic scores to assess treatment response. We sought to investigate if CA19-9 normalization in response to NAT can help guide the need for postoperative treatment. METHODS Patients with elevated baseline CA19-9 (CA19-9 > 37U/mL) who received NAT followed by surgery between 2011 and 2019 were retrospectively reviewed. Treatment response was determined by CA19-9 normalization following NAT and histopathologic scoring. The role of postoperative chemotherapy was analyzed in light of CA19-9 normalization and histopathologic response. RESULTS We identified and included 345 patients. Following NAT, CA19-9 normalization was observed in 125 patients (36.2%). CA19-9 normalization was associated with a favorable histopathologic response (41.6% vs 23.2%, p < 0.001) and a lower ypT (p < 0.001) and ypN stage (p = 0.003). Receipt of adjuvant chemotherapy was associated with improved overall survival in patients in whom CA19-9 did not normalize following NAT (26.8 vs 16.4 months, p = 0.008). In patients who received 5FU-based NAT and in whom CA19-9 did not normalize, receipt of 5FU-based adjuvant chemotherapy was associated with improved OS (p = 0.014). CONCLUSION CA19-9 normalization in response to NAT was associated with favorable outcomes and can serve as a biomarker for treatment response. In patients where CA19-9 did not normalize, receipt of postoperative chemotherapy was associated with improved OS. These patients also benefited from additional 5FU-based postoperative chemotherapy following 5FU-based NAT.
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Affiliation(s)
- Elie M Ghabi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 685, Baltimore, MD, 21287, USA
| | - Sami Shoucair
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 685, Baltimore, MD, 21287, USA
| | - Ding Ding
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 685, Baltimore, MD, 21287, USA
| | - Ammar A Javed
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Elizabeth D Thompson
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 685, Baltimore, MD, 21287, USA
| | | | - Christopher R Shubert
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 685, Baltimore, MD, 21287, USA
| | - Kelly J Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 685, Baltimore, MD, 21287, USA
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 685, Baltimore, MD, 21287, USA
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 685, Baltimore, MD, 21287, USA
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 685, Baltimore, MD, 21287, USA.
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Villano AM, Ruth K, Castellanos J, Farma JM, Reddy SS. Discrepancies in survival after conversion to open in minimally invasive pancreatoduodenectomy. Am J Surg 2023; 225:728-734. [PMID: 36333156 PMCID: PMC10656078 DOI: 10.1016/j.amjsurg.2022.10.056] [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: 09/30/2022] [Revised: 10/12/2022] [Accepted: 10/25/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The extent by which conversion to open (CTO) during minimally invasive procedures for pancreatic cancer impact survival outcomes is not fully understood. METHODS The 2010-2017 National Cancer Database identified 12,424 non-metastatic patients who underwent pancreatoduodenectomy for ductal adenocarcinoma. Patients were stratified into three cohorts: open (OPD), completed MIPD (cMIPD), and CTO. Subgroups were dichotomized by hospital MIPD volume. RESULTS Across the study period, 80.6% of patients underwent OPD, 19.4% MIPD, and 24% were CTO. Median overall survival was worse after CTO (21.8 months) than for OPD (23.6 months) or cMIPD (25.2 months) (p < 0.001). Although this effect persisted for <10 MIPD/year, CTO did comparably to OPD at hospitals performing ≥10MIPD/year (CTO = 26.8 months, OPD = 27.9 months; p = 0.128). Ninety-day mortality after CTO was worse at ≤ 10 MIPD/year hospitals (9.3% vs. 2.6%). CONCLUSIONS Short and long-term survival is impacted by CTO after MIPD, especially at lower surgical volumes, stressing careful adoption while ascending the learning curve.
