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Salirrosas O, Vega EA, Chirban AM, Harandi H, Cohen M, Anderson A, Bhargava R, Conrad C. Laparoscopic Total Pancreatectomy After Laparoscopic Whipple. Ann Surg Oncol 2024; 31:6193-6194. [PMID: 38958808 DOI: 10.1245/s10434-024-15576-3] [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: 02/01/2024] [Accepted: 05/22/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND The incidence of a second de novo pancreatic ductal adenocarcinoma (PDAC) among patients with prior cancer has been reported to be 6%.1,2 however, as survival increases through improvements in systemic therapy, this incidence of a de novo PDAC after prior PDAC may become more prevalent.3-8 In this context, a structured and stepwise approach to a total pancreatectomy for a second de novo PDAC after a prior PDAC treated with a pancreaticoduodenectomy is detailed. PATIENTS We present two similar cases. The first patient was a 71-year-old female with de novo body PDAC, and the second was a 50-year-old female with de novo tail PDAC. To rule out recurrence, immunohistochemical staining as well as the review of biopsies by two experienced pathologists were employed. Both patients had undergone a laparoscopic pancreatoduodenectomy for PDAC 4 and 3 years prior. Each patient received four cycles of neoadjuvant chemotherapy and underwent a safe laparoscopic total pancreatectomy. TECHNIQUE Prior to surgery, three-dimensional anatomic and port site modeling is performed to optimize the understanding of the spatial relationship between the tumor, blood vessels, and adjacent organs involved. The port site modeling (including pneumoperitoneum simulation) focuses on the optimal port set-up for dissecting the biliopancreatic limb off the portal vein. Following complete mobilization of the biliopancreatic limb, the biliopancreatic limb is staple-divided between the hepatico- and pancreaticojejunostomy. Great care must be taken to avoid accidental staple injury to the hepatic artery or celiac trunk. The remainder of the dissection is akin to a standard distal pancreaticosplenectomy. CONCLUSION Virtual pancreatectomy modeling facilitates an optimal set-up for the critical step of this case, i.e. dissection of the pancreaticojejunostomy off the portal vein. Early division of the biliopancreatic limb between hepatico- and pancreatojejunostomy is crucial to facilitating the remainder of the dissection. Laparoscopic total pancreatectomy for a de novo PDAC after laparoscopic pancreaticoduodenectomy may become more common as survival of patients with prior PDAC improves over time.
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Affiliation(s)
- Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Ariana M Chirban
- San Diego School of Medicine, University of California, La Jolla, CA, USA
| | - Hamed Harandi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Mark Cohen
- Department of Surgery, Carle Illinois College of Medicine, Carle Cancer Institute, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - Aaron Anderson
- Beckman Institute for Advanced Science and Technology, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - Rohit Bhargava
- Beckman Institute for Advanced Science and Technology, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - Claudius Conrad
- Department of Surgery, Carle Illinois College of Medicine, Carle Cancer Institute, University of Illinois Urbana-Champaign, Urbana, IL, USA.
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Codjia T, Hobeika C, Platevoet P, Pravisani R, Dokmak S, Aussilhou B, Marique L, Cros J, Cauchy F, Lesurtel M, Sauvanet A. Distal Pancreatectomy for Body Pancreatic Ductal Adenocarcinoma: Is Splenectomy Necessary? A Propensity Score Matched Study. Ann Surg Oncol 2024; 31:4611-4620. [PMID: 38526834 DOI: 10.1245/s10434-024-15220-0] [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: 01/11/2024] [Accepted: 03/10/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND The value of splenectomy for body localization (≥ 5 cm from spleen hilum) of pancreatic ductal adenocarcinoma (B-PDAC) is uncertain. This study assessed spleen-preserving distal pancreatectomy (SPDP) results for B-PDAC. PATIENTS AND METHODS This single-center study included patients who underwent SPDP (Warshaw's technique) or distal splenopancreactomy (DSP) for B-PDAC from 2008 to 2019. Propensity score matching was performed to balance SPDP and DSP patients regarding sex, age, American Society of Anesthesiologists (ASA), body mass index (BMI), laparoscopy, pathological features [American Joint Committee on Cancer (AJCC)/tumor node metastasis classification (TNM)], margins, and neoadjuvant/adjuvant therapies. RESULTS A total of 