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Liang JN, Anklowitz AJ, Livezey JB, O'Hara TA, Aranda MC, Bandera B. Practice Patterns of Pancreatic Surgery Within the Military. Am Surg 2024:31348241241746. [PMID: 38513255 DOI: 10.1177/00031348241241746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Pancreatic surgery is technically challenging, with mortality rates at high-volume centers ranging from 0% to 5%. An inverse relationship between surgeon volume and perioperative mortality has been reported suggesting that patients benefit from experienced surgeons at high-volume centers. There is little published on the volume of pancreatic surgeries performed in military treatment facilities (MTF) and there is no centralization policy regarding pancreatic surgery. This study evaluates pancreatic procedures at MTFs. We hypothesize that a small group of MTFs perform most pancreatic procedures, including more complex pancreatic surgeries. METHODS This is a retrospective review of de-identified data from MHS Mart (M2) from 2014 to 2020. The database contains patient data from all Defense Health Agency treatment facilities. Variables collected include number and types of pancreatic procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each MTF. RESULTS Twenty-six MTFs performed pancreatic surgeries from 2014 to 2020. There was a significant decrease in the number of cases from 2014 to 2020. Nine hospitals performed one surgery over eight years. The most common surgery was a distal pancreatectomy, followed by a pancreaticoduodenectomy. There was a decrease in the number of pancreaticoduodenectomies and distal pancreatectomies performed over this period. CONCLUSIONS Pancreatic surgery is being performed at few MTFs with a downward trajectory over time. Further studies would be needed to assess the impact on patient care regarding postoperative complications, barriers to timely patient care, and impact on readiness of military surgeons.
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Affiliation(s)
- Joy N Liang
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Andrew J Anklowitz
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Jonathan B Livezey
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Thomas A O'Hara
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Marcos C Aranda
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Bradley Bandera
- Reno School of Medicine, University of Nevada, Reno, NV, USA
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2
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Teres ligamentum wrap covering the pancreaticojejunostomy following pancreatoduodenectomy is associated with a lower rate of postoperative pancreas fistula: a prospective cohort study. HPB (Oxford) 2023; 25:116-123. [PMID: 36280427 DOI: 10.1016/j.hpb.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/26/2022] [Accepted: 10/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative pancreas fistula (POPF) is a common complication after pancreatoduodenectomy (PD). A Teres Ligamentum (TL)-wrap covering the pancreaticojejunostomy (PJ) is suggested as a potential solution to reduce POPF. The aim of this study was to compare POPF incidence (grade B/C) in patients with or without a TL-wrap. METHODS A prospective cohort study was performed between January 2019-December 2021. All consecutive patients were included. Patient, tumor and surgical characteristics and postoperative complications were compared in both open and robot-assisted surgery. RESULTS A total of 118 consecutive patients were included. The first 57 patients were treated without and the following 61 patients with a TL-wrap. There were no statistically significant differences between both groups regarding patient, pre-operative treatment and surgical characteristics. The occurrence of POPF was strongly reduced in the TL-wrap group compared to patients without a TL-wrap (3.3% vs 28.1%, P < 0.001). Also mean length of hospital stay was reduced (11.5 vs 18.8 days, P = 0.030). CONCLUSION The use of a TL-wrap covering the PJ as addition to the modified Blumgart anastomosis technique is associated with a significantly reduced POPF rate and a reduced length of hospital stay. A TL-wrap is a simple addition to a PJ that may be considered to improve postoperative outcome. This association must be studied more definitively in a randomized controlled trial.
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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4
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Short-term outcomes of robotic versus open pancreaticoduodenectomy in elderly patients: A multicenter retrospective cohort study. Int J Surg 2022; 104:106819. [DOI: 10.1016/j.ijsu.2022.106819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 02/07/2023]
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5
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Ratnayake B, Pendharkar SA, Connor S, Koea J, Sarfati D, Dennett E, Pandanaboyana S, Windsor JA. Patient volume and clinical outcome after pancreatic cancer resection: A contemporary systematic review and meta-analysis. Surgery 2022; 172:273-283. [PMID: 35034796 DOI: 10.1016/j.surg.2021.11.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/02/2021] [Accepted: 11/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatic cancer remains a highly fatal disease with a 5-year overall survival of less than 10%. In seeking to improve clinical outcomes, there is ongoing debate about the weight that should be given to patient volume in centralization models. The aim of this systematic review is to examine the relationship between patient volume and clinical outcome after pancreatic resection for cancer in the contemporary literature. METHODS The Google Scholar, PubMed, and Cochrane Library databases were systematically searched from February 2015 until June 2021 for articles reporting patient volume and outcomes after pancreatic cancer resection. RESULTS There were 46 eligible studies over a 6-year period comprising 526,344 patients. The median defined annual patient volume thresholds varied: low-volume 0 (range 0-9), medium-volume 9 (range 3-29), high-volume 19 (range 9-97), and very-high-volume 28 (range 17-60) patients. The latter 2 were associated with a significantly lower 30-day mortality (P < .001), 90-day mortality (P < .001), overall postoperative morbidity (P = .005), failure to rescue rate (P = .006), and R0 resection rate (P = .008) compared with very-low/low-volume hospitals. Centralization was associated with lower 30-day mortality in 3 out of 5 studies, while postoperative morbidity was similar in 4 out of 4 studies. Median survival was longer in patients traveling greater distance for pancreatic resection in 2 out of 3 studies. Median and 5-year survival did not differ between urban and rural settings. CONCLUSION The contemporary literature confirms a strong relationship between patient volume and clinical outcome for pancreatic cancer resection despite expected bias toward more complex surgery in high-volume centers. These outcomes include lower mortality, morbidity, failure-to-rescue, and positive resection margin rates.
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Affiliation(s)
- Bathiya Ratnayake
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand; HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand. https://twitter.com/ProfJohnWindsor
| | - Sayali A Pendharkar
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - Saxon Connor
- Department of Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Jonathan Koea
- Upper GI Unit, Northshore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Diana Sarfati
- Department of Public Health, University of Otago, Dunedin, New Zealand; Cancer Control Agency, Te Aho O Te Kahu, Ministry of Health, New Zealand
| | - Elizabeth Dennett
- Cancer Control Agency, Te Aho O Te Kahu, Ministry of Health, New Zealand
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK; Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand; HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand.
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6
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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7
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Papageorge MV, de Geus SWL, Woods AP, Ng SC, McAneny D, Tseng JF, Kenzik KM, Sachs TE. The impact of upper gastrointestinal surgical volume on short term pancreaticoduodenectomy outcomes for pancreatic adenocarcinoma in the SEER-Medicare population. HPB (Oxford) 2022; 24:868-874. [PMID: 34879991 DOI: 10.1016/j.hpb.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/03/2021] [Accepted: 10/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients undergoing pancreaticoduodenectomy (PD) at low volume PD hospitals with high volume for other complex operations have comparable outcomes to high volume PD centers. We evaluated the impact of upper gastrointestinal operations (UGI) hospital volume on the outcomes of elderly, high risk patients undergoing PD. METHODS Patients >65 years old who underwent PD for pancreatic adenocarcinoma were identified from SEER-Medicare (2008-2015). Four volume cohorts were created using PD tertiles and UGI median: low (1st tertile PD), mixed-low (2nd tertile PD, low UGI), mixed-high (2nd tertile PD, high UGI) and high (3rd tertile PD). Multivariable logistic and negative binomial regression assessed short-term complications. RESULTS In total, 2717 patients were identified with a median age of 74.5 years. Patients treated at low, mixed-low and mixed-high volume hospitals, versus high volume, had higher risk of short-term complications, including major complications (low: OR 1.441, 95%CI 1.165-1.783; mixed-low: OR 1.374, 95%CI 1.085-1.740; mixed-high: OR 1.418, 95%CI 1.098-1.832) and 90-day mortality (low: OR 2.16, 95%CI 1.454-3.209; mixed-low: OR 2.068, 95%CI 1.347-3.175; mixed-high: OR 1.96, 95%CI 1.245-3.086). CONCLUSION Patients with pancreatic adenocarcinoma who are older and more medically complex benefit from undergoing surgery at high volume PD centers, independent of the operative experience of that center.