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Affiliation(s)
- Anthony M Villano
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Karen Ruth
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Jason Castellanos
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Jeffrey M Farma
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Sanjay S Reddy
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Hammad AY, Khachfe HH, AlMasri S, DeSilva A, Liu H, Nassour I, Lee K, Zureikat AH, Paniccia A. Impact of Extended Antibiotic Use After Pancreaticoduodenectomy for Patients with Preoperative Metallic Biliary Stenting Treated with Neoadjuvant Chemotherapy. J Gastrointest Surg 2023; 27:716-723. [PMID: 36650416 PMCID: PMC11234506 DOI: 10.1007/s11605-023-05581-4] [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] [Received: 08/30/2022] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pancreaticoduodenectomy (PD) remains a complex surgical procedure with infectious complications affecting nearly 50% of patients. Patients who undergo biliary drainage with stent placement prior to neoadjuvant treatment (NAT) reportedly have higher infection rates following PD. The aim of the current study is to evaluate the differences in postoperative infectious complication rates based on the duration of post operative prophylactic antibiotics in patients with indwelling metal biliary stent who had NAT. METHODS A retrospective institutional pancreatic cancer database was queried for patients who had a metal biliary stent placed prior to NAT initiation, followed by subsequent PD between 2014 and 2021. Duration of postoperative prophylactic antibiotics was defined as short (SC: ≤ 24 h) or extended (EC: > 24 h-7 days). The primary outcome of interest was surgical site infection (SSI). RESULTS Two hundred and ninety-five (n = 295) patients were identified of which the majority (n = 205, 69.5%) received a short course of antibiotics postoperatively. Baseline characteristics were similar between the two cohorts including age, sex, BMI, and comorbidity index. EC patients received more NAT cycles (4 vs. 3, p < 0.001) and underwent an open PD more frequently (61.8% vs. 41.0%, p < 0.001). SSI occurred in 64 (21.7%) patients; SC cohort: 54, 26.3% vs. EC cohort:10, 11.1%, (p = 0.003). Additionally, the SC cohort demonstrated a higher incidence of major complications (Clavien-Dindo ≥ 3: 51 [24.9%] vs. 13 [14.4%], p = 0.045). On the logistic regression model examining factors associated with SSI, higher BMI (continuous variable) was associated with increased odds of SSI (OR: 1.05 [95%CI: 1.00, 1.10, p = 0.040), while EC was protective (OR: 0.36 [95%CI: 0.17, 0.75], p = 0.007). CONCLUSIONS These data suggest that an extended course of perioperative antibiotic correlates with reductions in SSI and major morbidity following PD in patients with a metallic biliary stent placed prior to NAT course. These results require validation in a future randomized clinical trial examining a larger cohort of patients with further emphasis on the types of perioperative antibiotics administered.
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Affiliation(s)
- Abdulrahman Y Hammad
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Hussein H Khachfe
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Samer AlMasri
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Annissa DeSilva
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Hao Liu
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Ibrahim Nassour
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Kenneth Lee
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Alessandro Paniccia
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA.
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Napoli N, Cacace C, Kauffmann EF, Jones L, Ginesini M, Gianfaldoni C, Salamone A, Asta F, Ripolli A, Di Dato A, Busch OR, Cappelle ML, Chao YJ, de Wilde RF, Hackert T, Jang JY, Koerkamp BG, Kwon W, Lips D, Luyer MDP, Nickel F, Saint-Marc O, Shan YS, Shen B, Vistoli F, Besselink MG, Hilal MA, Boggi U. The PD-ROBOSCORE: A difficulty score for robotic pancreatoduodenectomy. Surgery 2023; 173:1438-1446. [PMID: 36973127 DOI: 10.1016/j.surg.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/12/2023] [Accepted: 02/22/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Difficulty scoring systems are important for the safe, stepwise implementation of new procedures. We designed a retrospective observational study for building a difficulty score for robotic pancreatoduodenectomy. METHODS The difficulty score (PD-ROBOSCORE) aims at predicting severe postoperative complications after robotic pancreatoduodenectomy. The PD-ROBOSCORE was developed in a training cohort of 198 robotic pancreatoduodenectomies and was validated in an international multicenter cohort of 686 robotic pancreatoduodenectomies. Finally, all centers tested the model during the early learning curve (n = 300). Growing difficulty levels (low, intermediate, high) were defined using cut-off values set at the 33rd and 66th percentile (NCT04662346). RESULTS Factors included in the final multivariate model were a body mass index of ≥25 kg/m2 for males and ≥30 kg/m2 for females (odds ratio:2.39; P < .0001), borderline resectable tumor (odd ratio:1.98; P < .0001), uncinate process tumor (odds ratio:1.69; P < .0001), pancreatic duct size <4 mm (odds ratio:1.59; P < .0001), American Society of Anesthesiologists class ≥3 (odds ratio:1.59; P < .0001), and hepatic artery originating from the superior mesenteric artery (odds ratio:1.43; P < .0001). In the training cohort, the absolute score value (odds ratio = 1.13; P = .0089) and difficulty groups (odds ratio = 2.35; P = .041) predicted severe postoperative complications. In the multicenter validation cohort, the absolute score value predicted severe postoperative complications (odds ratio = 1.16, P < .001), whereas the difficulty groups did not (odds ratio = 1.94, P = .082). In the learning curve cohort, both absolute score value (odds ratio:1.078, P = .04) and difficulty groups (odds ratio: 2.25, P = .017) predicted severe postoperative complications. Across all cohorts, a PD-ROBOSCORE of ≥12.51 doubled the risk of severe postoperative complications. The PD-ROBOSCORE score also predicted operative time, estimated blood loss, and vein resection. The PD-ROBOSCORE predicted postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, and postoperative mortality in the learning curve cohort. CONCLUSION The PD-ROBOSCORE predicts severe postoperative complications after robotic pancreatoduodenectomy. The score is readily available via www.pancreascalculator.com.
