1
|
Radulova-Mauersberger O, von Bechtolsheim F, Teske C, Hempel S, Kroesen L, Pecqueux M, Kahlert C, Weitz J, Distler M, Oehme F. Preoperative anaemia in distal pancreatectomy: a propensity-score matched analysis. Langenbecks Arch Surg 2024; 409:119. [PMID: 38602554 PMCID: PMC11008068 DOI: 10.1007/s00423-024-03300-4] [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: 10/23/2023] [Accepted: 03/26/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Preoperative anaemia is a prevalent morbidity predictor that adversely affects short- and long-term outcomes of patients undergoing surgery. This analysis aimed to investigate preoperative anaemia and its detrimental effects on patients after distal pancreatectomy. MATERIAL AND METHODS The present study was a propensity-score match analysis of 286 consecutive patients undergoing distal pancreatectomy. Patients were screened for preoperative anaemia and classified according to WHO recommendations. The primary outcome measure was overall morbidity. The secondary endpoints were in-hospital mortality and rehospitalization. RESULTS The preoperative anaemia rate before matching was 34.3% (98 patients), and after matching a total of 127 patients (non-anaemic 42 vs. anaemic 85) were included. Anaemic patients had significantly more postoperative major complications (54.1% vs. 23.8%; p < 0.01), a higher comprehensive complication index (26.2 vs. 4.3; p < 0.01), and higher in-hospital mortality rate (14.1% vs. 2.4%; p = 0.04). Multivariate regression analysis confirmed these findings and identified preoperative anaemia as a strong independent risk factor for postoperative major morbidity (OR 4.047; 95% CI: 1.587-10.320; p < 0.01). CONCLUSION The current propensity-score matched analysis strongly considered preoperative anaemia as a risk factor for major complications following distal pancreatectomy. Therefore, an intense preoperative anaemia workup should be increasingly prioritised.
Collapse
Affiliation(s)
- Olga Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Felix von Bechtolsheim
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.
| | - Christian Teske
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Louisa Kroesen
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Mathieu Pecqueux
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| |
Collapse
|
2
|
Jeune F, Collard M, Augustin J, Guedj N, Marchese U, Rouquette A, Cunha AS, Sebagh M, Pessaux P, Avérous G, Wagner M, Bachet JB, Vaillant JC, Sauvanet A, Gaujoux S. Splenic vein tumor thrombosis is a major prognostic factor in distal pancreatic adenocarcinoma. Surgery 2024; 175:1111-1119. [PMID: 38071135 DOI: 10.1016/j.surg.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/11/2023] [Accepted: 10/25/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND The prognostic value of splenic vessel involvement in distal pancreatic adenocarcinoma remains controversial. The aim of the study was to assess its prognostic relevance in a large multicenter cohort. METHODS Patients who underwent pancreatosplenectomy for distal pancreatic adenocarcinoma were identified from 5 pancreatic surgical centers. A pathology review of the surgical specimens was performed to assess splenic vessel involvement, defined as invasion of the vessel's adventitia or deeper, and confirm the presence of splenic vein tumor thrombosis. Prognostic factors associated with overall and relapse-free survival were evaluated. RESULTS 149 patients underwent upfront surgery. Splenic vascular involvement was observed in 69 of them (46.3%). A parietal infiltration of the splenic artery or splenic vein was observed in 26 (17.5%) and 49 patients (32.8%), respectively. A pathologic tumor thrombosis of the splenic vein was identified in 22 patients (14.8%) and associated with larger tumors (>20 mm) (P = .023), more perineural (P = .017), and lymphovascular (P = .002) invasion, and more positive lymph node (P = .001). After a median follow-up of 50.8 months (95% confidence interval: 44.3-57.3), the cumulative 5-year overall and relapse-free survival were 46.2% and 33%, respectively. In multivariate analysis, in addition to lymph node metastasis (hazard ratio = 1.8; 95% confidence interval [1.1-3.1]; P = .023) and perineural invasion (hazard ratio = 3.5; 95% confidence interval [1.3-9.7]; P = .016), presence of splenic vein tumor thrombosis was the only splenic vascular involvement that affected independently the overall survival (HR = 2.3; 95% confidence interval [ 1.3-4.3]; P = .006). CONCLUSION In resectable distal pancreatic adenocarcinoma, a pathologic tumor thrombosis of the splenic vein is an independent prognostic factor of overall survival. To define the perioperative oncological strategy, a preoperative evaluation of splenic vessel involvement and thrombosis is needed.
Collapse
Affiliation(s)
- Florence Jeune
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France.
| | - Maxime Collard
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, APHP, Beaujon Hospital, University of Paris-Cité, Clichy, France
| | - Jérémy Augustin
- Department of Pathology, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Nathalie Guedj
- Department of Pathology, AP-HP, Beaujon Hospital, Clichy, France
| | - Ugo Marchese
- Department of Digestive and Endocrine Surgery, AP-HP, Cochin Hospital, Paris, France
| | | | - Antonio Sa Cunha
- Department of Hepato-Biliary-Pancreatic Surgery, Liver Center Transplant, Paul Brousse Hospital, Paris-Saclay University, Villejuif, France
| | - Mylène Sebagh
- Department of Pathology, Paul Brousse Hospital, Paris-Saclay University, Villejuif, France
| | - Patrick Pessaux
- Department of Viscerale and Digestive surgery, Nouvel Hopital Civil, University of Strasbourg, Strasbourg, France
| | - Gerlinde Avérous
- Department of Pathology, Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Mathilde Wagner
- Department of Radiology, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Jean-Baptiste Bachet
- Department of Hepatogastroenterology and Digestive Oncology, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Jean-Christophe Vaillant
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Alain Sauvanet
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, APHP, Beaujon Hospital, University of Paris-Cité, Clichy, France
| | - Sébastien Gaujoux
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France; Department of Digestive and Endocrine Surgery, AP-HP, Cochin Hospital, Paris, France
| |
Collapse
|
3
|
Aaquist T, Fristrup CW, Hasselby JP, Hamilton-Dutoit S, Eld M, Pfeiffer P, Mortensen MB, Detlefsen S. Prognostic value of margin clearance in total and distal pancreatectomy specimens with pancreatic ductal adenocarcinoma in a Danish population-based nationwide study. Pathol Res Pract 2024; 254:155077. [PMID: 38277754 DOI: 10.1016/j.prp.2023.155077] [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: 09/18/2023] [Revised: 12/27/2023] [Accepted: 12/30/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND The prognostic role of resection margin status following total (TP) and distal (DP) pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) is insufficiently evaluated. In Denmark, pancreatic surgery, including the postoperative pathological examination of the resection specimens, is confined to four centres, all reporting to the Danish Pancreatic Cancer Database (DPCD). In this Danish population-based nationwide study on TP and DP for PDAC from 2015-2019, based on data from DPCD, we evaluated whether there is a prognostically relevant minimum margin clearance definition and whether certain margins hold independent prognostic information. METHODS Clinical and pathological data were retrieved from DPCD and supplemented by review of pathology reports and re-microscopy, if needed. One of the study pathologists performed all re-microscopy. The prognostic significance of margin status was evaluated by dichotomisation of the TP cohort (n = 101) and the DP cohort (n = 90) into involved and uninvolved groups, using different clearance definitions (0.5 - ≥3.0 mm). RESULTS Following TP, direct involvement of the superior mesenteric artery (SMA) margin had independent prognostic value. When using a clearance definition of ≥ 0.5 or ≥ 1.5 mm for SMA, median survival for R0 versus R1 was 19 (95% CI 14-26) versus 10 (95% CI 5-20) months (p = 0.010), and 21 (95% CI 15-30) versus 10 (95% CI 8-19) months (p = 0.011), respectively. Overall margin status was not of significant prognostic importance following neither DP nor TP. CONCLUSION In this Danish population-based nationwide study, SMA margin involvement was a significant isolated prognostic factor following TP, whereas combined assessment of all circumferential margins did not hold statistically significant prognostic information. Following DP, resection margin status did not affect survival.
Collapse
Affiliation(s)
- Trine Aaquist
- Department of Pathology, Odense University Hospital, Odense, Denmark; Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Odense Patient data Exploratory Network-OPEN, Odense University Hospital, Odense, Denmark
| | - Claus W Fristrup
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Odense Patient data Exploratory Network-OPEN, Odense University Hospital, Odense, Denmark; Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Jane P Hasselby
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Mikkel Eld
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | - Per Pfeiffer
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Michael B Mortensen
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Pathology, Odense University Hospital, Odense, Denmark; Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Odense Patient data Exploratory Network-OPEN, Odense University Hospital, Odense, Denmark.
| |
Collapse
|
4
|
Ferrari C, Leon P, Falconi M, Boggi U, Piardi T, Sulpice L, Cavaliere D, Rosso E, Chirica M, Ravazzoni F, Memeo R, Pessaux P, De Blasi V, Mascherini M, De Cian F, Navarro F, Panaro F. Multi-visceral resection for left-sided pancreatic ductal adenocarcinoma: a multicenter retrospective analysis from European countries. Langenbecks Arch Surg 2023; 408:386. [PMID: 37776339 DOI: 10.1007/s00423-023-03110-0] [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: 03/12/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Due to delayed diagnosis and a lower surgical indication rate, left-sided pancreatic ductal adenocarcinoma (PDAC) is often associated with a poor prognosis in comparison to pancreatic head tumors. Multi-visceral resections (MVR) associated with distal pancreatectomy could be proposed for patients presenting with locally infiltrating disease. METHODS We retrospectively analyzed a multi-centric cohort of left-sided PDAC patients operated on from 2009 to 2020. Thirteen European high-volume HPB centers participated in this study. We analyzed patients who underwent distal pancreatectomy (DP) associated with MVR and compared them to standard DP patients. RESULTS Among 258 patients treated curatively for PDAC of the body and tail, 28 patients successfully underwent MVR. A longer operative time was observed in the MVR group (295 min +/- 74 vs. 250 min +/- 96, p= 0.248). The post-operative complication rate was comparable between the two groups (46.4% in the MVR group vs. 62.2% in the control group, p= 0.108). The incidence of positive margin (R1) was similar between the two groups (28.6% vs. 26.6%; p=0.827). After a median follow-up of 25 (9-111) months, overall survival was comparable between the two groups (p= 0.519). CONCLUSIONS Multi-visceral resection in left-sided pancreatic ductal adenocarcinoma is safe and feasible and should be considered in selected cases as it seems to provide acceptable surgical and oncological outcomes.