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Affiliation(s)
- Marianna V Papageorge
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, MA, USA
| | - Susanna W L de Geus
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, MA, USA
| | - Alison P Woods
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, MA, USA; Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sing Chau Ng
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, MA, USA
| | - David McAneny
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, MA, USA
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, MA, USA
| | - Kelly M Kenzik
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, MA, USA; Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, MA, USA.
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8
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Burgdorf SK, Storkholm JH, Chen IM, Hansen CP. Postoperative and long-term survival in relation to life-expectancy after pancreatic surgery in elderly patients (cohort study). Ann Med Surg (Lond) 2021; 69:102724. [PMID: 34457257 PMCID: PMC8379474 DOI: 10.1016/j.amsu.2021.102724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022] Open
Abstract
Background An evaluation of the outcome after pancreatic surgery with focus on post-operative and late survival in elderly patients was performed. Methods The study included 1.556 patients from a single HBP unit operated from 1. January 2010 to 31. December 2019. Patients were divided into two cohorts, < 75 years (n = 1.296) and ≥75 years (n = 260). Post-operative outcome was evaluated in all patients and late outcome in patients with adenocarcinoma in the pancreas (n = 765) and the duodenum (n = 117). The follow-up of patients with benign disease and adenocarcinoma was 57.95 (12.1–132.7) and 39.85 (12.0–131.7) months, respectively. Results Length of hospital-stay and surgical complications were not significantly different in the two cohorts, but in-hospital death was 1.1% (<75 years) and 3.5% (≥75 years) (p = 0.008). The median overall survival of adenocarcinoma was 29.7 (<75 years) and 24.3 months (≥75 years) (p = 0.3228) with a one, two, and five-years survival of 74.5%, 56.6% and 28.6% vs. 73.6%, 51.1%, and 25.5%. Median time to relapse (46.2% of patients <75 years and 40.5% of patients ≥75 years) was 9 (1 - 51) and 8 (1 - 78) months (p = 0.534), respectively. Adjuvant chemotherapy did not have impact on the survival of the old cohort. Patients who died during the observation period had lost 94% (<75 years) and 87% (≥75 years) of expected remnant life. Estimated years lost in the old cohort was 4.2 in males and 4.9 in females (p = 0.025) Conclusion Elderly patients may undergo pancreatic surgery with a low mortality and for adenocarcinoma with an acceptable long-term survival. Surgery is the only potentially curable treatment to pancreatic cancer. Elderly patients may tolerate pancreatic surgery with low mortality. Radical pancreatic surgery improves long-term survival, also in elderly patients. Operability should be evaluated from morbidity and biological age. Pancreatic surgery in elderly should only be performed in high volume centers.
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Affiliation(s)
- S K Burgdorf
- Department of Surgery Rigshospitalet, University of Copenhagen, Denmark
| | - J H Storkholm
- Department of Surgery Rigshospitalet, University of Copenhagen, Denmark
| | - I M Chen
- Department of Oncology, Herlev Hospital, University of Copenhagen, Denmark
| | - C P Hansen
- Department of Surgery Rigshospitalet, University of Copenhagen, Denmark
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Uhl W, Oldhafer K, Schnitzbauer AA, Bruns C, Schön M, Belyaev O. [Statement of the surgical working group for liver, gall bladder and pancreatic diseases (CALGP) of the German Society for General and Visceral Surgery (DGAV) on rapid report V19-03: association between volume of cases and quality in complex pancreatic surgery]. Chirurg 2021; 92:444-447. [PMID: 33871663 DOI: 10.1007/s00104-021-01396-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 11/26/2022]
Abstract
The Institute for Quality and Efficiency in Health Care (IQWiG) was commissioned by the Federal Joint Committee (G‑BA) to carry out a systematic literature search and assessment of the evidence for the association between the hospital and surgeon volume of cases and the quality of the treatment results in complex pancreatic surgery. The results are presented in the rapid report V19-03. The report confirms an association between the number of cases and the quality of the treatment results in favor of hospitals and surgeons with high volume case numbers; however, a statement with respect to the minimum numbers of complex pancreatic interventions is not given. The surgical working group for liver, gall bladder and pancreatic diseases (CALGP) of the German Society for General and Visceral Surgery (DGAV) comments on these conclusions.
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Affiliation(s)
- Waldemar Uhl
- Klinik für Allgemein- und Viszeralchirurgie, Klinik der Ruhr-Universität Bochum, St. Josef-Hospital Bochum, Bochum, Deutschland.
| | - Karl Oldhafer
- Klinik für Allgemein- und Viszeralchirurgie, Asklepios Klinik Barmbek, Hamburg, Deutschland
| | - Andreas A Schnitzbauer
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum, Frankfurt/Main, Deutschland
| | - Christiane Bruns
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum, Köln, Deutschland
| | - Michael Schön
- Klinik für Allgemein- und Viszeralchirurgie, Städtisches Klinikum, Karlsruhe, Deutschland
| | - Orlin Belyaev
- Klinik für Allgemein- und Viszeralchirurgie, Klinik der Ruhr-Universität Bochum, St. Josef-Hospital Bochum, Bochum, Deutschland
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10
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Brunner M, Mücke F, Langheinrich M, Struller F, Rückert F, Welsch T, Distler M, Kersting S, Weber GF, Grützmann R, Krautz C. Proposal of a Standardized Questionnaire to Structure Clinical Peer Reviews of Mortality and Failure of Rescue in Pancreatic Surgery. J Clin Med 2021; 10:jcm10061281. [PMID: 33808921 PMCID: PMC8003630 DOI: 10.3390/jcm10061281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/16/2021] [Indexed: 01/28/2023] Open
Abstract
Background: Quality management tools such as clinical peer reviews facilitate root cause analysis and may, ultimately, help to reduce surgery-related morbidity and mortality. This study aimed to evaluate the reliability of a standardized questionnaire for clinical peer reviews in pancreatic surgery. Methods: All cases of in-hospital-mortality following pancreatic surgery at two high-volume centers (n = 86) were reviewed by two pancreatic surgeons. A standardized mortality review questionnaire was developed and applied to all cases. In a second step, 20 cases were randomly assigned to an online re-review that was completed by seven pancreatic surgeons. The overall consistency of the results between the peer review and online re-review was determined by Cohen’s kappa (κ). The inter-rater reliability of the online re-review was assessed by Fleiss’ kappa (κ). Results: The clinical peer review showed that 80% of the patient mortality was related to surgery. Post-operative pancreatic fistula (POPF) (36%) followed by post-pancreatectomy hemorrhage (PPH) (22%) were the most common surgical underlying (index) complications leading to in-hospital mortality. Most of the index complications yielded in abdominal sepsis (62%); 60% of the cases exhibited potential of improvement, especially through timely diagnosis and therapy (42%). There was a moderate to substantial strength of agreement between the peer review and the online re-review in regard to the category of death (surgical vs. non-surgical; κ = 0.886), type of surgical index complication (κ = 0.714) as well as surgical and non-surgical index complications (κ = 0.492 and κ = 0.793). Fleiss’ kappa showed a moderate to substantial inter-rater agreement of the online re-review in terms of category of death (κ = 0.724), category of common surgical index complications (κ = 0.455) and surgical index complication (κ = 0.424). Conclusion: The proposed questionnaire to structure clinical peer reviews is a reliable tool for root cause analyses of in-hospital mortality and may help to identify specific options to improve outcomes in pancreatic surgery. However, the reliability of the peer feedback decreases with an increasing specificity of the review questions.