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Affiliation(s)
- Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Concetta Cacace
- Division of General and Transplant Surgery, University of Pisa, Italy
| | | | - Leia Jones
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Department of Surgery, Amsterdam UMC, University of Amsterdam, Netherlands; Cancer Center Amsterdam, Netherlands
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Italy
| | | | - Alice Salamone
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Fabio Asta
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Allegra Ripolli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Netherlands; Cancer Center Amsterdam, Netherlands
| | - Marie L Cappelle
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Ying Jui Chao
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Jin-Young Jang
- Department of Hepatobiliary and Pancreatic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Wooil Kwon
- Department of Hepatobiliary and Pancreatic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Daan Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Felix Nickel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Regional D'Orleans, Orléans, France
| | - Yan-Shen Shan
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Netherlands; Cancer Center Amsterdam, Netherlands
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Italy.
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Hill CS, Herman JM. The Current Role of Radiation in Pancreatic Cancer and Future Directions. Clin Colorectal Cancer 2023; 22:12-23. [PMID: 36804206 DOI: 10.1016/j.clcc.2023.01.002] [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: 07/25/2022] [Revised: 12/15/2022] [Accepted: 01/24/2023] [Indexed: 02/01/2023]
Abstract
Survival outcomes for localized pancreatic adenocarcinoma remains poor. Multimodality therapeutic regimens are critical to maximizing survival outcomes for these patients, which includes the use of systemic therapy, surgery, and radiation. In this review, the evolution of radiation techniques are discussed with a focus on modern techniques such as intensity modulated radiation and stereotactic body radiation therapy. However, the current role of radiation within the most common clinical scenarios for pancreatic cancer in the neoadjuvant, definitive, and adjuvant settings continues to be highly debated. The role of radiation in these settings is reviewed in the context of historical and modern clinical studies. In addition, emerging concepts including dose-escalated radiation, magnetic resonance-guided radiation therapy, and particle therapy are discussed to promote an understanding of how such concepts may change the role of radiation in the future.
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Affiliation(s)
- Colin S Hill
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Grossman School of Medicine, New York, NY.
| | - Joseph M Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY
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Brown ZJ, Heh V, Labiner HE, Brock GN, Ejaz A, Dillhoff M, Tsung A, Pawlik TM, Cloyd JM. Surgical resection rates after neoadjuvant therapy for localized pancreatic ductal adenocarcinoma: meta-analysis. Br J Surg 2022; 110:34-42. [PMID: 36346716 DOI: 10.1093/bjs/znac354] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 09/22/2022] [Accepted: 09/30/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Neoadjuvant therapy is increasingly being used before surgery for localized pancreatic cancer. Given the importance of completing multimodal therapy, the aim of this study was to characterize surgical resection rates after neoadjuvant therapy as well as the reasons for, and long-term prognostic impact of, not undergoing resection. METHODS A systematic review and meta-analysis of prospective trials and high-quality retrospective studies since 2010 was performed to calculate pooled resection rates using a generalized random-effects model for potentially resectable, borderline resectable, and locally advanced pancreatic cancer. Median survival times were calculated using random-effects models for patients who did and did not undergo resection. RESULTS In 125 studies that met the inclusion criteria, neoadjuvant therapy consisted of chemotherapy (36.8 per cent), chemoradiation (15.2 per cent), or chemotherapy and radiation (48.0 per cent). Among 11 713 patients, the pooled resection rates were 77.4 (95 per cent c.i. 71.3 to 82.5), 60.6 (54.8 to 66.1), and 22.2 (16.7 to 29.0) per cent for potentially resectable, borderline resectable, and locally advanced pancreatic cancer respectively. The most common reasons for not undergoing resection were distant progression for resectable and borderline resectable cancers, and local unresectability for locally advanced disease. Among 42 studies with survival data available, achieving surgical resection after neoadjuvant therapy was associated with improved survival for patients with potentially resectable (median 38.5 versus 13.3 months), borderline resectable (32.3 versus 13.9 months), and locally advanced (30.0 versus 14.6 months) pancreatic cancer (P < 0.001 for all). CONCLUSION Although rates of surgical resection after neoadjuvant therapy vary based on anatomical stage, surgery is associated with improved survival for all patients with localized pancreatic cancer. These pooled resection and survival rates may inform patient-provider decision-making and serve as important benchmarks for future prospective trials.