Collapse
Affiliation(s)
- Cecilia Ferrari
- HPB and Transplant Unit, University of Montpellier, Montpellier, France.
- Ospedale Policlinico San Martino, Genova, Italy.
| | - Piera Leon
- HPB and Transplant Unit, University of Montpellier, Montpellier, France
| | - Massimo Falconi
- Chirurgia Pancreatica, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Ugo Boggi
- Chirurgia HPB e Trapianto di Fegato, Ospedale Cisanello, Università degli Studi di Pisa, Pisa, Italy
| | | | | | | | - Edoardo Rosso
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | | | | | | | | | - Vito De Blasi
- Service de Chirurgie Générale et Mini-Invasive, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | | | | | - Francis Navarro
- HPB and Transplant Unit, University of Montpellier, Montpellier, France
| | - Fabrizio Panaro
- HPB and Transplant Unit, University of Montpellier, Montpellier, France
| |
Collapse
|
5
|
Bencini L, Minuzzo A. Distal pancreatectomy with or without radical approach, vascular resections and splenectomy: Easier does not always mean easy. World J Gastrointest Surg 2023; 15:1020-1032. [PMID: 37405088 PMCID: PMC10315131 DOI: 10.4240/wjgs.v15.i6.1020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/24/2023] [Accepted: 04/17/2023] [Indexed: 06/15/2023] Open
Abstract
Because distal pancreatectomy (DP) has no reconstructive steps and less frequent vascular involvement, it is thought to be the easier counterpart of pancreaticoduodenectomy. This procedure has a high surgical risk and the overall incidences of perioperative morbidity (mainly pancreatic fistula), and mortality are still high, in addition to the challenges that accompany delayed access to adjuvant therapies (if any) and prolonged impairment of daily activities. Moreover, surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes. From this perspective, new surgical approaches, and aggressive techniques, such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection, could lead to improved survival in those affected by more locally advanced tumors. Conversely, minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress. The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications, length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy. Because a dedicated multidisciplinary team is crucial to pancreatic surgery, hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign, borderline, and malignant diseases of the pancreas. The purpose of this review is to examine the state of the art in distal pancreatectomies, with a special focus on minimally invasive approaches and oncological-directed techniques. The widespread reproducibility, cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.
Collapse
Affiliation(s)
- Lapo Bencini
- Oncology and Robotic Surgery, Careggi Main Regional and University Hospital, Florence 50131, Italy
| | - Alessio Minuzzo
- Oncology and Robotic Surgery, Careggi Main Regional and University Hospital, Florence 50131, Italy
| |
Collapse
|
6
|
Funamizu N, Sogabe K, Shine M, Honjo M, Sakamoto A, Nishi Y, Matsui T, Uraoka M, Nagaoka T, Iwata M, Ito C, Tamura K, Sakamoto K, Ogawa K, Takada Y. Association between the Preoperative C-Reactive Protein-to-Albumin Ratio and the Risk for Postoperative Pancreatic Fistula following Distal Pancreatectomy for Pancreatic Cancer. Nutrients 2022; 14:nu14245277. [PMID: 36558435 PMCID: PMC9783157 DOI: 10.3390/nu14245277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) are major postoperative complications (POCs) following distal pancreatectomy (DP). Notably, POPF may worsen the prognosis of patients with pancreatic cancer. Previously reported risks for POCs include body mass index, pancreatic texture, and albumin levels. Moreover, the C-reactive protein-to-albumin ratio (CAR) is a valuable parameter for prognostication. On the other hand, POCs sometimes lead to a worse prognosis in several cancer types. Thus, we assumed that CAR could be a risk factor for POPFs. This study investigated whether CAR can predict POPF risk in patients with pancreatic cancer following DP. This retrospective study included 72 patients who underwent DP for pancreatic cancer at Ehime University between January 2009 and August 2022. All patients underwent preoperative CAR screening. Risk factors for POPF were analyzed. POPF were observed in 17 of 72 (23.6%) patients. POPF were significantly associated with a higher CAR (p = 0.001). The receiver operating characteristic curve analysis determined the cutoff value for CAR to be 0.05 (sensitivity: 76.5%, specificity: 88.9%, likelihood ratio: 6.88), indicating an increased POPF risk. Univariate and multivariate analysis revealed that CAR ≥ 0.05 was a statistically independent factor for POPF (p < 0.001, p = 0.013). Therefore, CAR has the potential to predict POPF following DP.
Collapse
Affiliation(s)
- Naotake Funamizu
- Correspondence: ; Tel.: +81-48-773-1111 (ext. 8625); Fax: +81-48-772-2205
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Holm MB, Verbeke CS. Prognostic Impact of Resection Margin Status on Distal Pancreatectomy for Ductal Adenocarcinoma. Curr Oncol 2022; 29:6551-6563. [PMID: 36135084 PMCID: PMC9498008 DOI: 10.3390/curroncol29090515] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic cancer is associated with a poor prognosis. While surgical resection is the only treatment option with curative intent, most patients die of locoregional and/or distant recurrence. The prognostic impact of the resection margin status has received much attention. However, the evidence is almost exclusively related to pancreatoduodenectomies, while corresponding data for distal pancreatectomy specimens are limited. The key data, such as the rate of microscopic margin involvement (“R1”), the site of margin involvement, and the impact of R1 on patient outcome, are divergent between studies and do not currently allow any general conclusions. The main reasons for the variability in the published data are the small size of the study cohorts and their heterogeneity, as well as the marked divergence in pathology examination practices. The latter is a consequence of the lack of concrete guidance, both for grossing and microscopic examination. The increasing administration of neoadjuvant chemo(radio)therapy introduces a further factor of uncertainty as the conventional definition of a tumour-free margin (“R0”) based on 1 mm clearance is inadequate for these specimens. This review discusses the published data regarding the prognostic impact of margin status in distal pancreatectomy specimens along with the challenges and uncertainties that are related to the assessment of the margins.
Collapse
Affiliation(s)
- Maia Blomhoff Holm
- Department of Pathology, Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
- Department of Pathology, Oslo University Hospital, 0424 Oslo, Norway
| | - Caroline Sophie Verbeke
- Department of Pathology, Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
- Department of Pathology, Oslo University Hospital, 0424 Oslo, Norway
- Correspondence: ; Tel.: +47-405-578-36
| |
Collapse
|
8
|
Turner KM, Delman AM, Ammann AM, Sohal D, Olowokure O, Choe KA, Smith MT, Kharofa JR, Ahmad SA, Wilson GC, Patel SH. Is There a Benefit to Adjuvant Chemotherapy in Resected, Early Stage Pancreatic Ductal Adenocarcinoma? Ann Surg Oncol 2022; 29:10.1245/s10434-022-11580-7. [PMID: 35357614 DOI: 10.1245/s10434-022-11580-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of systemic therapy for Stage IA pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim of our study was to evaluate the impact of adjuvant chemotherapy (AC) on survival in patients with early stage disease. METHODS The National Cancer Database was queried from 2006 to 2017 for resected pT1N0M0 (Stage 1A) PDAC. Exclusion criteria included neoadjuvant therapy, radiation, or those who suffered a 90-day mortality. RESULTS Of the 1526 patients included in the study, 42.2% received AC and 57.8% underwent surgery alone. Patients who received AC were younger, had fewer comorbidities, and were more likely to have private insurance, compared with those treated with surgery alone. Patients who received AC had longer median overall survival (OS) compared with those who underwent surgery alone (105.7 months vs 72.0 months, p < 0.01). Subset analyses based on individual "good" prognostic features (size ≤ 1.0 cm, lymphovascular invasion negative, well/moderately differentiated, margin negative resection) demonstrated improved OS with AC. Following propensity score matching based on key clinicopathologic features, AC remained associated with improved median OS (83.7 months vs 59.8 months, p < 0.01). However, in the cohort with body/tail tumors (101.2 months vs 95.0 months, p = 0.19) and those with all "good" prognostic features (95.9 months vs 90.6 months, p = 0.15), AC was not associated with improved survival. CONCLUSIONS In resected, Stage IA PDAC, AC is associated with improved overall survival in the vast majority of patients; however, in select cohorts the role of AC is unclear. Further study is needed to tailor treatment to individual patients with PDAC.