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Affiliation(s)
- Maximilian Brunner
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
- Correspondence:
| | - Franziska Mücke
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Melanie Langheinrich
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Florian Struller
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Felix Rückert
- Department of Surgery, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, 68167 Mannheim, Germany;
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (T.W.); (M.D.)
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (T.W.); (M.D.)
| | - Stephan Kersting
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Georg F. Weber
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Robert Grützmann
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Christian Krautz
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
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11
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The Impact of the Aging Population on Surgical Diseases. CURRENT GERIATRICS REPORTS 2021. [DOI: 10.1007/s13670-020-00352-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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12
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Groen JV, Douwes TA, van Eycken E, van der Geest LGM, Johannesen TB, Besselink MG, Koerkamp BG, Wilmink JW, Bonsing BA, Portielje JEA, van de Velde CJH, Bastiaannet E, Mieog JSD. Treatment and Survival of Elderly Patients with Stage I-II Pancreatic Cancer: A Report of the EURECCA Pancreas Consortium. Ann Surg Oncol 2020; 27:5337-5346. [PMID: 32388741 PMCID: PMC7669775 DOI: 10.1245/s10434-020-08539-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Elderly patients with pancreatic cancer are underrepresented in clinical trials, resulting in a lack of evidence. OBJECTIVE The aim of this study was to compare treatment and overall survival (OS) of patients aged ≥ 70 years with stage I-II pancreatic cancer in the EURECCA Pancreas Consortium. METHODS This was an observational cohort study of the Belgian (BE), Dutch (NL), and Norwegian (NOR) cancer registries. The primary outcome was OS, while secondary outcomes were resection, 90-day mortality after resection, and (neo)adjuvant and palliative chemotherapy. RESULTS In total, 3624 patients were included. Resection (BE: 50.2%; NL: 36.2%; NOR: 41.3%; p < 0.001), use of (neo)adjuvant chemotherapy (BE: 55.9%; NL: 41.9%; NOR: 13.8%; p < 0.001), palliative chemotherapy (BE: 39.5%; NL: 6.0%; NOR: 15.7%; p < 0.001), and 90-day mortality differed (BE: 11.7%; NL: 8.0%; NOR: 5.2%; p < 0.001). Furthermore, median OS in patients with (BE: 17.4; NL: 15.9; NOR: 25.4 months; p < 0.001) and without resection (BE: 7.0; NL: 3.9; NOR: 6.5 months; p < 0.001) also differed. CONCLUSIONS Differences were observed in treatment and OS in patients aged ≥ 70 years with stage I-II pancreatic cancer, between the population-based cancer registries. Future studies should focus on selection criteria for (non)surgical treatment in older patients so that clinicians can tailor treatment.
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Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
| | - Tom A Douwes
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | | | - Lydia G M van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Tom B Johannesen
- Registry Department, The Cancer Registry of Norway, Oslo, Norway
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam Amsterdam, UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Johanna E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cornelus J H van de Velde
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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13
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Baltatzis M, Rodriquenz MG, Siriwardena AK, De Liguori Carino N. Contemporary management of pancreas cancer in older people. Eur J Surg Oncol 2020; 47:560-568. [PMID: 32950314 DOI: 10.1016/j.ejso.2020.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/20/2022] Open
Abstract
As the population of western countries is aging, the number of patients diagnosed with cancer is growing. Therefore older people, more susceptible to develop pancreatic malignancy, will likely represent the prototype of a pancreatic cancer patient in the near future. Diagnostic modalities utilised for younger patients are also applicable for older individuals. There is accumulative evidence that biological age is not an independent factor predicting poor outcome in elderly patients with resectable disease undergoing surgery, however increased postoperative morbidity and mortality within the elderly group has also been reported. Adjuvant chemotherapy should be offered in all patients with good performance status regardless of their age. Palliative measures for unresectable tumours including relief from biliary and duodenal obstruction as well as chemotherapy should be considered in non-frail patients with reasonable life expectancy. Palliative chemotherapy options are FOLFIRINOX or gemcitabine/nab-paclitaxel for patients with good performance status (0-1) and gemcitabine alone for patients with performance status 2-3. The cornerstone for improving the outcomes of the elderly age group is careful patient selection and perioperative optimization of those who have indication for surgery. Patients and their carers should be involved in the decision making process with emphasis on the expected functional recovery after the proposed treatment modality. The presence of geriatricians in the multidisciplinary team meetings is crucial in order to identify the optimal treatment pathway for elderly patients. Geriatric input regarding peri-habilitation pathways to improve surgical outcomes, to decrease mortality and to expedite patients' functional recovery is highly recommended.
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Affiliation(s)
- Minas Baltatzis
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Maria Grazia Rodriquenz
- Oncology Unit, Foundation IRCCS, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Ajith K Siriwardena
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nicola De Liguori Carino
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
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14
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Shannon AB, Mo J, Song Y, Paulson EC, Roses RE, Fraker DL, Kelz RR, Miura JT, Karakousis GC. Does multicenter care impact the outcomes of surgical patients with gastrointestinal malignancies requiring complex multimodality therapy? J Surg Oncol 2020; 122:729-738. [PMID: 32563196 DOI: 10.1002/jso.26075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/10/2020] [Indexed: 12/01/2023]
Abstract
BACKGROUND Regionalization of oncologic care has increased, but less is known whether patient outcomes are influenced by receipt of multimodality care through multicenter care (MCC) or single-center care (SCC). METHODS Patients from 2004 to 2015 National Cancer Data Base diagnosed with stage II-III esophageal (EA), stage II-III pancreatic (PA), and stage II-IV rectal (RA) adenocarcinoma who underwent resection at a high volume center (HVC) and required radiation and/or chemotherapy were included. MCC (care at 2+ facilities) and SCC patients were propensity-score matched 1:2 and Cox proportional hazards regression used to analyze survival. RESULTS On multivariable regression analysis, MCC in RA patients (N = 325/2097, 15.5%) was more associated with residing ≥40 miles from the HVC (odds ratio [OR] = 2.37; P = .044) and receipt of neoadjuvant chemotherapy (1.42, P = .040). In PA patients (N = 75/380, 19.7%), residing ≥40 miles from the HVC (OR = 3.22; P = .001), and in EA patients (N = 88/534, 16.5%), younger patients (<50 years: OR = 2.96; P = .011) were associated with MCC. Following propensity score matching, EA (N = 147), PA (N = 133), and RA (N = 661) patients had no difference in 1-year and 3-year overall survival when comparing MCC to SCC. CONCLUSIONS The use of MCC appears safe without a difference in survival and may offer significant advantages in convenience to patients as they undergo their complex oncologic care.