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Affiliation(s)
- Zachary J Brown
- Division of Surgical Oncology, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Victor Heh
- Division of Surgical Oncology, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Biomedical Informatics and Center for Biostatistics, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hanna E Labiner
- Division of Surgical Oncology, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Guy N Brock
- Department of Biomedical Informatics and Center for Biostatistics, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Division of Surgical Oncology, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Chase M, Friedman HS, Joo S, Navaratnam P. Adjuvant and neoadjuvant treatment patterns among resectable pancreatic cancer patients in the USA. Future Oncol 2022; 18:3929-3939. [PMID: 36520480 DOI: 10.2217/fon-2021-1583] [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: 12/23/2022] Open
Abstract
Aim: Chemotherapy is standard before and/or after pancreatic cancer resection, yet benefits of pre-resection chemotherapy are unclear. Real-world pre- and post-resection treatment patterns were evaluated retrospectively. Methods: Neoadjuvant (3-months pre-surgery) and adjuvant (6-months post-surgery) treatment claims from 1 January 2016 to 31 December 2019 in US adults with resectable pancreatic cancer were analyzed. Results: Of the 737 patients, 29% received no chemotherapy in either setting; 22% received chemotherapy in both settings. In the neoadjuvant and adjuvant settings, 69 and 33% of patients, respectively, received no treatment at all. FOLFIRINOX and gemcitabine monotherapy were the most common chemotherapies in the neoadjuvant and adjuvant settings, respectively. Adjuvant FOLFIRINOX increased post-2018, whereas gemcitabine-based regimens decreased. Conclusion: Several chemotherapy regimens were used in both settings. Treatment patterns differed between the two settings.
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Ivey GD, Shoucair S, Delitto DJ, Habib JR, Kinny-Köster B, Shubert CR, Lafaro KJ, Cameron JL, Burns WR, Burkhart RA, Thompson EL, Narang A, Zheng L, Wolfgang CL, He J. Postoperative Chemotherapy is Associated with Improved Survival in Patients with Node-Positive Pancreatic Ductal Adenocarcinoma After Neoadjuvant Therapy. World J Surg 2022; 46:2751-2759. [PMID: 35861852 PMCID: PMC9532378 DOI: 10.1007/s00268-022-06667-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Postoperative chemotherapy following pancreatic cancer resection is the standard of care. The utility of postoperative chemotherapy for patients who receive neoadjuvant therapy (NAT) is unclear. METHODS Patients who underwent pancreatectomy after NAT with FOLFIRINOX or gemcitabine-based chemotherapy for non-metastatic pancreatic adenocarcinoma (2015-2019) were identified. Patients who received less than 2 months of neoadjuvant chemotherapy or died within 90 days from surgery were excluded. RESULTS A total of 427 patients (resectable, 22.2%; borderline resectable, 37.9%; locally advanced, 39.8%) were identified with the majority (69.3%) receiving neoadjuvant FOLFIRINOX. Median duration of NAT was 4.1 months. Following resection, postoperative chemotherapy was associated with an improved median overall survival (OS) (28.7 vs. 20.4 months, P = 0.006). Risk-adjusted multivariable modeling showed negative nodal status (N0), favorable pathologic response (College of American Pathologists score 0 & 1), and receipt of postoperative chemotherapy to be independent predictors of improved OS. Regimen, duration, and number of cycles of NAT were not significant predictors. Thirty-four percent (60/176) of node-positive and 50.1% (126/251) of node-negative patients did not receive postoperative chemotherapy due to poor functional status, postoperative complications, and patient preference. Among patients with node-positive disease, postoperative chemotherapy was associated with improved median OS (27.2 vs. 10.5 months, P < 0.001). Among node-negative patients, postoperative chemotherapy was not associated with a survival benefit (median OS, 30.9 vs. 36.9 months; P = 0.406). CONCLUSION Although there is no standard NAT regimen for patients with pancreatic cancer, postoperative chemotherapy following NAT and resection appears to be associated with improved OS for patients with node-positive disease.