Collapse
Affiliation(s)
- Kevin M Turner
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aaron M Delman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Allison M Ammann
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Davendra Sohal
- Department of Internal Medicine, Division of Hematology & Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Olugbenga Olowokure
- Department of Internal Medicine, Division of Hematology & Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Milton T Smith
- Department of Internal Medicine, Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jordan R Kharofa
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| |
Collapse
|
9
|
Kyros E, Davakis S, Charalabopoulos A, Tsourouflis G, Papalampros A, Felekouras E, Nikiteas N. Role and Efficacy of Robotic-assisted Radical Antegrade Modular Pancreatosplenectomy (RAMPS) in Left-sided Pancreatic Cancer. CANCER DIAGNOSIS & PROGNOSIS 2022; 2:144-149. [PMID: 35399180 PMCID: PMC8962807 DOI: 10.21873/cdp.10088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/26/2022] [Indexed: 06/14/2023]
Abstract
Distal pancreatectomy with splenectomy is the gold-standard surgery for the treatment of left-sided pancreatic cancer. Margin negative resection accompanied by effective lymphadenectomy are the deciding factors affecting the outcome of tail-body pancreatic adenocarcinoma. Radical antegrade modular pancreatosplenectomy (RAMPS) is considered as a reasonable approach for margin-negative and systemic lymph node clearance. Herein, we aim to present all existing data regarding this novel approach including surgical technique and comparison with standardized procedures. RAMPS has shown oncological superiority comparing to distal pancreatectomy with splenectomy due to radical lymphadenectomy and improved dissection of the posterior pancreatic aspects. Robotic-assisted RAMPS has recently been described as a valuable alternative to open RAMPS. With this novel technique, anterior, posterior or modified approaches can be achieved; favorable clinical and oncological outcomes have been reported in the current literature, with reduced conversion rates compared to other minimally invasive approaches, as well as vastly improved maneuverability, accuracy and vision. Robotic-assisted RAMPS is not only technically feasible but also oncologically safe in cases of well-selected, left-sided pancreatic cancer.
Collapse
Affiliation(s)
- Eleandros Kyros
- First Department of Surgery, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Davakis
- First Department of Surgery, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Charalabopoulos
- First Department of Surgery, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Tsourouflis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Alexandros Papalampros
- First Department of Surgery, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Evangelos Felekouras
- First Department of Surgery, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Nikolaos Nikiteas
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| |
Collapse
|
10
|
Liu B, Wu J, Li C, Li Y, Qiu H, Lv A, Liu Q, Liu D, Wang Z, Hao C. The role of coeliac axis resection in resected ductal adenocarcinoma of the distal pancreas: A result of tumour topography or a prognostic factor? Pancreatology 2022; 22:112-122. [PMID: 34764022 DOI: 10.1016/j.pan.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/21/2021] [Accepted: 11/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Whether coeliac axis resection (CAR) results from tumour topography or a prognostic factor for distal pancreatic ductal adenocarcinoma (PDAC) remains unclear. We aimed to compare the clinicopathological data between distal pancreatectomy with en bloc CAR (DP-CAR) and distal pancreatectomy plus splenectomy (DP-S) and analyse the prognostic factors. METHODS We retrospectively analysed clinicopathological data from 102 patients who underwent distal pancreatectomy for PDAC and the factors affecting disease-free survival (DFS) and overall survival (OS). Of these patients, 45 and 57 underwent DP-CAR and DP-S, respectively. RESULTS DP-CAR was associated with more operative challenges than DP-S: more portomesenteric vein resections (48.9% vs. 14.0%), longer operations (320 vs. 242 min), and greater estimated blood loss (EBL) (600 vs. 200 ml). DP-CAR had larger tumours (5 vs. 4 cm), more perineural invasion (91.1% vs. 73.7%), and more microscopically positive surgical margins (20% vs. 3.5%), compared to DP-S. The major complication was clinically relevant postoperative pancreatic fistula (20.6%). The median DFS was 15.8 months and the median OS was 20.1 months. CAR was not associated with DFS or OS. EBL>700 ml, lymphovascular invasion (LVI), and adjuvant chemotherapy independently affected DFS and OS. CONCLUSION DP-CAR was associated with larger tumours and more surgical challenges but not with poorer DFS and OS than DP-S. CAR was more likely to result from tumour topography rather than from an adverse prognostic factor for resected distal PDAC. EBL>700 ml, LVI, and adjuvant chemotherapy were independent factors affecting the survival of patients with distal PDAC who underwent surgical resection.
Collapse
Affiliation(s)
- Bonan Liu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Jianhui Wu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Chengpeng Li
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Yang Li
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Hui Qiu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Ang Lv
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Qiao Liu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Daoning Liu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Zhen Wang
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Chunyi Hao
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China.
| |
Collapse
|
11
|
Kang JS, Choi YJ, Byun Y, Han Y, Kim JH, Lee JM, Sohn HJ, Kim H, Kwon W, Jang JY. Radiological tumour invasion of splenic artery or vein in patients with pancreatic body or tail adenocarcinoma and effect on recurrence and survival. Br J Surg 2021; 109:105-113. [PMID: 34718433 DOI: 10.1093/bjs/znab357] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 09/03/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Major vessel invasion is an important factor for determining the surgical approach and long-term prognosis for patients with pancreatic head cancer. However, clinical implications of vessel invasion have seldom been reported in pancreatic body or tail cancer. This study aimed to evaluate the clinical relevance of splenic vessel invasion with pancreatic body or tail cancer compared with no invasion and investigate prognostic factors. METHODS This study enrolled patients who underwent upfront distal pancreatectomy from 2005 to 2018. The circular degree of splenic vessel invasion was investigated and categorized into three groups (group 1, no invasion; group 2, 0-180°; group 3, 180° or more). Clinicopathological variables and perioperative and survival outcomes were evaluated, and multivariable Cox proportional analysis was performed to evaluate prognostic factors. RESULTS Among 249 enrolled patients, tumour size was larger in patients with splenic vessel invasion (3.9 versus 2.9 cm, P = 0.001), but the number of metastatic lymph nodes was comparable to that in patients with no vessel invasion (1.7 versus 1.4, P = 0.241). The 5-year overall survival rates differed significantly between the three groups (group 1, 38.4 per cent; group 2, 16.8 per cent; group 3, 9.7 per cent, P < 0.001). Patients with both splenic artery and vein invasion had lower 5-year overall survival rates than those with one vessel (7.5 versus 20.2 per cent, P = 0.021). Cox proportional analysis revealed adjuvant treatment, R0 resection and splenic artery invasion as independent prognostic factors for adverse outcomes in pancreatic body or tail cancer. CONCLUSION Splenic vessel invasion was associated with higher recurrence and lower overall survival in pancreatic body or tail cancers suggesting a need for a neoadjuvant approach.
Collapse
Affiliation(s)
- Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoo Jin Choi
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoonhyeong Byun
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung Min Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee Ju Sohn
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
12
|
Sahakyan MA, Verbeke CS, Tholfsen T, Ignjatovic D, Kleive D, Buanes T, Lassen K, Røsok BI, Labori KJ, Edwin B. Prognostic Impact of Resection Margin Status in Distal Pancreatectomy for Ductal Adenocarcinoma. Ann Surg Oncol 2021; 29:366-375. [PMID: 34296358 PMCID: PMC8677636 DOI: 10.1245/s10434-021-10464-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/29/2021] [Indexed: 02/05/2023]
Abstract
Background Resection margin status is considered one of the few surgeon-controlled parameters affecting prognosis in pancreatic ductal adenocarcinoma (PDAC). While studies mostly focus on resection margins in pancreatoduodenectomy, little is known about their role in distal pancreatectomy (DP). This study aimed to investigate resection margins in DP for PDAC. Methods Patients who underwent DP for PDAC between October 2004 and February 2020 were included (n = 124). Resection margins and associated parameters were studied in two consecutive time periods during which different pathology examination protocols were used: non-standardized (period 1: 2004–2014) and standardized (period 2: 2015–2020). Microscopic margin involvement (R1) was defined as ≤1 mm clearance. Results Laparoscopic and open resections were performed in 117 (94.4%) and 7 (5.6%) patients, respectively. The R1 rate for the entire cohort was 73.4%, increasing from 60.4% in period 1 to 83.1% in period 2 (p = 0.005). A significantly higher R1 rate was observed for the posterior margin (35.8 vs. 70.4%, p < 0.001) and anterior pancreatic surface (based on a 0 mm clearance; 18.9 vs. 35.4%, p = 0.045). Pathology examination period, poorly differentiated PDAC, and vascular invasion were associated with R1 in the multivariable model. Extended DP, positive anterior pancreatic surface, lymph node ratio, perineural invasion, and adjuvant chemotherapy, but not R1, were significant prognostic factors for overall survival in the entire cohort. Conclusions Pathology examination is a key determinant of resection margin status following DP for PDAC. A high R1 rate is to be expected when pathology examination is meticulous and standardized. Involvement of the anterior pancreatic surface affects prognosis. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10464-6.
Collapse
Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway. .,Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway. .,Department of Surgery N1, Yerevan State Medical University, Yerevan, Armenia.
| | - Caroline S Verbeke
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pathology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Tore Tholfsen
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Dejan Ignjatovic
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Dyre Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Trond Buanes
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristoffer Lassen
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Bård I Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Knut Jørgen Labori
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
13
|
Liu Q, Zhao G, Zhao Z, Zhang X, Gao Y, Tan X, Liu R. The standardized technique in robotic radical antegrade modular pancreatosplenectomy using the flip-up approach. Langenbecks Arch Surg 2021; 406:1697-1703. [PMID: 33585959 DOI: 10.1007/s00423-021-02113-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/02/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Radical antegrade modular pancreatosplenectomy (RAMPS) was first introduced in 2003. It has been accepted as an alternative technique for pancreatic cancer of the body and tail. However, robotic RAMPS is not yet popular because of its technical difficulty and lack of standardized technique. This study describes in detail the standard steps of robotic RAMPS using the flip-up approach with the benefit of a robotic view when treating pancreatic cancer of the body and tail. METHOD We took advantage of our single-center experience to provide a step-by-step technique of robotic RAMPS procedure using the da Vinci Si system. RESULTS We divided the procedure into 11 key steps. The surgical steps are optimized to achieve margin-negative curative resection and sufficient regional lymphadenectomy. The artery-first approach is usually used to determine tumor resectability early before performing an irreversible operative step. We also determine the borders of surgical resection and divide the splenic artery after dividing the pancreatic neck and the splenic vein, which facilitates a complete lymphadenectomy around the celiac axis with a bottom-up view. CONCLUSION Robotic RAMPS using the flip-up approach is safe and feasible in performing curative resection for well-selected pancreatic cancer of the body and tail. A randomized controlled trial comparing open and robotic RAMPS is needed in the future.