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Affiliation(s)
- Adrienne B Shannon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Mo
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yun Song
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily C Paulson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Miura
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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15
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The effect of performing two pancreatoduodenectomies by a single surgical team in one day on surgeons and patient outcomes. HPB (Oxford) 2020; 22:1185-1190. [PMID: 31843446 DOI: 10.1016/j.hpb.2019.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The centralization of pancreatoduodenectomy (PD) has been shown to improve patient outcomes. The scheduling of two PDs in one day is one option to shorten the waiting time for patients referred to high volume centers. The effect on the surgical team or patient outcomes of such an approach have not previously been explored. This study aimed to investigate the effect of scheduling two PDs in one day on the surgeon's workload and patient outcomes. METHODS A retrospective review of patients undergoing PD by a single surgeon between 2007 and 2018 was performed. Patients were allocated into: first PD (FIRSTPD group) or second PD (SECONDPD group) according to the position on the surgical operating list. The intraoperative, postoperative outcomes, and workload (the Surgery Task Load Index; SURG-TLX) were assessed between two groups. RESULTS A total of 967 (91%) and 101 (9%) patients were included in the FIRSTPD and SECONDPD group, respectively. There were no differences in the duration of surgery (coefficient = -9.65; 95% confidence interval: -29.26 to 9.94; P = 0.334), incidence of major complications (odds ratio = 1.08; 95% confidence interval: 0.67-1.73; P = 0.739), or 90-day mortality (odds ratio = 1.03; 95% confidence interval: 0.12-8.53; P = 0.978) for those patients in the SECONDPD group as compared to the FIRSTPD group. The mean scores of two (physical and temporal demand) of the six SURG-TLX subscales of surgical workload were recorded as significantly higher by surgeons following two PD's as compared to one PD. CONCLUSIONS Although scheduling a second PD in one day shows no association with adverse patient outcomes, there is an increase in the physical and temporal subscales of surgical workload and consideration should be given to how this could be minimized.
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16
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Delpero JR, Véran O, Turrini O, Pessaux P. Can we talk about "illegal" surgery? Round table at the 121st Congress of the French Association of Surgery (Association Française de Chirurgie [AFC]). J Visc Surg 2020; 157:75-77. [PMID: 32178933 DOI: 10.1016/j.jviscsurg.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- J R Delpero
- Oncologic surgery Department, Marseille University, Institut Paoli-Calmette, 232, Boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - O Véran
- Neurology Department, University Hospital of la Tronche, Avenue Maquis du Grésivaudan, 38700 La Tronche, France
| | - O Turrini
- Oncologic surgery Department, Marseille University, Institut Paoli-Calmette, 232, Boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - P Pessaux
- Department of Digestive and Endocrine Surgery, Hepato-biliary and Pancreatico department, Strasbourg University, Nouvel Hôpital Civil, 1, place de l'Hôpital, 67100 Strasbourg, France.
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17
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Warschkow R, Tsai C, Köhn N, Erdem S, Schmied B, Nussbaum DP, Gloor B, Müller SA, Blazer D, Worni M. Role of lymphadenectomy, adjuvant chemotherapy, and treatment at high-volume centers in patients with resected pancreatic cancer-a distinct view on lymph node yield. Langenbecks Arch Surg 2020; 405:43-54. [PMID: 32040705 DOI: 10.1007/s00423-020-01859-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/27/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE While the importance of lymphadenectomy is well-established for patients with resectable pancreatic cancer, its direct impact on survival in relation to other predictive factors is still ill-defined. METHODS The National Cancer Data Base 2006-2015 was queried for patients with resected pancreatic adenocarcinoma (stage IA-IIB). Patients were dichotomized into the following two groups, those with 1-14 resected lymph nodes and those with ≥ 15. Optimal number of resected lymph nodes and the effect of lymphadenectomy on survival were assessed using various statistical modeling techniques. Mediation analysis was performed to differentiate the direct and indirect effect of lymph node resection on survival. RESULTS A total of 21,912 patients were included; median age was 66 years (IQR 59-73), 48.9% were female. Median number of resected lymph nodes was 15 (IQR 10-22), 10,163 (46.4%) had 1-14 and 11,749 (53.6%) had ≥ 15 lymph nodes retrieved. Lymph node positivity increased by 4.1% per lymph node up to eight examined lymph nodes, and by 0.6% per lymph node above eight. Five-year overall survival was 17.9%. Overall survival was better in the ≥ 15 lymph node group (adjusted HR 0.91, CI 0.88-0.95, p < 0.001). On a continuous scale, survival improved with increasing LNs collected. Patients who underwent adjuvant chemotherapy and were treated at high-volume centers had improved overall survival compared with their counterparts (adjusted HR 0.59, CI 0.57-0.62, p < 0.001; adjusted HR 0.86, CI 0.83-0.89, p < 0.001, respectively). Mediation analysis revealed that lymphadenectomy had only 18% direct effect on improved overall survival, while 82% of its effect were mediated by other factors like treatment at high-volume hospitals and adjuvant chemotherapy. DISCUSSION While higher number of resected lymph nodes increases lymph node positivity and is associated with better overall survival, most of the observed survival benefit is mediated by chemotherapy and treatment at high-volume centers.
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Affiliation(s)
- Rene Warschkow
- Department of Surgery, Kantonsspital St. Gallen, Gallen, Switzerland
| | - Catherine Tsai
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Nastassja Köhn
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Suna Erdem
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Bruno Schmied
- Department of Surgery, Kantonsspital St. Gallen, Gallen, Switzerland
| | - Daniel P Nussbaum
- Berner Viszeralchirurgie, Klinik Beau-Site, Hirslanden, Bern, Switzerland
| | - Beat Gloor
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Sascha A Müller
- Berner Viszeralchirurgie, Klinik Beau-Site, Hirslanden, Bern, Switzerland
| | - Dan Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mathias Worni
- Department of Surgery, Duke University Medical Center, Durham, NC, USA. .,Swiss Institute for Translational and Entrepreneurial Medicine, Stiftung Lindenhof, Campus SLB, Bern, Switzerland. .,Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, CH-4058, Basel, Switzerland.
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18
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Latenstein AEJ, van der Geest LGM, Bonsing BA, Groot Koerkamp B, Haj Mohammad N, de Hingh IHJT, de Meijer VE, Molenaar IQ, van Santvoort HC, van Tienhoven G, Verheij J, Vissers PAJ, de Vos-Geelen J, Busch OR, van Eijck CHJ, van Laarhoven HWM, Besselink MG, Wilmink JW. Nationwide trends in incidence, treatment and survival of pancreatic ductal adenocarcinoma. Eur J Cancer 2019; 125:83-93. [PMID: 31841792 DOI: 10.1016/j.ejca.2019.11.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/24/2019] [Accepted: 11/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND In recent years, new treatment options have become available for pancreatic ductal adenocarcinoma (PDAC) including 5-fluorouracil, leucovorin, irinotecan and oxaliplatin. The impact hereof has not been assessed in nationwide cohort studies. This population-based study aimed to investigate nationwide trends in incidence, treatment and survival of PDAC. MATERIALS AND METHODS Patients with PDAC (1997-2016) were included from the Netherlands Cancer Registry. Results were categorised by treatment and by period of diagnosis (1997-2000, 2001-2004, 2005-2008, 2009-2012 and 2013-2016). Kaplan-Meier survival analysis was used to calculate overall survival. RESULTS In a national cohort of 36,453 patients with PDAC, the incidence increased from 12.1 (1997-2000) to 15.3 (2013-2016) per 100,000 (p < 0.001), whereas median overall survival increased from 3.1 to 3.8 months (p < 0.001). Over time, the resection rate doubled (8.3%-16.6%, p-trend<0.001), more patients received adjuvant chemotherapy (3.0%-56.2%, p-trend<0.001) and 3-year overall survival following resection increased (16.9%-25.4%, p < 0.001). Over time, the proportion of patients with metastatic disease who received palliative chemotherapy increased from 5.3% to 16.1% (p-trend<0.001), whereas 1-year survival improved from 13.3% to 21.2% (p < 0.001). The proportion of patients who only received supportive care decreased from 84% to 61% (p-trend<0.001). CONCLUSION The incidence of PDAC increased in the past two decades. Resection rates and use of adjuvant or palliative chemotherapy increased with improved survival in these patients. In all patients with PDAC, however, the survival benefit of 3 weeks is negligible because the majority of patients only received supportive care.