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Affiliation(s)
- Gabriel D Ivey
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sami Shoucair
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel J Delitto
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph R Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Christopher R Shubert
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly J Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth L Thompson
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol Narang
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Long term assessment of antibiotic prophylaxis and biliary microbiome in pancreaticoduodenectomy. HPB (Oxford) 2022; 24:1861-1868. [PMID: 35918214 DOI: 10.1016/j.hpb.2022.07.005] [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: 03/23/2022] [Revised: 06/07/2022] [Accepted: 07/08/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Surgical site infections (SSI) can represent a major complication of pancreaticoduodenectomy (PD). We summarize the outcomes of process improvement efforts to reduce the SSI rates in PD that includes replacing Cefazolin with Ceftriaxone-Metronidazole as antibiotic prophylaxis. Additional efforts included current assessment of biliary microbiome and potential prophylactic failures based on bile cultures and suspected antibiotic allergies. METHOD A single-center review of PD patients from January-2012 to March-2021. Study groups were divided into Pre and Post May-2015 (Group 1 and 2, respectively) when Ceftriaxone-Metronidazole prophylaxis and routine intraoperative cultures were standardized. Univariate and multivariable analyses were conducted to assess groups' differences and association with SSI. RESULTS Six hundred ninety patients identified [267(38.7%) and 423(61.3%) in Group 1 and Group2, respectively]. After antibiotic change, SSI rates decreased from 28.1% to 16.5% (incisional: 17.6%-7.5%, organ-space or abscess: 17.2%-13.0%), Group 1 and Group 2, respectively, P<0.001. Ceftriaxone-Metronidazole was used in 75.9% of patients Group 2. When adjusting for other covariates, an SSI-decrease was associated only with Ceftriaxone-Metronidazole (OR 0.34, P<0.001). CONCLUSIONS Ongoing process improvement has resulted in decreased SSIs with Ceftriaxone-Metronidazole prophylaxis. The benefit of Ceftriaxone-Metronidazole is independent of the biliary microbiome. Improving prophylaxis for those with suspected penicillin allergy is warranted.
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Al Abbas AI, Hamad AB, Zenati MS, Zureikat AH, Zeh HJ, Hogg ME. Does CT scanning after pancreatoduodenectomy reduce readmission rates: an analysis of 900 resections at a high-volume center. HPB (Oxford) 2022; 24:1770-1779. [PMID: 35871133 DOI: 10.1016/j.hpb.2022.06.012] [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: 02/08/2022] [Revised: 06/18/2022] [Accepted: 06/27/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) remains associated with significant complication and readmission rates. Infection constitutes a significant proportion of morbidity. We aim to evaluate whether CT scans performed prior to discharge for suspected infection prevents readmission. METHODS A retrospective review of patients undergoing PD at a tertiary referral center from 2010 to 2018. RESULTS A total of 982 patients underwent PD: 74% had no clinical infection at the index admission. Of the non-infected patients, 59% exhibited leukocytosis, 27% underwent a CT scan, and 33.6% were readmitted. Of the non-infected patients, 148 (20.3%) experienced major complications, and this was the strongest predictor of readmission (OR: 10.5, [95% CI: 6.5-17], p = 0.0001). In the non-infected patients who had major complications, CT scanning was predictive of lower risk of readmission (OR: 0.38, [95% CI: 0.17-0.83], p = 0.015). Leukocytosis was also found to be predictive of lower risk of readmission (OR: 0.42, [95% CI: 0.18-0.98], p = 0.044). These findings did not hold true for those who had yet to experience major complications on their index admission. CONCLUSION CT scanning without evidence of infection was associated with reduction of readmission in the cohort with major complications and showed a trend towards preventing readmission in the overall cohort. Development of clinical algorithms to maximize the utility of this test is warranted.
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Affiliation(s)
- Amr I Al Abbas
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Mazen S Zenati
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amer H Zureikat
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert J Zeh
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Wei JP, Tai S, Su ZL. One-half layer pancreaticojejunostomy with the rear wall of the pancreas reinforced: A valuable anastomosis technique. World J Clin Cases 2022; 10:9276-9284. [PMID: 36159416 PMCID: PMC9477674 DOI: 10.12998/wjcc.v10.i26.9276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 03/26/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is one of the most common and serious complications after pancreaticoduodenectomy (PD). To effectively reduce the incidence of POPF, we designed a new type of pancreaticojejunostomy (PJ), which was termed one-half layer PJ with the rear wall of the pancreas reinforced.
AIM To explore the clinical application value of this new technique.