129 patients (64 male, median age 68 years, median BMI 24 kg/m2) were enrolled with a median follow-up of 63 months (95% CI 52-96 months), including 59 (46%) SPDP and 70 (54%) DSP patients. A total of 39 SPDP patients were matched to 39 DSP patients. SPDP patients had fewer harvested nodes (19 vs 22; p = 0.038) with a similar number of positive nodes (0 vs 0; p = 0.237). R0 margins were achieved similarly in SPDP and DSP patients (75% vs 71%; p = 0.840). SPDP patients were associated with decreased comprehensive complication index (CCI, 8.7 vs 16.6; p = 0.004), rates of grade B/C postoperative pancreatic fistula (POPF, 14% vs 29%; p = 0.047), and hospital stay (11 vs 16 days; p < 0.001). SPDP patients experienced similar disease-free survival (DFS, 5 years: 38% vs 32%; p = 0.180) and overall survival (OS, 5 years 54% vs 44%; p = 0.710). After matching, SPDP patients remained associated with lower CCI (p = 0.034) and hospital stay (p = 0.028) while not associated with risks of local recurrence (HR 0.85; 95% CI 0.28-2.62; p = 0.781), recurrence (HR 1.04; 95% CI 0.61-1.78; p = 0.888), or death (HR 1.20; 95% CI 0.68-2.11; p = 0.556). CONCLUSION SPDP for B-PDAC is associated with less postoperative morbidity than DSP, without impairing oncological outcomes.
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Affiliation(s)
- Tatiana Codjia
- Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Christian Hobeika
- Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France
- UMR Inserm 1275 CAP Paris-Tech, Hôpital Lariboisière, Université Paris-Cité, Paris, France
| | - Pierre Platevoet
- Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Riccardo Pravisani
- Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Béatrice Aussilhou
- Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Lancelot Marique
- Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Jérome Cros
- Department of Pathology, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Mickael Lesurtel
- Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Alain Sauvanet
- Department of HPB Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris Cité, Clichy, France.
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The impact of chemotherapy sequencing on resectable pancreatic cancer by stage. Surg Oncol 2021; 40:101694. [PMID: 34973593 DOI: 10.1016/j.suronc.2021.101694] [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: 08/24/2021] [Revised: 11/30/2021] [Accepted: 12/11/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION While chemotherapy is an important therapeutic modality for pancreatic cancer (PDAC), the optimal sequence of chemotherapy to surgery remains unclear. Further, the precise added benefit of including chemotherapy at each (especially early) stage has not been quantified. METHODS The National Cancer Database (NCDB) was queried for patients with PDAC who underwent pancreaticoduodenectomy between 2004 and 2016. Cox multivariable and Kaplan-Meier survival analyses were performed for disease-specific survival (DSS) and overall survival (OS) after correcting for confounders. Permutations of chemotherapy/surgery were compared: preoperative only (NCT), postoperative only (ACT), pre- and post-operative (perioperative, PCT), and no therapy (NoT). RESULTS 22975 patients met inclusion criteria. 13944(61%) received ACT, 1793(8%) received NCT and 946(4%) received PCT, while 6292(27%) did not receive chemotherapy. Log-rank test showed inferior survival in the NoT group compared to NCT, ACT, and PCT. Compared to the NoT group, PCT had the lowest rate of death (HR 0.704, p < 0.001) followed by NCT (HR 0.721, p < 0.001) and ACT (HR 0.759, p < 0.001).). CONCLUSION PDAC patients receiving chemotherapy, independent of their stage, will result in better DSS and OS. NCT should be given consideration for resectable disease including early stage PDAC and ideally complemented with postoperative chemotherapy. While there was a trend towards improved survival for PCT, NCT and ACT are reasonable options for stages IB-III.
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Salehi O, Vega EA, Kutlu OC, Conrad C. ASO Visual Abstract: Does a Laparoscopic Approach to Distal Pancreatectomy for Cancer Contribute to Optimal Adjuvant Chemotherapy Utilization? Ann Surg Oncol 2021. [PMID: 34275049 DOI: 10.1245/s10434-021-10413-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Salehi O, Vega EA, Kutlu OC, Conrad C. ASO AUTHOR REFLECTIONS: Laparoscopic Distal Pancreatectomy for Pancreatic Cancer: Good, Bad, or Even Ugly? Ann Surg Oncol 2021; 28:8281-8282. [PMID: 34169382 DOI: 10.1245/s10434-021-10332-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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