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Affiliation(s)
- Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Lydia G M van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Nadia Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Vincent E de Meijer
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Izaak Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Pauline A J Vissers
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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Tan E, Song J, Lam S, D'Souza M, Crawford M, Sandroussi C. Postoperative outcomes in elderly patients undergoing pancreatic resection for pancreatic adenocarcinoma: A systematic review and meta-analysis. Int J Surg 2019; 72:59-68. [PMID: 31580919 DOI: 10.1016/j.ijsu.2019.09.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/11/2019] [Accepted: 09/26/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND Pancreatic cancer is a disease of the elderly. Surgical resection is usually offered to patients in early stage disease; however, pancreatic resection in the elderly is controversial. METHODS MEDLINE, EMBASE and Cochrane Library, were searched for studies comparing short- and long-term outcomes of elderly (above the age of 70) with non-elderly patients (below the age of 70) following pancreatic resection for pancreatic adenocarcinoma over the period from the inception of electronic database to 2017. Twelve articles documenting 4860 patients were included. A meta-analysis of data on patient characteristics, operative techniques, and perioperative outcomes were analysed. Our primary endpoint was postoperative mortality, defined as 30-day mortality or in-hospitalisation mortality. RESULTS There were 919 patients in the elderly group and 3941 patients in the non-elderly group. Elderly patients had worse ASA scores (p < 0.001) and more cardiovascular comorbidities (p = 0.002). Tumour size, T-stage, N-stage and tumour grade were similar between the elderly and non-elderly group (p > 0.05). Fewer elderly patients received a concomitant venous resection with their pancreatectomy (RR0.80, p = 0.003, I2 = 0%), achieved a negative margin status (RR0.76, p = 0.02, I2 = 28%) and underwent adjuvant chemotherapy treatment (RR0.69, p < 0.001, I2 = 42%). Overall complication (RR1.15, p < 0.001, I2 = 47%), in particular, respiratory complications (RR2.33, p = 0.004, I2 = 39%), was higher in the elderly group. There was no difference in postoperative pancreatic fistula formation, postoperative haemorrhage, intraabdominal abscess and length of hospital stay between both groups (p > 0.05). Postoperative mortality was similar between both groups (p = 0.17). Subgroup analysis according to the time of enrolment (<2000, ≥2000) showed a significant subgroup effect (Chi2 = 3.44, p = 0.06, I2 = 70.9%) and revealed that postoperative mortality in the elderly group improved over time (Before 2000: n = 1654, subtotal RR2.27, p = 0.02, I2 = 0%; From 2000 onwards: n = 3206, subtotal RR1.00, p = 0.99, I2 = 0%). CONCLUSION Fewer elderly patients received chemotherapy and portal vein resection to achieve a clear margin. Pancreatic resection of pancreatic adenocarcinoma can be performed safely on elderly patients with acceptable risks in experienced centres by specialist hepatobiliary surgeons. Age alone should not be the only determinant for the selection of patients for surgical treatment of pancreatic adenocarcinoma.
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Affiliation(s)
- Elinor Tan
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia; Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia.
| | - Jialu Song
- Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia
| | - Susanna Lam
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia
| | - Mario D'Souza
- Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia; Sydney Local Health District Clinical Research Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Michael Crawford
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Charbel Sandroussi
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia; Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, 145-147 Missenden Road, Camperdown, NSW, 2050, Australia
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20
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Shaib WL, Zakka K, Hoodbhoy FN, Belalcazar A, Kim S, Cardona K, Russell MC, Maithel SK, Sarmiento JM, Wu C, Akce M, Alese OB, El-Rayes BF. In-hospital 30-day mortality for older patients with pancreatic cancer undergoing pancreaticoduodenectomy. J Geriatr Oncol 2019; 11:660-667. [PMID: 31706832 DOI: 10.1016/j.jgo.2019.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/01/2019] [Accepted: 10/16/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Surgical resection remains the only potentially curative therapy for pancreatic ductal adenocarcinoma (PDAC). There is paucity of literature about morbidity and mortality in older patients with PDAC undergoing pancreaticoduodenectomy. This retrospective analysis evaluates the in-hospital 30-day mortality of this population utilizing the Nationwide Inpatient Sample (NIS) database. SUBJECTS AND METHODS All US patients hospitalized for pancreaticoduodenectomy (Whipple procedure) were included. Data was obtained from the NIS provided by the Agency for Healthcare Research and Quality. Pancreaticoduodenectomy diagnoses were identified using Clinical Classifications Software codes based on ICD-9 between 2007 and 2010. Univariable and multivariable analyses were performed using the logistic model, weighted chi-square test, and generalized linear model. RESULTS A total of 6149 patient discharges for pancreaticoduodenectomy were identified. Mean age was 64.9 years (SD ± 12.3); 21% of patients were ≥ 76 years of age. Majority were White (N = 5257, 77.9%) with a male:female ratio of 1. Patients aged 76 and older (OR: 1.76; 1.36-2.28; p < .001), Hispanics (OR: 1.40; 0.92-2.13; p = .12), and high comorbidity score (OR: 5.70; 3.44-9.46; p < .001) were found to be associated with a higher risk of 30-day in-hospital mortality. In the multivariable analysis, advanced age (>76) remained a significant predictor of longer in-hospital length of stay (OR: 1.09; 1.04-1.14; p < .001) and 30-day in-hospital mortality (OR 1.46; 1.07-2.00; p = .016). The 30-day in-hospital mortality rate for all patients across all years was 3.24%, for patients >76 years 4.11% and for patients <76 years 2.77%. Patients who underwent surgery at teaching hospitals (OR: 0.61; 0.42-0.88; p = .008) had a lower risk of 30-day in-hospital mortality compared to non-teaching hospitals. CONCLUSION In-hospital 30 day mortality was higher in selected older patients with PDAC undergoing pancreaticoduodenectomy. Mortality was lower at high volume and teaching centers. Further stringent selection criteria are needed to decrease mortality in the older population.