METHODS We compared 62 patients who had undergone PD by either the traditional duct-to-mucosa anastomoses or the new one-half layer PJ with the rear wall of the pancreas reinforced method at our hospital from May 2015 to September 2019. All 62 patients were operated by the same surgeon experienced in both procedures. We retrospectively analyzed patient characteristics, perioperative outcomes, and surgical results.
RESULTS There was no significant difference between the two groups in basic information except the postoperative hospital stays, 14.7 ± 5.4 d in the traditional duct-to-mucosa anastomoses group and 12.0 ± 4.2 d in the one-half layer PJ group (P = 0.042). In terms of postoperative complications, the one-half layer PJ group had a lower rate of POPF than the traditional group. The overall number of cases with POPF was 8 (24.2%) in the traditional group and 2 (6.9%) in the one-half layer group (P = 0.017). Additionally, the rate of grades B and C POPF was lower in the one-half layer group (3.4%) compared with that (12.1%) in the traditional group (P = 0.010). One patient died due to hemorrhage caused by severe pancreatic fistula in the traditional group.
CONCLUSION One-half layer PJ with the rear wall of the pancreas reinforced is a safe and feasible procedure that can successfully reduce the rate of POPF. It may be a promising technique for PJ after PD.
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Affiliation(s)
- Jin-Ping Wei
- Department of General Surgery, Beijing Chuiyangliu Hospital, Beijing 100022, China
| | - Sheng Tai
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
| | - Zhi-Lei Su
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
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Marcus R, Christopher W, Keller J, Nassoiy S, Chang SC, Goldfarb M, Wolf R, Jutric Z. Systemic Therapy Is Associated with Improved Oncologic Outcomes in Resectable Stage II/III Intrahepatic Cholangiocarcinoma: An Examination of the National Cancer Database over the Past Decade. Cancers (Basel) 2022; 14:4320. [PMID: 36077855 PMCID: PMC9454548 DOI: 10.3390/cancers14174320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/19/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Limited evidence-based management guidelines for resectable intrahepatic cholangiocarcinoma (ICC) currently exist. Using a large population-based cancer registry; the utilization rates and outcomes for patients with clinical stages I-III ICC treated with neoadjuvant chemotherapy (NAT) in relation to other treatment strategies were investigated, as were the predictors of treatment regimen utilization. Oncologic outcomes were compared between treatment strategies. Amongst 2736 patients, chemotherapy utilization was low; however, NAT use increased from 4.3% to 7.2% (p = 0.011) over the study period. A higher clinical stage was predictive of the use of NAT, while higher pathologic stage and margin-positive resections were predictive of the use of adjuvant therapy (AT). For patients with more advanced disease, the receipt of NAT or AT was associated with significantly improved survival compared to surgery alone (cStage II, p = 0.040; cStage III, p = 0.003). Furthermore, patients receiving NAT were more likely to undergo margin-negative resections compared to those treated with AT (72.5% vs. 62.6%, p = 0.027), despite having higher-risk tumors. This analysis of treatment strategies for resectable ICC suggests a benefit for systemic therapy. Prospective and randomized studies evaluating the sequencing of treatments for patients with high-risk resectable ICC are needed.
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Affiliation(s)
- Rebecca Marcus
- Department of Surgical Oncology, Providence Saint John’s Cancer Institute, Santa Monica, CA 90404, USA
| | - Wade Christopher
- Department of Surgical Oncology, Providence Saint John’s Cancer Institute, Santa Monica, CA 90404, USA
| | - Jennifer Keller
- Department of Surgical Oncology, Providence Saint John’s Cancer Institute, Santa Monica, CA 90404, USA
| | - Sean Nassoiy
- Department of Surgical Oncology, Providence Saint John’s Cancer Institute, Santa Monica, CA 90404, USA
| | - Shu-Ching Chang
- Medical Data Research Center, Providence Saint Joseph Health, Portland, OR 97229, USA
| | - Melanie Goldfarb
- Department of Surgical Oncology, Providence Saint John’s Cancer Institute, Santa Monica, CA 90404, USA
| | - Ronald Wolf
- Division of Hepatobiliary and Pancreas Surgery, University of California Irvine, Orange, CA 92868, USA
| | - Zeljka Jutric
- Division of Hepatobiliary and Pancreas Surgery, University of California Irvine, Orange, CA 92868, USA
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Záruba P, Rousek M, Kočišová T, Havlová K, Ryska M, Pohnán R. A comparison of surgical approaches in the treatment of grade C postoperative pancreatic fistula: A retrospective study. Front Surg 2022; 9:927737. [PMID: 36017512 PMCID: PMC9395924 DOI: 10.3389/fsurg.2022.927737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostoperative pancreatic fistula is one of the most dreaded complications following pancreatic resections with Grade C the most severe. Several possible types of surgical intervention are available but to date, none of them have clearly shown superiority. This study aims to compare different surgical approaches.MethodsA retrospective analysis of patients who underwent revision surgery for postoperative pancreatic fistula between 2008 and 2020 was performed. Three surgical approaches were compared: open drainage; a disconnection of the pancreaticojejunostomy; and salvage total pancreatectomy. The data of nine monitored parameters were collected. Selected parameters were statistically analyzed and compared.ResultsA total of 54 patients were included. Eighteen patients underwent open drainage, 28 had disconnections of the pancreaticojejunostomy and eight had salvage total pancreatectomy. Statistically significant differences were observed in the time of Intensive Care Unit stay, the number of surgical interventions, 90-day mortality, the number of administered blood transfers and treatment costs. Open drainage showed to be superior in each category. The difference in long-term survival also slightly favored simple drainage.ConclusionOpen drainage procedure showed to be superior to other types of interventions in most of the monitored parameters. Disconnection of the pancreaticojejunostomy and a salvage total pancreatectomy had similar results, which correlated with the surgical burden of these interventions.