Collapse
Affiliation(s)
- Qu Liu
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Guodong Zhao
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Zhiming Zhao
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Xiuping Zhang
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yuanxing Gao
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Xianglong Tan
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Rong Liu
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China.
| |
Collapse
|
14
|
Driedger MR, Puig CA, Thiels CA, Bergquist JR, Ubl DS, Habermann EB, Grotz TE, Smoot RL, Nagorney DM, Cleary SP, Kendrick ML, Truty MJ. Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients. BMC Surg 2020; 20:169. [PMID: 32718311 PMCID: PMC7385869 DOI: 10.1186/s12893-020-00822-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/10/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND While emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown. METHODS ACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DP - distal pancreatectomy, PD - pancreaticoduodenectomy, or TP- total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of > 4 units RBCs in 72 h prior to resection. Chi-square tests, Fisher's exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types. RESULTS Of 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p < 0.001) for emergent vs. elective operations. Emergent operations resulted in increased transfusion rates (47.6% vs. 23.4%, p < 0.001), return to OR (14.0% vs. 5.6%, p < 0.001), organ-space infection (14.6 vs. 10.5, p = 0.002), unplanned intubation (9.% vs. 4.1%, p < 0.001), pneumonia (9.6% vs. 4.2%, p < 0.001), length of stay (14 days vs. 8 days, p < 0.001), and discharge to skilled facility (31.1% vs. 13.9%). These differences persisted when stratified by pancreatic resection type. The 30-day operative mortality was higher in the emergent group (9.4%vs. 2.7%, p < 0.001) and highest for emergent TP (20%). CONCLUSION Emergent pancreatic resection is markedly uncommon in the setting of neoplastic disease. Although these operations result in increased morbidity and mortality compared to elective resections, they can be life-saving in specific circumstances. The results of this large series of modern era national data may assist surgeons as well as patients and their families in making critical decisions in select cases of acutely complicated neoplastic disease.
Collapse
Affiliation(s)
- Michael R Driedger
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Carlos A Puig
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Cornelius A Thiels
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - John R Bergquist
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Daniel S Ubl
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Health Care Research and Policy, Mayo Clinic, Rochester, MN, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| |
Collapse
|
15
|
Korrel M, Lof S, van Hilst J, Alseidi A, Boggi U, Busch OR, van Dieren S, Edwin B, Fuks D, Hackert T, Keck T, Khatkov I, Malleo G, Poves I, Sahakyan MA, Bassi C, Abu Hilal M, Besselink MG. Predictors for Survival in an International Cohort of Patients Undergoing Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2020; 28:1079-1087. [PMID: 32583198 PMCID: PMC7801299 DOI: 10.1245/s10434-020-08658-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Indexed: 02/06/2023]
Abstract
Background Surgical factors, including resection of Gerota’s fascia, R0-resection, and lymph node yield, may be associated with survival after distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), but evidence from large multicenter studies is lacking. This study aimed to identify predictors for overall survival after DP for PDAC, especially those related to surgical technique. Patients and Methods Data from an international retrospective cohort including patients from 11 European countries and the USA who underwent DP for PDAC (2007–2015) were analyzed. Cox proportional hazard analyses were performed and included Gerota’s fascia resection, R0 resection, lymph node ratio, extended resection, and a minimally invasive approach. Results Overall, 1200 patients from 34 centers with median follow-up of 15 months [interquartile range (IQR) 5–31 months] and median survival period of 30 months [95% confidence interval (CI), 27–33 months] were included. Gerota’s fascia resection [hazard ratio (HR) 0.74; p = 0.019], R0 resection (HR 0.70; p = 0.006), and decreased lymph node ratio (HR 0.28; p < 0.001) were associated with improved overall survival, whereas extended resection (HR 1.75; p < 0.001) was associated with worse overall survival. A minimally invasive approach did not improve survival as compared with an open approach (HR 1.14; p = 0.350). Adjuvant chemotherapy (HR 0.67; p = 0.003) was also associated with improved overall survival. Conclusions This international cohort identified Gerota’s fascia resection, R0 resection, and decreased lymph node ratio as factors associated with improved overall survival during DP for PDAC. Surgeons should strive for R0 resection and adequate lymphadenectomy and could also consider Gerota’s fascia resection in their routine surgical approach. Electronic supplementary material The online version of this article (10.1245/s10434-020-08658-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- M Korrel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Lof
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - J van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, OLVG Oost, Amsterdam, The Netherlands
| | - A Alseidi
- Division of Hepatopancreatobiliary and Endocrine Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - U Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - O R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S van Dieren
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - B Edwin
- Department of HPB Surgery, The Intervention Center, Institute for Clinical Medicine, Oslo University Hospital, Oslo, Norway
| | - D Fuks
- Department of Surgery, Institut Mutualiste Montsouris, Paris, France
| | - T Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - T Keck
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - I Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russian Federation
| | - G Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - I Poves
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - M A Sahakyan
- Department of HPB Surgery, The Intervention Center, Institute for Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
| | - C Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - M Abu Hilal
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | | |
Collapse
|
16
|
Open and Minimal Approaches to Pancreatic Adenocarcinoma. Gastroenterol Res Pract 2020; 2020:4162657. [PMID: 32565781 PMCID: PMC7273371 DOI: 10.1155/2020/4162657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 11/01/2019] [Indexed: 12/24/2022] Open
Abstract
Surgical options and approaches to pancreatic cancer are changing in the current era. Neoadjuvant treatment strategies for pancreatic cancer combined with the increased use of minimal access surgical techniques mean that the modern pancreatic surgeon requires mastering a number of surgical approaches with to optimally manage patients. Whilst traditional open surgery remains the most frequent approach for surgery, the specific steps during surgery may need to be modified in light of the aforementioned neoadjuvant treatments. Robotic and laparoscopic approaches to pancreatic resection are feasible, but these surgical methods remain in their infancy. In this review article, we summarise the current surgical approaches to pancreatic cancer and how these are adapted to the minimal access setting with discussion of the patient outcome data.
Collapse
|
17
|
Lan J, Chen Y, Wang S, Zhou Y. Distal pancreatectomy with en bloc celiac axis resection for pancreatic cancer: a pooled analysis of 109 cases. Updates Surg 2020; 72:709-715. [PMID: 32495281 DOI: 10.1007/s13304-020-00826-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/29/2020] [Indexed: 12/19/2022]
Abstract
The aim of this study was to define the clinical outcome and prognostic determinants of distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for pancreatic body/tail cancer. A pooled data analysis was performed on individual data for patients who underwent DP-CAR for pancreatic body/tail cancer as identified by systematic literature search. A total of 32 articles involving 109 patients were eligible for inclusion. Postoperative morbidity and mortality were 53% and 4%, respectively. Preoperative abdominal and/or back pain was completely relieved immediately after surgery in 98% of patients. The 1, 3 and 5 years overall survival (OS) rates were 59%, 21% and 10%, and the median OS was 14 months. Patients who received neoadjuvant treatment had a median OS of 23 months. In conclusion, DP-CAR for locally advanced pancreatic body/tail cancer can be performed safely with low mortality and provides survival benefit when combined with neoadjuvant treatment.
Collapse
Affiliation(s)
- Jianfa Lan
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yufeng Chen
- Department of General Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Shijie Wang
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yanming Zhou
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China.
| |
Collapse
|
18
|
Zhang G, Kang Y, Zhang H, Wang F, Liu R. Robotic radical antegrade modular pancreatosplenectomy (RAMPS) versus standard retrograde pancreatosplenectomy (SRPS): study protocol for a randomized controlled trial. Trials 2020; 21:306. [PMID: 32245518 PMCID: PMC7119168 DOI: 10.1186/s13063-020-04250-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 03/13/2020] [Indexed: 11/24/2022] Open
Abstract
Background Data from meta-analysis suggest that robotic radical antegrade modular pancreatosplenectomy (RAMPS) is a safe and effective procedure for treating adenocarcinoma in the body or tail of the pancreas, and is oncologically superior to standard retrograde pancreatosplenectomy (SRPS). RAMPS is an operation that actively expands the scope of resection, and achieves a higher R0 resection rate and lymph nodes acquisition through expanded resection. However, previous studies on RAMPS were conducted under open and laparoscopic surgery. Robotic surgery, on the other hand, plays a role in ergonomics and offers several advantages, including less fatigue, tremor filtering, 7° of wrist-like motion, motion scaling, and three-dimensional vision. At present, there is still a world-wide lack of clinical studies to observe the safety and clinical efficacy of robotic RAMPS. Hence, prospective randomized controlled trials (RCTs) comparing robotic RAMPS and SRPS are required. We begin an RCT to compare short-term surgical and oncological outcomes of robotic RAMPS and SRPS in patients undergoing distal pancreatectomy. Methods This is a randomized, single-center clinical trial. All participants are adult patients with primary pancreatic cancer, who are undergoing RAMPS or SRPS. The primary endpoints are R0 rate (resection margins are classified by a margin to tumor distance ≥ 1 mm). The secondary endpoints are the number of harvested lymph nodes, perioperative complications and perioperative indicators (duration of surgery, blood loss, blood transfusion volume, costs). Discussion We are undertaking a prospective RCT to evaluate the surgical and oncological outcomes of robotic RAMPS. This procedure may become a standard approach to robotic pancreatosplenectomy. Trial registration Chinese Clinical Trial Registry: ChiCTR1900020833, Registered on 20 January 2019.