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Affiliation(s)
- Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.
| | - Katerina Zakka
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Farhan N Hoodbhoy
- College of Arts and Sciences, Boston University, Boston, MA, United States of America
| | - Astrid Belalcazar
- Eastern Maine Medical Center Cancer Care, Brewer, ME, United States of America
| | - Sungjin Kim
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Kenneth Cardona
- Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Maria C Russell
- Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Shishir K Maithel
- Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Juan M Sarmiento
- General Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Christina Wu
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mehmet Akce
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Olatunji B Alese
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bassel F El-Rayes
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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21
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Polonski A, Izbicki JR, Uzunoglu FG. Centralization of Pancreatic Surgery in Europe. J Gastrointest Surg 2019; 23:2081-2092. [PMID: 31037503 DOI: 10.1007/s11605-019-04215-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of this article is a review and an analysis of the current state of centralization of pancreatic surgery in Europe. Numerous recent publications demonstrate higher postoperative in-hospital mortality rates in low-volume clinics after pancreatic resection than previously assumed due to their not publishing significantly worse outcomes when compared to high-volume centres. Although the benefits of centralization of pancreatic surgery in high-volume centres have been demonstrated in many studies, numerous countries have so far failed to establish centralization in their respective health care systems. METHODS A systematic literature search of the Medline database for studies concerning centralization of pancreatic surgery in Europe was conducted. The studies were reviewed independently for previously defined inclusion and exclusion criteria. We included 14 studies with a total of 117,634 patients. All data were extracted from or provided by health insurance company or governmental registry databases. RESULTS Thirteen out of the 14 studies demonstrate an improvement in their respective outcome related to volume. Twelve studies showed a significantly lower postoperative mortality rate in the highest annual volume group in comparison to overall postoperative mortality rate in the whole patient cohort. CONCLUSION As the available data indicate, most European countries have so far failed to establish centralization of pancreatic surgery to high-volume centres due to numerous reasons. Considering a plateau in survival rates of patients undergoing treatment for pancreatic cancer in Europe during the last 15 years, this review enforces the worldwide plea for centralization to lower post-operative mortality after pancreatic surgery.
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Affiliation(s)
- Adam Polonski
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany. .,Department of General Visceral and Thoracic Surgery, University of Hamburg Medical Institutions, Martinistr 52, 20252, Hamburg, Germany.
| | - Faik G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
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Ahola R, Sand J, Laukkarinen J. Pancreatic resections are not only safest but also most cost-effective when performed in a high-volume centre: A Finnish register study. Pancreatology 2019; 19:769-774. [PMID: 31239104 DOI: 10.1016/j.pan.2019.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/26/2019] [Accepted: 06/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND It is not known whether the treatment costs of pancreatic surgery can be reduced by centralisation. The aim of this study was to analyse the impact of hospital volume on the short-term prognosis and costs in a nationwide study. METHODS The National registry was searched for patients undergoing pancreatoduodenectomy (PD) in Finland between 2012 and 2014. Patient data was recorded up to ninety days postoperatively and Charlson comorbidity index (CCI) calculated. Complications were classified according to Clavien-Dindo. A CCI was calculated for each patient. The hospitals were categorized by yearly resection rate: high (≥20, HVC), medium (6-19, MVC) and low (≤5, LVC). Costs were calculated according to the 2012 billing list. RESULTS The study population comprised 466 patients. Demographics were similar in the HVC, MVC and LVC groups. Mortality was lower in the HVCs than in MVCs and LVCs at 30 days (0.8% vs. 8.8-12.9%; p < 0.01) and at 90 days (1.9% vs. 10.5-16.1%; p < 0.01). Hospital volume and CCI were significant factors for mortality in multivariate analysis. Median costs among all patients were lower in the HVC group than in the MVC/LVC groups (p = 0.019), among Clavien-Dindo class III (0.020), among patients over 75 years (p < 0.001) and among patients who survived over five days (p = 0.015). CONCLUSIONS Thirty- and 90-day mortality is 10 times lower when the patient is operated on in an HVC. The study shows that the median overall costs of surgical treatment are 82-88% of the median costs in lower volume centres.
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Affiliation(s)
- R Ahola
- Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland
| | - J Sand
- Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland; Päijät-Häme Central Hospital, Medical School, University of Tampere, Finland
| | - J Laukkarinen
- Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland; Medical School, University of Tampere, Finland.
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Ramia JM, Serrablo A, Gomez Bravo MA. National survey on Pancreatic Surgery Units. Cir Esp 2019; 97:254-260. [PMID: 30981466 DOI: 10.1016/j.ciresp.2019.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The technical, human, scientific and treatment characteristics of the Units that manage complex pathologies have not been studied in depth. METHODS Multi-institutional descriptive study (survey) developed jointly by the Hepatobiliary-Pancreatic Division of the Spanish Association of Surgeons and the Spanish Chapter of the IHPBA (International Hepatopancreatobiliary Association) on the characteristics of the Units where pancreatic surgery is performed in Spain. RESULTS 82 surveys were sent. 69 medical centers responded (84%), belonging to 16 autonomous regions of Spain. The total population of these regions was 23,183,262 (50% of the Spanish population). The average number of beds per hospital was 673. The unit that performs pancreatic surgery is a Hepatobiliary-Pancreatic Surgery Unit or HPB and Liver Transplant Surgery Unit in 56 hospitals (77%). The average number of surgeons is 4.5 per Unit. Fifty-five Units (80%) lack specific anesthetists. The number of pancreatectomies performed during 2017 at the hospitals surveyed was 1,315 pancreaticoduodenectomies (PD), 566 distal pancreatectomies (DP) and 178 total pancreaticoduodenectomies (TPD). The mean per hospital was 19.1 PD, 8.2 DP and 2.6 TPD. PD was usually performed using a classic approach, with pancreatojejunostomy, single-loop technique, antecolic gastrojejunostomy and using two drain tubes. Only 7 Units performed PD laparoscopically and only 13 units did not perform laparoscopic DP. CONCLUSIONS This survey provides updated information about the majority of the Units where pancreatic surgery is performed in Spain and could also serve as a starting point for prospective multicenter studies.
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Affiliation(s)
- José Manuel Ramia
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Universidad de Alcalá, Guadalajara, España.
| | - Alejandro Serrablo
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Miguel Servet, Zaragoza, España; Capítulo Español de la Asociación Internacional Hepatopancreatobiliar (IHPBA)
| | - Miguel Angel Gomez Bravo
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Virgen del Rocío, Sevilla, España; Sección Hepatobiliopancreática (HPB) de la Asociación Española de Cirujanos
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24
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Groen JV, Sibinga Mulder BG, van Eycken E, Valerianova Z, Borras JM, van der Geest LGM, Capretti G, Schlesinger-Raab A, Primic-Zakelj M, Ryzhov A, van de Velde CJH, Bonsing BA, Bastiaannet E, Mieog JSD. Differences in Treatment and Outcome of Pancreatic Adenocarcinoma Stage I and II in the EURECCA Pancreas Consortium. Ann Surg Oncol 2018; 25:3492-3501. [PMID: 30151560 DOI: 10.1245/s10434-018-6705-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The EUropean REgistration of Cancer CAre (EURECCA) consortium aims to investigate differences in treatment and to improve cancer care through Europe. The purpose of this study was to compare neo- and adjuvant chemotherapy (ACT) and outcome after tumor resection for pancreatic adenocarcinoma stage I and II in the EURECCA Pancreas consortium. METHODS The eight, collaborating national, regional, and single-center partners shared their anonymized dataset. Patients diagnosed in 2012-2013 who underwent tumor resection for pancreatic adenocarcinoma stage I and II were investigated with respect to treatment and survival and compared using uni- and multivariable logistic and Cox regression analyses. All comparisons were performed separately per registry type: national, regional, and single-center registries. RESULTS In total, 2052 patients were included. Stage II was present in the majority of patients. The use of neo-ACT was limited in most registries (range 2.8-15.5%) and was only different between Belgium and The Netherlands after adjustment for potential confounders. The use of ACT was different between the registries (range 40.5-70.0%), even after adjustment for potential confounders. Ninety-day mortality was also different between the registries (range 0.9-13.6%). In multivariable analyses for overall survival, differences were observed between the national and regional registries. Furthermore, patients in ascending age groups and patients with stage II showed a significant worse overall survival. CONCLUSIONS This study provides a clear insight in clinical practice in the EURECCA Pancreas consortium. The differences observed in (neo-)ACT and outcome give us the chance to further investigate the best practices and improve outcome of pancreatic adenocarcinoma.