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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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Weng Y, Shen Z, Gemenetzis G, Jin J, Chen H, Deng X, Peng C, Shen B. Oncological outcomes of robotic pancreatectomy in patients with pancreatic cancer who receive adjuvant chemotherapy: A propensity score-matched retrospective cohort study. Int J Surg 2022; 104:106801. [DOI: 10.1016/j.ijsu.2022.106801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/25/2022]
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Loveček M, Skalický P, Urban O, Tesaříková J, Kliment M, Psár R, Švébišová H, Urban K, Mohelníková-Duchoňová B, Klos D, Stašek M. Isolated Gastric Metastases of Pancreatic Ductal Adenocarcinoma following Radical Resection—Impact of Endosonography-Guided Fine Needle Aspiration Tract Seeding. Biomedicines 2022; 10:biomedicines10061392. [PMID: 35740414 PMCID: PMC9220227 DOI: 10.3390/biomedicines10061392] [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: 04/16/2022] [Revised: 05/06/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Endosonography-guided fine needle aspiration biopsy (EUS-FNA)-associated metachronous gastric seeding metastases (GSM) of pancreatic ductal adenocarcinoma (PDAC) represent a serious condition with insufficient evidence. Methods: Retrospective analysis of PDAC resections with a curative-intent, proven pathological diagnosis of PDAC, preoperative EUS-FNA and post-resection follow-up of at least 60 months. The systematic literature search of published data was used for the GSM growth evaluation using Pearson correlation and the linear regression analyses. Results: The inclusion criteria met 59/134 cases, 16 (27%) had retained needle tract (15 following distal pancreatectomy, 1 following pylorus-sparing head resection). In total, 3/16 cases (19%) developed identical solitary GSM (10–26th month following primary surgery) and were radically resected. A total of 30 published cases of PDAC GSM following EUS-FNA were identified. Lesion was resected in 20 distal pancreatectomy cases with complete information in 14 cases. A correlation between the metastasis size and time (r = 0.612) was proven. The regression coefficient b = 0.72 expresses the growth of 0.72 mm per month. Conclusions: The GSM represent a preventable and curable condition. A remarkably high number of GSM following EUS-FNA was identified, leading to follow-up recommendation of EUS-FNA sampled patients. Multimodal management (gastric resection, adjuvant chemotherapy) may prolong survival.
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Affiliation(s)
- Martin Loveček
- Department of Surgery I, University Hospital Olomouc, I.P. Pavlova 185/6, 77900 Olomouc, Czech Republic; (M.L.); (P.S.); (J.T.); (D.K.)
| | - Pavel Skalický
- Department of Surgery I, University Hospital Olomouc, I.P. Pavlova 185/6, 77900 Olomouc, Czech Republic; (M.L.); (P.S.); (J.T.); (D.K.)
| | - Ondřej Urban
- Department of Internal Medicine II—Gastroentrology and Geriatrics, University Hospital Olomouc, I.P. Pavlova 185/6, 77900 Olomouc, Czech Republic;
| | - Jana Tesaříková
- Department of Surgery I, University Hospital Olomouc, I.P. Pavlova 185/6, 77900 Olomouc, Czech Republic; (M.L.); (P.S.); (J.T.); (D.K.)