Collapse
Affiliation(s)
- Gong Zhang
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yuhao Kang
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Haifeng Zhang
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Fei Wang
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Rong Liu
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing, 100853, China.
| |
Collapse
|
19
|
Seaton M, Hanna A, Boutros C, Hanna N. Adjuvant therapy for pancreatic body or tail adenocarcinoma: a study of the National Cancer Database. Ther Adv Med Oncol 2019; 11:1758835919842438. [PMID: 31105777 PMCID: PMC6501493 DOI: 10.1177/1758835919842438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 01/23/2019] [Indexed: 01/19/2023] Open
Abstract
Background: The optimal multimodality therapy for pancreatic ductal adenocarcinoma in the body or tail of the pancreas (PDAC-BT) is unclear. The purpose of this study was to compare overall 5-year survival between patients treated with adjuvant chemotherapy, adjuvant chemoradiation, and surgery alone. Methods: Patients from the National Cancer Database (1998–2012) with resected stage I or II PDAC-BT were included. Overall survival between the three treatment groups was compared using Cox proportional-hazards regression, propensity-score matching, and the Kaplan–Meier method. Results: Of the 700 patients included in the analysis, 189 (27%) were treated with chemotherapy, 226 (32%) were treated with chemoradiation, and 285 (41%) were treated with surgery alone. Chemoradiation was associated with higher survival than surgery alone [adjusted hazard ratio (HRadj): 0.67; 95% confidence interval (CI): 0.54, 0.84; p = 0.001], but there was no difference between chemotherapy and chemoradiation (HRadj: 0.82; 95% CI: 0.65, 1.05; p = 0.115). In propensity-score matched cohorts, median survival was 24.1 months (95% CI: 20.4, 28.4) with chemotherapy and 25.4 months (95% CI: 22.1, 31.7) with chemoradiation (log-rank p = 0.122). Among patients with positive resection margins, chemoradiation was associated with higher survival compared with chemotherapy (HRadj: 0.54; 95% CI: 0.32, 0.92; p = 0.022). In this subgroup of the propensity-score matched cohorts, median survival was 9.5 months (95% CI: 8.4, 16.0) with chemotherapy and 18.3 months (95% CI: 11.6, 26.3) with chemoradiation (log-rank p = 0.011). Conclusion: In patients with resected pancreatic body or tail adenocarcinoma, adjuvant chemoradiation was associated with higher survival compared with surgery alone. Among patients with positive resection margins, adjuvant chemoradiation was associated with higher survival compared with adjuvant chemotherapy.
Collapse
Affiliation(s)
- Max Seaton
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Andrew Hanna
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Cherif Boutros
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA Department of Surgery, Tate Cancer Center, Baltimore Washington Medical Center, Glen Burnie, MD, USA
| | - Nader Hanna
- Professor of Surgery, University of Maryland Medical Center, 29 South Greene Street, Suite 600, Baltimore, MD 21201-1595, USA
| |
Collapse
|
20
|
Central pancreatectomy for benign or low-grade malignant pancreatic lesions - A single-center retrospective analysis of 116 cases. Eur J Surg Oncol 2019; 45:788-792. [DOI: 10.1016/j.ejso.2018.11.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/28/2018] [Indexed: 01/04/2023] Open
|
21
|
Watanabe G, Ito H, Sato T, Ono Y, Mise Y, Inoue Y, Takahashi Y, Saiura A. Left kidney mobilization technique during radical antegrade modular pancreatosplenectomy (RAMPS). Langenbecks Arch Surg 2019; 404:247-252. [PMID: 30810806 DOI: 10.1007/s00423-019-01767-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/18/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE Radical antegrade modular pancreatosplenectomy (RAMPS) has been accepted as a standard operation for distal pancreatic cancer. While enbloc retroperitoneal dissection in the "medial to lateral" direction is one of the most important steps in this oncologic procedure, it is technically challenging due to the depth of organs under the left costal margin, and poor exposure of the resecting organs in this area will increase the risk of incomplete oncologic dissection. METHODS To improve exposure of the left upper quadrant organs, left kidney was completely mobilized during RAMPS, and all the left upper quadrant organs were elevated and medialized by lap sponges packed in the retro-renal space. The operative and oncologic outcomes for patients who underwent our modified RAMPS with left kidney mobilization were evaluated. RESULTS One hundred and forty-four patients with distal pancreatic cancer underwent this procedure from 2005 through 2016. The median operation time was 310 min (range, 132-899), and blood loss was 440 ml (25-2430). There was no complication associated to left kidney mobilization. The median number of harvested lymph nodes was 27 (3-87). While 77% of the tumors had microscopic retroperitoneal invasion, 96% of patients achieved negative retroperitoneal margin. CONCLUSIONS Left kidney mobilization is useful for safe and oncologically sound lateral retroperitoneal dissection during RAMPS for distal pancreatic cancer.
Collapse
Affiliation(s)
- Genki Watanabe
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Mise
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.,Department of Surgery, Juntendo University Hospital, Hongo, Tokyo, Japan
| |
Collapse
|
22
|
Yang DJ, Xiong JJ, Lu HM, Wei Y, Zhang L, Lu S, Hu WM. The oncological safety in minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis. Sci Rep 2019; 9:1159. [PMID: 30718559 PMCID: PMC6362067 DOI: 10.1038/s41598-018-37617-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 12/11/2018] [Indexed: 02/08/2023] Open
Abstract
The safety of minimally invasive distal pancreatectomy (MIDP) and open distal pancreatectomy (ODP) regarding oncological outcomes of pancreatic ductal adenocarcinoma (PDAC) remains inconclusive. Therefore, the aim of this study was to examine the oncological safety of MIDP and ODP for PDAC. Major databases including PubMed, Embase, Science Citation Index Expanded, and the Cochrane Library were searched for studies comparing outcomes in patients undergoing MIDP and ODP for PDAC from January 1994 to August 2018. In total, 11 retrospective comparative studies with 4829 patients (MIDP: 1076, ODP: 3753) were included. The primary outcome was long-term survival, including 3-year overall survival (OS) and 5-year OS. The 3-year OS (hazard ratio (HR): 1.03, 95% confidence interval (CI): 0.89, 1.21; P = 0.66) and 5-year OS (HR: 0.91, 95% CI: 0.65, 1.28; P = 0.59) showed no significant differences between the two groups. Furthermore, the positive surgical margin rate (weighted mean difference (WMD): 0.71, 95% CI: 0.56, 0.89, P = 0.003) was lower in the MIDP group. However, patients in the MIDP group had less intraoperative blood loss (WMD: -250.03, 95% CI: -359.68, -140.39; P < 0.00001), a shorter hospital stay (WMD: -2.76, 95% CI: -3.73, -1.78; P < 0.00001) and lower morbidity (OR: 0.57, 95% CI: 0.46, 0.71; P < 0.00001) and mortality (OR: 0.50, 95% CI: 0.31, 0.81, P = 0.005) than patients in the ODP group. The limited evidence suggested that MIDP might be safer with regard to oncological outcomes in PDAC patients. Therefore, future high-quality studies are needed to examine the oncological safety of MIDP.
Collapse
Affiliation(s)
- Du-Jiang Yang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Jun-Jie Xiong
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Hui-Min Lu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Yi Wei
- Department of Transportation Center, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Ling Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Shan Lu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Wei-Ming Hu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
| |
Collapse
|
23
|
Early and Late Complications After Surgery for MEN1-related Nonfunctioning Pancreatic Neuroendocrine Tumors. Ann Surg 2019; 267:352-356. [PMID: 27811505 DOI: 10.1097/sla.0000000000002050] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To estimate short and long-term morbidity after pancreatic surgery for multiple endocrine neoplasia type 1 (MEN1)-related nonfunctioning pancreatic neuroendocrine tumors (NF-pNETs). BACKGROUND Fifty percent of the MEN1 patients harbor multiple NF-pNETs. The decision to proceed to NF-pNET surgery is a balance between the risk of disease progression versus the risk of surgery-related morbidity. Currently, there are insufficient data on the surgical complications after MEN1 NF-pNET surgery. METHODS MEN1 patients diagnosed with a NF-pNET who underwent surgery were selected from the DutchMEN1 study group database, including >90% of the Dutch MEN1 population. Early postoperative complications, new-onset diabetes mellitus, and exocrine pancreatic insufficiency were captured. RESULTS Sixty-one patients underwent NF-pNET surgery at 1 of the 8 Dutch academic centers. Patients were young (median age 41 years) with low American Society of Anesthesiologists scores. Median NF-pNET size on imaging was 22 mm (3-157). Thirty-three percent (19/58) of the patients developed major early-Clavien-Dindo grade III to IV-complications mainly consisting International Study Group of Pancreatic Surgery grade B/C pancreatic fistulas. Twenty-three percent of the patients (14/61) developed endocrine or exocrine pancreas insufficiency. The development of major early postoperative complications was independent of the NF-pNET tumor size. Twenty-one percent of the patients (12/58) developed multiple major early complications. CONCLUSIONS MEN1 NF-pNET surgery is associated with high rates of major short and long-term complications. Current findings should be taken into account in the shared decision-making process when MEN1 NF-pNET surgery is considered.