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Affiliation(s)
- J V Groen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - B G Sibinga Mulder
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Z Valerianova
- Bulgarian National Cancer Registry/National Oncological Hospital, Sofia, Bulgaria
| | - J M Borras
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | - L G M van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - G Capretti
- Pancreatic Surgery Unit, Department of Surgery, Humanitas University, Milan, Italy
| | - A Schlesinger-Raab
- Munich Cancer Registry, Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
| | - M Primic-Zakelj
- Epidemiology and Cancer Registry/Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - A Ryzhov
- Taras Shevchenko National University of Kyiv and Ukrainian National Cancer Institute, Kiev, Ukraine
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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Is Nighttime Really Not the Right Time for a Laparoscopic Cholecystectomy? Can J Gastroenterol Hepatol 2018; 2018:6076948. [PMID: 30151356 PMCID: PMC6087598 DOI: 10.1155/2018/6076948] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/10/2018] [Accepted: 07/24/2018] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The impact of an out-of-hours laparoscopic cholecystectomy on outcome is controversial. We sought to determine the association between an out-of-hours procedure and postoperative complications within 90 days. METHODS Between 2014 and 2016, 1553 laparoscopic cholecystectomies were performed. Therapeutic, operative, and outcome data were prospectively collected and analyzed. We defined out of hours as during weekends, national holidays, and daily between 5PM and 8AM. RESULTS Most patients operated on were female (n=988; 63.6%) and the majority of procedures were electives (n=1341; 86.3%). Although all procedures were performed with a laparoscopic intent, 42 (2.7%) were converted to open procedure. In total, 145 (9.3%) procedures were out of hours, all nonelective, and in most cases for acute cholecystitis (n=111; 7.1%). Overall, there were 212 complications in 191 patients (12.3%), most (n=153; 9.9%) classified as minor. The conversion rate in the out-of-hours group was significantly higher (9.7% vs 2.0%; p<0.001). While univariate analyses revealed out-of-hours procedure (OR=1.83; p=0.008) to be associated with an increased risk of complications, when controlling for confounding factors by multivariate analysis, this association was not found. However, operation by surgical staff (OR=1.71) and conversion to laparotomy (OR=3.74) were found to be independently associated with an increased risk of complications (both p<0.05), while an emergency procedure tended to be associated with postoperative morbidity (OR=1.82; p=0.069). CONCLUSION An out-of-hours laparoscopic cholecystectomy was not found to be an independent risk factor for developing postoperative morbidity and time of day should therefore only be a relative contraindication.
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Ahola R, Hölsä H, Kiskola S, Ojala P, Pirttilä A, Sand J, Laukkarinen J. Access to radical resections of pancreatic cancer is region-dependent despite the public healthcare system in Finland. J Epidemiol Community Health 2018; 72:803-808. [PMID: 29720389 DOI: 10.1136/jech-2017-210187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/23/2018] [Accepted: 04/16/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Surgical resection is the best treatment option to improve the prognosis of pancreatic cancer (PC). Our aim was to analyse whether PC treatment strategies show regional variation in Finland, a country with a nationwide public healthcare system. METHODS All patients diagnosed with PC in 2003 and 2008 were identified from the Finnish Cancer Registry. The data regarding tumour, treatment, demographics and timespans to treatment were recorded from the patient archives. Patients were included in the healthcare district where the diagnosis was made. The healthcare districts were classified according to experience in pancreatic surgery into three groups (high level of experience region (HLER), n=2; medium level of experience region (MLER), n=6, and low level of experience region (LLER), n=13). RESULTS Patients included numbered 1546 (median age 72 years (range 34-97), 45% men). Demographics and the ratio of stage IV disease (53%) were similar between the regional groups. Despite this, the proportion of radical surgery was greater in HLERs than in the MLERs and LLERs (18% vs 8%-11%; p<0.01). Logistic regression analysis including age, American Society of Anesthesiologists classification, stage and level of experience showed that more radical resections were performed in the HLERs. Preoperative bile drainage showed no regional differences (p=0.137). Palliative chemotherapy only was used more frequently in MLER and LLER than in HLERs (24% vs 33%-30%; p<0.01). CONCLUSION Access to PC curative treatment was more likely for patients in healthcare districts including a hospital with high level of experience in pancreatic surgery. This highlights the importance of centralized treatment guidance.
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Affiliation(s)
- Reea Ahola
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Heini Hölsä
- Medicine, University of Tampere, Tampere, Finland
| | | | - Pirkka Ojala
- Medicine, University of Tampere, Tampere, Finland
| | | | - Juhani Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.,Medicine, University of Tampere, Tampere, Finland
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Kitazawa T, Matsumoto K, Fujita S, Seto K, Wu Y, Nagahama T, Hasegawa T. Effects of the concentration of digestive surgical operations in regional Japan. Surg Today 2017; 48:416-421. [PMID: 29075927 DOI: 10.1007/s00595-017-1601-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/10/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this study was to investigate the relationship between the concentration of digestive system surgery and outcomes at a regional level in Japan, using time-series data. METHODS We used nationwide data from 2008 to 2013, and analyzed the ten most common surgical procedures. The unit of analysis was secondary medical areas (SMAs), which cover several municipalities and provide medical services for common diseases. The concentration of surgery in these areas was measured using the Herfindahl-Hirschman Index (HHI) and the relationship between the concentration of surgery and length of stay in hospital (LOS) was analyzed, in accordance with surgical difficulty. RESULTS There was a downward trend in both the HHI and LOS from 2008 to 2013. SMAs showing an upward trend in the HHI (increased concentration) were associated with a greater reduction in LOS than those showing a downward trend for eight surgical procedures. For three easy surgical procedures, increased concentration of surgery was significantly associated with a reduction in LOS. After adjustment for trends in the aging population and the surgical volume in 2008, an increasing concentration for three easy surgical procedures was significantly related to a reduction in the LOS. CONCLUSION Concentrating relatively easy surgical procedures at a regional level may be associated with a reduction in LOS.
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Affiliation(s)
- Takefumi Kitazawa
- Department of Social Medicine, Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Kunichika Matsumoto
- Department of Social Medicine, Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Shigeru Fujita
- Department of Social Medicine, Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Kanako Seto
- Department of Social Medicine, Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Yinghui Wu
- School of Nursing, Shanghai Jiao Tong University, No.227 South Chongqing Rd, 200025, Shanghai, China
| | - Takayoshi Nagahama
- Department of Social Medicine, Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Tomonori Hasegawa
- Department of Social Medicine, Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.