| | - Martin Kliment
- Helios Kliniken Schwerin, Klinik für Gastroenterologie und Infektiologie, Wismarsche Strasse 393-397, 19055 Schwerin, Germany;
| | - Róbert Psár
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hněvotínská 976/3, 77900 Olomouc, Czech Republic;
| | - Hana Švébišová
- Department of Oncology, University Hospital Olomouc, I.P. Pavlova 185/6, 77900 Olomouc, Czech Republic;
| | - Kateřina Urban
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacký University, Olomouc, Hněvotínská 1333/5, 77900 Olomouc, Czech Republic; (K.U.); (B.M.-D.)
| | - Beatrice Mohelníková-Duchoňová
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacký University, Olomouc, Hněvotínská 1333/5, 77900 Olomouc, Czech Republic; (K.U.); (B.M.-D.)
- Department of Oncology, Faculty of Medicine and Dentistry, Palacký University, Hněvotínská 976/3, 77900 Olomouc, Czech Republic
| | - Dušan Klos
- Department of Surgery I, University Hospital Olomouc, I.P. Pavlova 185/6, 77900 Olomouc, Czech Republic; (M.L.); (P.S.); (J.T.); (D.K.)
| | - Martin Stašek
- Department of Surgery I, University Hospital Olomouc, I.P. Pavlova 185/6, 77900 Olomouc, Czech Republic; (M.L.); (P.S.); (J.T.); (D.K.)
- Correspondence: ; Tel.: +42-058-844-2962
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Kaslow SR, Prendergast K, Vitiello GA, Hani L, Berman RS, Lee AY, Correa-Gallego C. Systemic therapy for duodenal adenocarcinoma: An analysis of the National Cancer Database (NCDB). Surgery 2022; 172:358-364. [DOI: 10.1016/j.surg.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/21/2022] [Accepted: 03/03/2022] [Indexed: 10/18/2022]
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Davis CH, Beane JD, Gazivoda VP, Grandhi MS, Greenbaum AA, Kennedy TJ, Langan RC, August DA, Alexander HR, Pitt HA. Neoadjuvant Therapy for Pancreatic Cancer: Increased Use and Improved Optimal Outcomes. J Am Coll Surg 2022; 234:436-443. [PMID: 35290262 DOI: 10.1097/xcs.0000000000000095] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The introduction of more effective chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to assess the evolving use of NAT in individuals with PDAC undergoing pancreatoduodenectomy (PD) and to compare their outcomes with patients undergoing upfront operation. STUDY DESIGN The American College of Surgeons NSQIP Procedure Targeted Pancreatectomy database was queried from 2014 to 2019. Patients undergoing pancreatoduodenectomy were evaluated based on the use of NAT versus upfront operation. Multivariable analysis was performed to determine the effect of NAT on postoperative outcomes, including the composite measure optimal pancreatic surgery (OPS). Mann-Kendall trend tests were performed to assess the use of NAT and associated outcomes over time. RESULTS A total of 13,257 patients were identified who underwent PD for PDAC between 2014 and 2019. Overall, 33.6% of patients received NAT. The use of NAT increased steadily from 24.2% in 2014 to 42.7% in 2019 (p < 0.0001). On multivariable analysis, NAT was associated with reduced serious morbidity (odds ratio [OR] 0.83, p < 0.001), clinically relevant pancreatic fistulas (OR 0.52, p < 0.001), organ space infections (OR 0.74, p < 0.001), percutaneous drainage (OR 0.73, p < 0.001), reoperation (OR 0.76, p = 0.005), and prolonged length of stay (OR 0.63, p < 0.001). OPS was achieved more frequently in patients undergoing NAT (OR 1.433, p < 0.001) and improved over time in patients receiving NAT (50.7% to 56.6%, p < 0.001). CONCLUSION NAT before pancreatoduodenectomy increased more than 3-fold over the past decade and was associated with improved optimal operative outcomes.
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Affiliation(s)
- Catherine H Davis
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Joal D Beane
- Division of Surgical Oncology, The Ohio State University, Columbus, OH (Beane)
| | - Victor P Gazivoda
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Miral S Grandhi
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Alissa A Greenbaum
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Timothy J Kennedy
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Russell C Langan
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- the Department of Surgery, Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, NJ (Langan)
| | - David A August
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - H Richard Alexander
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
| | - Henry A Pitt
- From the Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School, New Brunswick, NJ (Davis, Gazivoda, Grandhi, Greenbaum, Kennedy, Langan, August, Alexander, Pitt)
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