Collapse
|
24
|
Rodriguez-Lopez M, Tejero-Pintor FJ, Perez-Saborido B, Barrera-Rebollo A, Bailon-Cuadrado M, Pacheco-Sanchez D. Severe morbidity after pancreatectomy is accurately predicted by preoperative pancreatic resection score (PREPARE): A prospective validation analysis from a medium-volume center. Hepatobiliary Pancreat Dis Int 2018; 17:559-565. [PMID: 30316626 DOI: 10.1016/j.hbpd.2018.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 09/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Major morbidity in pancreatic surgery remains high. Different scores for predicting complications have been described. Preoperative pancreatic resection (PREPARE) score is based on objective preoperative variables and offers good predictive accuracy for Clavien ≥ III complications. This study aimed to validate this score and analyze other preoperative variables in a prospective study performed in a medium-volume center. METHODS A total of 50 pancreatic resections were included. Preoperative variables were registered and PREPARE was calculated. The main outcome was severe morbidity (Clavien ≥ III) up to 30 days after discharge. The secondary outcomes were length of stay (LOS) and readmission. Statistical validation was performed to compare severe morbidity rate among the scores categories. Association with other preoperative variables (not included in PREPARE) was also tested. RESULTS Of the 50 pancreatic resections, the severe morbidity was 34.0%, with median LOS of 11 days. Readmission rate was 25.5%. Severe morbidity rates according to PREPARE categories were 18.5% in low-risk group, 41.7% in intermediate-risk group, and 63.6% in high-risk group, respectively (P = 0.023). The accuracy was 72% (Hosmer-Lemeshow, P = 0.86). ROC curve was obtained both for PREPARE score expressed as incremental values and categorized as the three risk groups, showing an area under curve (AUC) of 0.736 (95% CI: 0.586-0.887; P = 0.007) and 0.712 (95% CI: 0.555-0.869; P = 0.015), respectively. PREPARE was significant in multivariate analysis. Median LOS was statistically higher as PREPARE category increases (9, 11 and 15 days in low-, intermediate- and high-risk groups, respectively; P = 0.009). Readmission was not associated with any variables. CONCLUSIONS PREPARE behaves as an independent risk factor for severe morbidity after pancreatic surgery. Score validation shows good accuracy prediction. Increasing PREPARE category is also associated with longer LOS.
Collapse
Affiliation(s)
- Mario Rodriguez-Lopez
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain.
| | | | - Baltasar Perez-Saborido
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - Asterio Barrera-Rebollo
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - Martin Bailon-Cuadrado
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - David Pacheco-Sanchez
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| |
Collapse
|
25
|
Sahakyan MA, Kleive D, Kazaryan AM, Aghayan DL, Ignjatovic D, Labori KJ, Røsok BI, Edwin B. Extended laparoscopic distal pancreatectomy for adenocarcinoma in the body and tail of the pancreas: a single-center experience. Langenbecks Arch Surg 2018; 403:941-948. [DOI: 10.1007/s00423-018-1730-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/06/2018] [Indexed: 12/11/2022]
|
26
|
Distal Pancreatectomy Combined with Multivisceral Resection Is Associated with Postoperative Complication Rates and Survival Comparable to Those After Standard Procedures. J Gastrointest Surg 2018; 22:1549-1556. [PMID: 29748738 DOI: 10.1007/s11605-018-3804-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/02/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND For pancreatic tumors located in the body or tail of the pancreas, distal pancreatectomy (DP) remains the surgical procedure of choice to achieve radical tumor removal. Purpose of this study was to evaluate outcome and overall survival of patients who underwent DP combined with multivisceral resection (MVR). METHODS Retrospective single-center case-matched analysis. Between January 1994 and June 2014, 494 consecutive patients were entered into a prospective database, and 126 patients undergoing DP + MVR (cases) were matched with 126 patients undergoing DP (controls) for gender, age, and underlying final diagnosis. RESULTS There were no significant differences in patient demographics. Rates of postoperative pancreatic fistula (POPF) (36 (28.6%) vs. 29 (23.0%); p = 0.388) and postpancreatectomy hemorrhage (PPH) (7 (5.5%) vs. 5 (3.9%); p = 0.769) did not reveal any significant differences. Although operative time (237.8 ± 57.9 vs. 203.5 ± 34.5; p < 0.001) and the necessity for intraoperative transfusions (18 (14.3%) vs. 5 (4.0%); p < 0.001) was significantly higher, the number of patients with major complications (the Clavien-Dindo ≥ 3) was not increased (27 (19.8%) vs. 20 (15.9%); p = 0.332) in the DP + MVR group. Midterm survival analysis indicated no significant difference for adenocarcinoma and neuroendocrine tumors for either group. CONCLUSION DP + MVR is a feasible and safe surgical procedure to achieve radical tumor removal and can offer beneficial survival outcomes. Although operative time and intraoperative transfusions are enhanced, POPF, PPH, or major complications (the Clavien-Dindo ≥ 3) are not significantly increased after DP + MVR. DP + MVR can therefore be recommended in selected patients for resection of extended tumors within the concept of interdisciplinary strategies.
Collapse
|
27
|
Wang Y, Fang T, Huang L, Wang H, Zhang L, Wang Z, Cui Y. Neutrophils infiltrating pancreatic ductal adenocarcinoma indicate higher malignancy and worse prognosis. Biochem Biophys Res Commun 2018; 501:313-319. [PMID: 29738769 DOI: 10.1016/j.bbrc.2018.05.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 05/04/2018] [Indexed: 02/07/2023]
Abstract
CD177 is considered to represent neutrophils. We analyzed mRNA expression level of CD177 and clinical follow-up survey of PDAC to estimate overall survival (OS) from Gene Expression Omnibus (GEO) dataset (GSE21501, containing samples from 102 PDAC patients) by R2 platform (http://r2.amc.nl). We also analyzed correlated genes of CD177 by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis to predict the potential relationship between neutrophils and prognosis of PDAC. We then performed hematoxylin and eosin (H&E) staining and immunohistochemical staining of surgical specimens to verify infiltration of neutrophils in PDAC tissues. After analyzing mRNA expression data and clinical follow-up survey provided in the GEO dataset (GSE21501, containing samples from 102 PDAC patients) and clinicopathological data of 23 PDAC patients, we demonstrated that CD177 was correlated with poor prognosis. The univariate Kaplan-Meier survival analysis revealed that OS was inversely associated with increased expression of CD177 (P = 0.012). Expression of phosphodiesterase (PDE)4D was positively related to CD177 in gene correlation analysis (R = 0.413, P < 0.001) by R2 platform. H&E staining and immunohistochemistry of CD177 in 23 PDAC surgical samples showed accumulation of neutrophils in the stroma and blood vessels around the cancer cells. In addition, immunohistochemical staining showed that CD177 was highly expressed in the stroma and blood vessels around tumor tissues of PDAC, which was similar to H&E staining. Expression of CD177 can be used to represent infiltration of neutrophils, which may have potential prognostic value in PDAC.
Collapse
Affiliation(s)
- Yufu Wang
- Department of Hepatopancreatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, Heilongjiang Province, China
| | - Tianyi Fang
- Department of Hepatopancreatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, Heilongjiang Province, China
| | - Lining Huang
- Department of Hepatopancreatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, Heilongjiang Province, China
| | - Hao Wang
- Department of Hepatopancreatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, Heilongjiang Province, China
| | - Lei Zhang
- Department of Pathology, Harbin Medical University, Harbin, 150000, Heilongjiang Province, China
| | - Zhidong Wang
- Department of Hepatopancreatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, Heilongjiang Province, China.
| | - Yunfu Cui
- Department of Hepatopancreatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, Heilongjiang Province, China.
| |
Collapse
|
28
|
Hank T, Hinz U, Tarantino I, Kaiser J, Niesen W, Bergmann F, Hackert T, Büchler MW, Strobel O. Validation of at least 1 mm as cut-off for resection margins for pancreatic adenocarcinoma of the body and tail. Br J Surg 2018; 105:1171-1181. [PMID: 29738626 DOI: 10.1002/bjs.10842] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/27/2017] [Accepted: 01/29/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND The definition of resection margin (R) status in pancreatic cancer is under debate. Although a margin of at least 1 mm is an independent predictor of survival after resection for pancreatic head cancer, its relevance to pancreatic body and tail cancers remains unclear. This study aimed to validate R status based on a 1-mm tumour-free margin as a prognostic factor for resected adenocarcinoma involving the pancreatic body and tail. METHODS Patients who underwent distal or total pancreatectomy for adenocarcinomas of the pancreatic body and tail between January 2006 and December 2014 were identified from a prospective database. Resection margins were evaluated using a predefined cut-off of 1 mm. Rates of R0, R1 with invasion within 1 mm of the margin (R1 less than 1 mm), and R1 with direct invasion of the resection margin (R1 direct) were determined, and overall survival in each group assessed by Kaplan-Meier analysis. Univariable and multivariable Cox regression analyses were performed to identify predictors of survival. RESULTS R0 resection was achieved in 107 (23·5 per cent) and R1 in 348 (76·5 per cent) of 455 patients. Among R1 resections, invasion within 1 mm of the margin was found in 104 (22·9 per cent) and direct invasion in 244 (53·6 per cent). The R0 rate was 28·9 per cent after distal and 18·6 per cent after total pancreatectomy. In the total cohort, median survival times for patients with R0, R1 (less than 1 mm) and R1 (direct) status were 62·4, 24·6 and 17·2 months respectively, with 5-year survival rates of 52·6, 16·8 and 13·0 per cent (P < 0·001). In patients who received adjuvant chemotherapy, respective median survival times were 68·6, 32·8 and 21·4 months, with 5-year survival rates of 56, 22 and 16·0 per cent (P < 0·001). In multivariable analysis, R status was independently associated with survival. CONCLUSION A cut-off of at least 1 mm for evaluation of resection margins is an independent determinant of survival after resection of adenocarcinomas of the pancreatic body and tail.