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Fang JZ, Lu CD, Wu SD, Huang J, Zhou J. Portal vein/superior mesenteric vein resection in pancreatic cancer treatment in the elderly. Medicine (Baltimore) 2017; 96:e7335. [PMID: 28682880 PMCID: PMC5502153 DOI: 10.1097/md.0000000000007335] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
There is an increased interest in extending surgical criteria for pancreatic cancer by performing pancreaticoduodenectomy (PD) combined with portal vein (PV) or superior mesenteric vein (SMV) resection and reconstruction for borderline resectable patients. However, whether this procedure suitable for elderly patients remains unclear. Here, we studied cases of pancreatic cancer treatment in our medical center to evaluate feasibility and safety of this procedure in the elderly.Eighty-three patients 65 years of age or older who underwent PD from January 2009 to March 2014 were divided into 2 groups: PD only (Group A, 52 cases), and PD combined with PV/SMV resection and reconstruction (Group B, 31 cases). Surgical outcomes and survival rates were compared between groups. Information regarding preoperative, intraoperative and postoperative conditions, and follow-up visits were provided. The outcomes of postoperative complications and survival rates were investigated.No difference in the preoperative data was detected between 2 groups with the exception that the serum albumin level was significantly lower in Group B (P = .013), indicating more deteriorating health conditions in this group. Although intraoperative time and blood loss were higher in Group B (P < .001 and P = .048, respectively), the overall postoperative complications and survival curve showed no statistical differences between 2 groups with one exception in that there was higher incidence of intractable diarrhea in Group B (P = .034). The symptoms, however, resolved later on with conservative treatment. The median survival time for patients in this study was comparable to other reported PD treatments. There was zero postoperative mortality in both groups.PD combined with PV/SMV treatment did not lead to increased morbidity and motility in elderly patients 65 years of age and above. This procedure could provide a promising opportunity for borderline resectable elderly pancreatic cancer patients.
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Affiliation(s)
- Jiong-Ze Fang
- Department of Hepatobiliary Surgery, Southern Medical University, Nanfang Hospital, Guangzhou, Guangdong
- Department of Hepatopancreatobiliary Surgery, Ningbo Lihuili Eastern Hospital, Medical School of Ningbo University, Zhejiang, China
| | - Cai-De Lu
- Department of Hepatopancreatobiliary Surgery, Ningbo Lihuili Eastern Hospital, Medical School of Ningbo University, Zhejiang, China
| | - Sheng-Dong Wu
- Department of Hepatopancreatobiliary Surgery, Ningbo Lihuili Eastern Hospital, Medical School of Ningbo University, Zhejiang, China
| | - Jing Huang
- Department of Hepatopancreatobiliary Surgery, Ningbo Lihuili Eastern Hospital, Medical School of Ningbo University, Zhejiang, China
| | - Jie Zhou
- Department of Hepatobiliary Surgery, Southern Medical University, Nanfang Hospital, Guangzhou, Guangdong
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Busweiler LAD, Dikken JL, Henneman D, van Berge Henegouwen MI, Ho VKY, Tollenaar RAEM, Wouters MWJM, van Sandick JW. The influence of a composite hospital volume on outcomes for gastric cancer surgery: A Dutch population‐based study. J Surg Oncol 2017; 115:738-745. [DOI: 10.1002/jso.24562] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/26/2016] [Accepted: 01/10/2017] [Indexed: 12/16/2022]
Affiliation(s)
| | - Johan L. Dikken
- Department of SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | - Daniel Henneman
- Department of SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | | | - Vincent K. Y. Ho
- Netherlands Comprehensive Cancer Organization (IKNL)UtrechtThe Netherlands
| | | | - Michel W. J. M. Wouters
- Department of Surgical OncologyThe Netherlands Cancer Institute—Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
| | - Johanna W. van Sandick
- Department of Surgical OncologyThe Netherlands Cancer Institute—Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
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Glowka TR, Webler M, Matthaei H, Schäfer N, Schmitz V, Kalff JC, Standop J, Manekeller S. Delayed gastric emptying following pancreatoduodenectomy with alimentary reconstruction according to Roux-en-Y or Billroth-II. BMC Surg 2017; 17:24. [PMID: 28320386 PMCID: PMC5359898 DOI: 10.1186/s12893-017-0226-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 03/16/2017] [Indexed: 02/06/2023] Open
Abstract
Background Delayed gastric emptying (DGE) remains the most frequent complication following pancreatoduodenectomy (PD) with published incidences as high as 61%. The present study investigates the impact of bowel reconstruction techniques on DGE following classic PD (Whipple-Kausch procedure) with pancreatogastrostomy (PG). Methods We included 168 consecutive patients who underwent PD with PG with either Billroth II type (BII, n = 78) or Roux-en-Y type reconstruction (ReY, n = 90) between 2004 and 2015. Excluded were patients with conventional single loop reconstruction after pylorus preserving procedures. DGE was classified according to the 2007 International Study Group of Pancreatic Surgery definition. Patients were analyzed regarding severity of DGE, morbidity and mortality, length of hospital stay and demographic factors. Results No difference was observed between BII and ReY regarding frequency of DGE. Overall rate for clinically relevant DGE was 30% (ReY) and 26% (BII). BII and ReY did not differ in terms of demographics, morbidity or mortality. DGE significantly prolongs ICU (four vs. two days) and hospital stay (20.5 vs. 14.5 days). Risk factors for DGE development are advanced age, retrocolic reconstruction, postoperative hemorrhage and major complications. Conclusions The occurrence of DGE can not be influenced by the type of alimentary reconstruction (ReY vs. BII) following classic PD with PG. Old age and major complications could be identified as important risk factors in multivariate analysis. Trial registration German Clinical Trials Register (DRKS) DRKS00011860. Registered 14 March 2017.
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Affiliation(s)
- Tim R Glowka
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.
| | - Markus Webler
- Department of Orthopedic and Trauma Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Hanno Matthaei
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Nico Schäfer
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Volker Schmitz
- Department of Gastroenterology, St. Marienwörth Hospital, Mühlenstr. 39, 55543, Bad Kreuznach, Germany
| | - Jörg C Kalff
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Jens Standop
- Department of Surgery, Maria Stern Hospital, Am Anger 1, 53424, Remagen, Germany
| | - Steffen Manekeller
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
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The Short- and Long-Term Outcomes of Pancreatic Resection for Pancreatic Adenocarcinoma in Patients Older Than 75 Years. Int Surg 2016. [DOI: 10.9738/intsurg-d-16-00192.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The short- and long-term outcomes of pancreatic resection for pancreatic adenocarcinoma have not been fully evaluated in elderly patients. This retrospective study selected patients who underwent curative surgery for pancreatic cancer at our institution. Patients were categorized into 2 groups: nonelderly patients (age < 75 years; group A) and elderly patients (age ≥ 75 years; group B). The surgical morbidity, surgical mortality, overall survival (OS), and recurrence-free survival (RFS) rates in the 2 groups were compared. A total of 221 patients were evaluated in the study. The overall complication rates were 44.8% in group A and 52.6% in group B. Surgical mortality was observed in 2 patients due to an abdominal abscess and cardiovascular disease in group A (1.1%) and in 1 patient due to postoperative bleeding in group B (2.6%). There were no significant differences (P = 0.379 and P = 0.456, respectively). Furthermore, the 5-year OS and RFS rates were similar between the elderly patients and nonelderly patients (18.55 versus 20.2%, P = 0.946 and 13.1% versus 16.0%, P = 0.829, respectively). The short-term outcomes and long-term survival after pancreatic resection for pancreatic adenocarcinoma were almost equal in the elderly and the nonelderly patients in this study. Therefore, it is unnecessary to avoid pancreatic resection for pancreatic adenocarcinoma in elderly patients simply because of their age.
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Surgery in Italy. Criteria to identify the hospital units and the tertiary referral centers entitled to perform it. Updates Surg 2016; 68:115-6. [DOI: 10.1007/s13304-016-0378-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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