Collapse
Affiliation(s)
- T Hank
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - U Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - I Tarantino
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - J Kaiser
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - W Niesen
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - F Bergmann
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - O Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
29
|
Chen K, Pan Y, Zhang B, Maher H, Cai XJ. Laparoscopic versus open pancreatectomy for pancreatic ductal adenocarcinoma: A systematic review and meta-analysis. Int J Surg 2018; 53:243-256. [DOI: 10.1016/j.ijsu.2017.12.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 11/16/2017] [Accepted: 12/30/2017] [Indexed: 12/11/2022]
|
30
|
Li X, Liu Z, Ye Z, Gou S, Wang C. Impact of age on survival of patients with pancreatic cancer after surgery: Analysis of SEER data. Pancreatology 2018; 18:133-138. [PMID: 29170052 DOI: 10.1016/j.pan.2017.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/04/2017] [Accepted: 11/17/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND To explore the impact of age on all-cause death and cancer-specific death in patients with pancreatic duct adenocarcinoma (PDAC) undergoing surgery. MATERIALS AND METHODS Individuals with PDAC undergoing surgery between 2004 and 2013 (N = 11,138) were retrospectively studied from the Surveillance, Epidemiology, and End Results (SEER) cancer registry database. The impact of age on all-cause death and cancer-specific death was assessed using Cox regression model and competing risk model respectively. RESULTS Multivariate Cox regression analysis indicated that the risks of all-cause death increased with age: hazard ratios (95% confidence interval, 95%CI) were 1.10 (1.04-1.17), 1.31 (1.23-1.38), 1.47 (1.35-1.61) for groups 61-70 years, 71-80 years, and >80 years, respectively, compared with ≤60 years. Multivariate competing risk analysis indicated that the risk of cancer-specific death was similar between patients ≤60 years and 61-70 years (subhazard ratio 0.93; 95% confidence interval 0.87-1.00), but decreased in patients 71-80 years (subhazard ratio 0.84; 95%CI 0.79-0.90) and >80 years (subhazard ratio 0.76; 95%CI 0.68-0.85). CONCLUSION Age at diagnosis appeared to be an independent predictor of prognosis, with reverse impacts on all-cause death and cancer-specific death.
Collapse
Affiliation(s)
- Xiaogang Li
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Department of General Surgery, Xiangyang Central Hospital, Hubei University of Arts and Science, Xiangyang 441021, China
| | - Zhiqiang Liu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Zeng Ye
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Shanmiao Gou
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Chunyou Wang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| |
Collapse
|
31
|
Thomaschewski M, Neeff H, Keck T, Neumann HPH, Strate T, von Dobschuetz E. Is there any role for minimally invasive surgery in NET? Rev Endocr Metab Disord 2017; 18:443-457. [PMID: 29127554 DOI: 10.1007/s11154-017-9436-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Neuroendocrine tumors (NET) represent the variability of almost benign lesions either secreting hormones occurring as a single lesion up to malignant lesions with metastatic potential. Treatment of NET is usually performed by surgical resection. Due to the rarity of NET, surgical treatment is mainly based on the experience and recommendations of experts and less on the basis of prospective randomized studies. In addition, the development and establishment of new surgical procedures is made more difficult by their rarity. The development of laparoscopic-assisted surgery has significantly improved the treatment of many diseases. Due to the well-known advantages of laparoscopic surgery, this method has also been increasingly used to treat NET. However, due to limited comparative data, the assumed superiority of laparoscopic surgery in the area NET remains often unclear or not yet proven. This review focuses on the present usage of laparoscopic techniques in the area of NET. Relating to the current literature, this review presents the evidence of various laparoscopic procedures for treatment of adrenal, pancreatic and intestine NET as well as extraadrenal pheochromocytoma and neuroendocrine liver metastases. Further, this review focuses on recent new developments of minimally invasive surgery in the area of NET. Here, robotic-assisted surgery and single-port surgery are promising approaches.
Collapse
Affiliation(s)
- M Thomaschewski
- Department of Surgery, University of Lübeck and University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - H Neeff
- Department of Visceral and General Surgery, University Medical Center Freiburg, Freiburg, Germany
| | - T Keck
- Department of Surgery, University of Lübeck and University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - H P H Neumann
- Section for Preventive Medicine, Department of Nephrology and General Medicine, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany
| | - T Strate
- Department of General, Visceral and Thoracic Surgery, Academic Teaching Hospital University of Hamburg, Reinbek, Germany
| | - E von Dobschuetz
- Section of Endocrine Surgery, Department of General, Visceral and Thoracic Surgery, Academic Teaching Hospital University of Hamburg, Reinbek, Germany.
| |
Collapse
|
32
|
|
33
|
Sahakyan MA, Kim SC, Kleive D, Kazaryan AM, Song KB, Ignjatovic D, Buanes T, Røsok BI, Labori KJ, Edwin B. Laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: Long-term oncologic outcomes after standard resection. Surgery 2017; 162:802-811. [PMID: 28756944 DOI: 10.1016/j.surg.2017.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/30/2017] [Accepted: 06/06/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Surgical resection is the only curative option in patients with pancreatic ductal adenocarcinoma. Little is known about the oncologic outcomes of laparoscopic distal pancreatectomy. This bi-institutional study aimed to examine the long-term oncologic results of standard laparoscopic distal pancreatectomy in a large cohort of patients with pancreatic ductal adenocarcinoma. METHODS From January 2002 to March 2016, 207 patients underwent standard laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma at Oslo University Hospital-Rikshospitalet (Oslo, Norway) and Asan Medical Centre (Seoul, Republic of Korea). After the exclusion criteria were applied (distant metastases at operation, conversion to an open operation, loss to follow-up), 186 patients were eligible for the analysis. Perioperative and oncologic variables were analyzed for association with recurrence and survival. RESULTS Median overall and recurrence-free survivals were 32 and 16 months, while 5-year overall and recurrence-free survival rates were estimated to be 38.2% and 35.9%, respectively. Ninety-six (52%) patients developed recurrence: 56 (30%) extrapancreatic, 27 (15%) locoregional, and 13 (7%) combined locoregional and extrapancreatic. Thirty-seven (19.9%) patients had early recurrence (within 6 months of operation). In the multivariable analysis, tumor size >3 cm and no adjuvant chemotherapy were associated with early recurrence (P = .017 and P = .015, respectively). The Cox regression model showed that tumor size >3 cm and lymphovascular invasion were independent predictors of decreased recurrence-free and overall survival. CONCLUSION Standard laparoscopic distal pancreatectomy is associated with satisfactory long-term oncologic outcomes in patients with pancreatic ductal adenocarcinoma. Several risk factors, such as tumor size >3 cm, no adjuvant chemotherapy, and lymphovascular invasion, are linked to poor prognosis after standard laparoscopic distal pancreatectomy.
Collapse
Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.
| | - Song Cheol Kim
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Dyre Kleive
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway; Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Airazat M Kazaryan
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway; Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Ki Byung Song
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Trond Buanes
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway; Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Bård I Røsok
- Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Knut Jørgen Labori
- Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway; Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| |
Collapse
|
34
|
S D, L W, B GY, F YH, H SX, Q MZ, Hao C, W CQ, S LZ. Risk factors of liver metastasis from advanced pancreatic adenocarcinoma: a large multicenter cohort study. World J Surg Oncol 2017; 15:120. [PMID: 28673297 PMCID: PMC5496221 DOI: 10.1186/s12957-017-1175-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 05/23/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clinical prognostic parameters of liver metastasis from pancreatic adenocarcinoma have not been specifically identified.This study is to explore the risk factors of liver metastasis in advanced pancreatic adenocarcinoma (PDAC) patients in China. METHODS A multicenter cohort study was conducted to explore whether liver metastasis in locally advanced and metastatic PDAC could be reflected by some common laboratory indexes. We collected 1787 advanced PDAC patients from three participating hospitals between 2004 and 2014. The associations between some laboratory indexes and risks of liver metastases were analyzed. RESULTS Results have shown that 87% of stage IV patients developed synchronous liver metastasis. Primary tumor location (body/tail vs. head/neck, OR 0.55, 95% CI 0.36-0.83), primary tumor diameter (≥20 mm vs. <20 mm, OR 1.77, 95% CI 1.16-2.70), elevated ALT and AST (OR 1.62, 95% CI 0.92-2.83), and elevated CA19-9 (OR 2.72, 95% CI 1.85-3.99) upon diagnosis are significantly associated with risk of synchronous liver metastasis. Among stage III patients, 30.1% developed metachronous liver metastasis. However, no risk factors were identified among these patients. CONCLUSIONS Primary tumor location, diameter, elevated ALT and AST, and increased CA19-9 are independent risk factors of synchronous liver metastasis in PDAC patients.
Collapse
Affiliation(s)
- Dong S
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong-An Road, 200032, Shanghai, China
| | - Wang L
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, 169 Changhai Road, 200433, Shanghai, China
| | - Guo Y B
- Department of Integrative Medicine of Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | - Ying H F
- Department of Integrative Medicine of Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | - Shen X H
- Department of Integrative Medicine of Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | - Meng Z Q
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong-An Road, 200032, Shanghai, China
| | - Chen Hao
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
- Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong-An Road, 200032, Shanghai, China.
| | - Chen Q W
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
- Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong-An Road, 200032, Shanghai, China.
- Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, 200032, Shanghai, China.
| | - Li Z S
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, 169 Changhai Road, 200433, Shanghai, China.
| |
Collapse
|
35
|
Zhang AB, Wang Y, Hu C, Shen Y, Zheng SS. Laparoscopic versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a single-center experience. J Zhejiang Univ Sci B 2017; 18:532-538. [PMID: 28585429 PMCID: PMC5482047 DOI: 10.1631/jzus.b1600541] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 03/04/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to compare complications and oncologic outcomes of patients undergoing laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) at a single center. METHODS Distal pancreatectomies performed for pancreatic ductal adenocarcinoma during a 4-year period were included in this study. A retrospective analysis of a database of this cohort was conducted. RESULTS Twenty-two patients underwent LDP for pancreatic ductal adenocarcinoma, in comparison to seventy-six patients with comparable tumor characteristics treated by ODP. No patients with locally advanced lesions were included in this study. Comparing LDP group to ODP group, there were no significant differences in operation time (P=0.06) or blood loss (P=0.24). Complications (pancreatic fistula, P=0.62; intra-abdominal abscess, P=0.44; postpancreatectomy hemorrhage, P=0.34) were similar. There were no significant differences in the number of lymph nodes harvested (11.2±4.6 in LDP group vs. 14.4±5.5 in ODP group, P=0.44) nor the rate of patients with positive lymph nodes (36% in LDP group vs. 41% in ODP group, P=0.71). Incidence of positive margins was similar (9% in LDP group vs. 13% in ODP group, P=0.61). The mean overall survival time was (29.6±3.7) months for the LDP group and (27.6±2.1) months for ODP group. There was no difference in overall survival between the two groups (P=0.34). CONCLUSIONS LDP is a safe and effective treatment for selected patients with pancreatic ductal adenocarcinoma. A slow-compression of pancreas tissue with the GIA stapler is effective in preventing postoperative pancreatic fistula. The oncologic outcome is comparable with the conventional open approach. Laparoscopic radical antegrade modular pancreatosplenectomy contributed to oncological clearance.
Collapse
|
36
|
Klompmaker S, de Rooij T, Korteweg JJ, van Dieren S, van Lienden KP, van Gulik TM, Busch OR, Besselink MG. Systematic review of outcomes after distal pancreatectomy with coeliac axis resection for locally advanced pancreatic cancer. Br J Surg 2017; 103:941-9. [PMID: 27304847 DOI: 10.1002/bjs.10148] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/07/2016] [Accepted: 02/08/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreatic cancer involving the coeliac axis is considered unresectable by most guidelines, with a median survival of 6-11 months. A subgroup of these patients can undergo distal pancreatectomy with coeliac axis resection, but consensus on the value of this procedure is lacking. The evidence for this procedure, including the impact of preoperative hepatic artery embolization and (neo)adjuvant therapy, was evaluated. METHODS A systematic review was performed according to the PRISMA guidelines until 27 May 2015. The primary endpoint was overall survival; secondary endpoints included morbidity and radical resection rates. RESULTS A total of 19 retrospective studies, involving 240 patients, were included. The methodological quality of the studies ranged from poor to moderate. A radical resection was reported in 74·5 per cent (152 of 204), major morbidity in 27 per cent (26 of 96), ischaemic morbidity in 9·0 per cent (21 of 223) and 90-day mortality in 3·5 per cent (4 of 113). Overall, 35·5 per cent of patients (55 of 155) underwent preoperative hepatic artery embolization without an apparent beneficial impact on ischaemic morbidity. Overall, 15·7 per cent (29 of 185) had neoadjuvant and 51·0 per cent (75 of 147) had adjuvant therapy. There was a difference in survival between patient series where less than half of patients had (neo)adjuvant chemotherapy and series where more than half were receiving this treatment: case-weighted median overall survival was 16 (range 9-48) versus 18 (10-26) months respectively (P = 0·002). Overall median survival for the whole study population was 14·4 (range 9-48) months. CONCLUSION Distal pancreatectomy with coeliac axis resection seems a valuable option for selected patients with pancreatic cancer involving the coeliac axis with acceptable morbidity and mortality, and a median survival of 18 months when combined with (neo)adjuvant therapy.
Collapse
Affiliation(s)
- S Klompmaker
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - T de Rooij
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - J J Korteweg
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - S van Dieren
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - K P van Lienden
- Departments of Interventional Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - T M van Gulik
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - O R Busch
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M G Besselink
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|
37
|
Abstract
BACKGROUND The first International conference on Minimally Invasive Pancreas Resection was arranged in conjunction with the annual meeting of the International Hepato-Pancreato-Biliary Association (IHPBA), in Sao Paulo, Brazil on April 19th 2016. The presented evidence and outcomes resulting from the session for minimally invasive distal pancreatectomy (MIDP) is summarized and addressed perioperative outcome, the outcome for cancer and patient selection for the procedure. METHODS A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to compare MIDP and open distal pancreatectomy. Patient selection was discussed based on plenary talks, panel discussions and a worldwide survey on MIDP. RESULTS Of 582 studies, 52 (40 observational and 12 case-matched) were included in the assessment for outcome for LDP (n = 5023) vs. ODP (n = 16,306) whereas 16 observational comparative studies were identified for cancer outcome. No randomized trials were identified. MIDP resulted in similar outcome to ODP with a tendency for lower blood loss and shorter hospital stay in the MIDP group. DISCUSSION Available evidence for comparison of MIDP to ODP is weak, although the number of studies is high. Observed outcomes of MIDP are promising. In the absence of randomized control trials, an international registry should be established.
Collapse
|
38
|
A systematic review of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas. HPB (Oxford) 2017; 19:10-15. [PMID: 27553838 DOI: 10.1016/j.hpb.2016.07.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 07/23/2016] [Accepted: 07/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND To assess the published evidence on clinical outcomes following radical antegrade modular pancreatosplenectomy (RAMPS) for adenocarcinoma in the body or tail of the pancreas. METHOD PubMed and Chinese Biomedical Literature databases were searched. The results of comparisons between RAMPS and standard retrograde pancreatosplenectomy (SRPS) were analyzed by meta-analytical techniques. RESULTS The literature search identified 13 observational studies involving 354 patients undergoing RAMPS. The overall morbidity and 30-day mortality was 40% and 0% respectively. The R0 resection rate was 88%; the median number of retrieved lymph nodes was 21; and the median 5-year overall survival rate was 37%. The result of meta-analysis showed that RAMPS was associated with a significantly less intraoperative bleeding [weighted mean difference -195.2 (95% confidence interval (CI) -223.27 to -167.13); P < 0.001], a greater number of retrieved lymph nodes [odds ratio (OR) 6.19 (95% CI 3.72 to 8.67); P < 0.001] and a higher percentage of R0 resection [OR 2.46 (95% CI 1.13 to 5.35); P = 0.02] as compared with SRPS. CONCLUSION The current literature provides supportive evidence that RAMPS is a safe and effective procedure for adenocarcinoma in the body or tail of the pancreas, and is oncologically superior to SRPS.
Collapse
|
39
|
Distal pancreatectomy associated with multivisceral resection: results from a single centre experience. Langenbecks Arch Surg 2016; 402:457-464. [DOI: 10.1007/s00423-016-1514-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 09/12/2016] [Indexed: 01/03/2023]
|
40
|
Measuring the quality of melanoma surgery - Highlighting issues with standardization and quality assurance of care in surgical oncology. Eur J Surg Oncol 2016; 43:561-571. [PMID: 27422583 DOI: 10.1016/j.ejso.2016.06.397] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/09/2016] [Accepted: 06/18/2016] [Indexed: 01/21/2023] Open
Abstract
In an attempt to ensure high standards of cancer care, there is increasing interest in determining and monitoring the quality of interventions in surgical oncology. In recent years, this has been particularly the case for melanoma surgery. The vast majority of patients with melanoma undergo surgery. Usually, this is with combinations of wide excision, sentinel lymph node biopsy and lymphadenectomy. The indications for these procedures evolved during a time when no effective systemic adjuvant therapy was available, and whilst the rationale has been sound, the justification for differences in extent and thoroughness has generally been supported by inadequate or low-level evidence. This has led to a substantial variation among melanoma centres or even among surgeons within a centre in how these procedures are done. With recent rapid progress in the efficacy of systemic treatments that are impacting on overall survival, the prospect of long-term survival in these previously high risk patients means that more than ever long-term locoregional control of melanoma is imperative. Furthermore, the understanding of effects of systemic therapy on locoregional disease will only be interpretable if surgeons use standardized, high quality techniques. This article focuses on standardization and evolution of quality indicators for melanoma surgery and how these might have a positive impact on patient care.
Collapse
|
41
|
de Rooij T, Klompmaker S, Abu Hilal M, Kendrick ML, Busch OR, Besselink MG. Laparoscopic pancreatic surgery for benign and malignant disease. Nat Rev Gastroenterol Hepatol 2016; 13:227-38. [PMID: 26882881 DOI: 10.1038/nrgastro.2016.17] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Laparoscopic surgery for benign and malignant pancreatic lesions has slowly been gaining acceptance over the past decade and is being introduced in many centres. Some studies suggest that this approach is equivalent to or better than open surgery, but randomized data are needed to assess outcomes. In this Review, we aim to provide a comprehensive overview of the state of the art in laparoscopic pancreatic surgery by aggregating high-quality published evidence. Various aspects, including the benefits, limitations, oncological efficacy, learning curve and latest innovations, are discussed. The focus is on laparoscopic Whipple procedure and laparoscopic distal pancreatectomy for both benign and malignant disease, but robot-assisted surgery is also addressed. Surgical and oncological outcomes are discussed as well as quality of life parameters and the cost efficiency of laparoscopic pancreatic surgery. We have also included decision-aid algorithms based on the literature and our own expertise; these algorithms can assist in the decision to perform a laparoscopic or open procedure.
Collapse
Affiliation(s)
- Thijs de Rooij
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Sjors Klompmaker
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Mohammad Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire SO16 6YD, UK
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905, USA
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| |
Collapse
|