Determinants of survival and attempted resection in patients with non-metastatic pancreatic cancer: An Australian population-based study

BACKGROUND

There are indications that pancreatic cancer survival may differ according to sociodemographic factors, such as residential location. This may be due to differential access to curative resection. Understanding factors associated with the decision to offer a resection might enable strategies to increase the proportion of patients undergoing potentially curative surgery.

METHODS

Data were extracted from medical records and cancer registries for patients diagnosed with pancreatic cancer between July 2009 and June 2011, living in one of two Australian states. Among patients clinically staged with non-metastatic disease we examined factors associated with survival using Cox proportional hazards models. To investigate survival differences we examined determinants of: 1) attempted surgical resection overall; 2) whether patients with locally advanced disease were classified as having resectable disease; and 3) attempted resection among those considered resectable.

RESULTS

Data were collected for 786 eligible patients. Disease was considered locally advanced for 561 (71%) patients, 510 (65%) were classified as having potentially resectable disease and 365 (72%) of these had an attempted resection. Along with age, comorbidities and tumour stage, increasing remoteness of residence was associated with poorer survival. Remoteness of residence and review by a hepatobiliary surgeon were factors influencing the decision to offer surgery.

CONCLUSIONS

This study indicated disparity in survival dependent on patients' residential location and access to a specialist hepatobiliary surgeon. Accurate clinical staging is a critical element in assessing surgical resectability and it is therefore crucial that all patients have access to specialised clinical services.

Meta-analysis of radical resection rates and margin assessment in pancreatic cancer

BACKGROUND

R0 resection rates (complete tumour removal with negative resection margins) in pancreatic cancer are 70-80 per cent when a 0-mm margin is used, declining to 15-24 per cent with a 1-mm margin. This review evaluated the R0 resection rates according to different margin definitions and techniques.

METHODS

Three databases (MEDLINE from 1946, PubMed from 1946 and Embase from 1949) were searched to mid-October 2014. The search terms included 'pancreatectomy OR pancreaticoduodenectomy' and 'margin'. A meta-analysis was performed with studies in three groups: group 1, axial slicing technique (minimum 1-mm margin); group 2, other slicing techniques (minimum 1-mm margin); and group 3, studies with minimum 0-mm margin.

RESULTS

The R0 rates were 29 (95 per cent c.i. 26 to 32) per cent in group 1 (8 studies; 882 patients) and 49 (47 to 52) per cent in group 2 (6 studies; 1568 patients). The combined R0 rate (groups 1 and 2) was 41 (40 to 43) per cent. The R0 rate in group 3 (7 studies; 1926 patients) with a 0-mm margin was 72 (70 to 74) per cent The survival hazard ratios (R1 resection/R0 resection) revealed a reduction in the risk of death of at least 22 per cent in group 1, 12 per cent in group 2 and 23 per cent in group 3 with an R0 compared with an R1 resection. Local recurrence occurred more frequently with an R1 resection in most studies.

CONCLUSION

Margin clearance definitions affect R0 resection rates in pancreatic cancer surgery. This review collates individual studies providing an estimate of achievable R0 rates, creating a benchmark for future trials.

The prognostic and predictive value of serum CA19.9 in pancreatic cancer

Background

Current staging methods for pancreatic cancer (PC) are inadequate, and biomarkers to aid clinical decision making are lacking. Despite the availability of the serum marker carbohydrate antigen 19.9 (CA19.9) for over two decades, its precise role in the management of PC is yet to be defined, and as a consequence, it is not widely used.

Methods

We assessed the relationship between perioperative serum CA19.9 levels, survival and adjuvant chemotherapeutic responsiveness in a cohort of 260 patients who underwent operative resection for PC.

Results

By specifically assessing the subgroup of patients with detectable CA19.9, we identified potential utility at key clinical decision points. Low postoperative CA19.9 at 3 months (median survival 25.6 vs 14.8 months, P = 0.0052) and before adjuvant chemotherapy were independent prognostic factors. Patients with postoperative CA 19.9 levels >90 U/ml did not benefit from adjuvant chemotherapy (P = 0.7194) compared with those with a CA19.9 of ≤90 U/ml (median 26.0 vs 16.7 months, P = 0.0108). Normalization of CA19.9 within 6 months of resection was also an independent favorable prognostic factor (median 29.9 vs 14.8 months, P = 0.0004) and normal perioperative CA19.9 levels identified a good prognostic group, which was associated with a 5-year survival of 42%.

Conclusions

Perioperative serum CA19.9 measurements are informative in patients with detectable CA19.9 (defined by serum levels of >5 U/ml) and have potential clinical utility in predicting outcome and response to adjuvant chemotherapy. Future clinical trials should prioritize incorporation of CA19.9 measurement at key decision points to prospectively validate these findings and facilitate implementation.

Superior mesenteric artery syndrome: diagnosis and treatment strategies

INTRODUCTION

Superior mesenteric artery (SMA) syndrome is an unusual cause of vomiting and weight loss resulting from the compression of the third part of the duodenum by the SMA. Various medical and psychiatric conditions may result in the initial rapid weight loss which causes narrowing of the aortomesenteric angle. The vomiting and obstructive syndrome is then self-perpetuated regardless of the initiating factors. The young age and nonspecific symptoms often lead to a delay in diagnosis.

DISCUSSION

A series of eight cases is presented reviewing the presentation, investigations, surgical treatment by division of duodenum and duodenojejunostomy, and outcomes.

CONCLUSION

SMA syndrome is a well-described entity which must be considered as a cause of vomiting associated with significant weight loss in young adults. Surgical treatment should be allied with psychological assessment to treat any underlying psychosocial abnormality.

Use of the novel biomarker (HOXB2) to predict response to pancreatectomy for pancreatic cancer

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Background: Pancreatectomy is the only therapeutic intervention that offers the chance of long term survival for patients with pancreatic cancer, however, only 10% of patients who undergo pancreatectomy survive > 3 years with prognostic factors only determined after pathological examination of the resected specimen. Identification of a biomarker of response to surgical resection that can be determined preoperatively offers the potential to significantly improve survival and quality of life for patients with PC by improving patient selection for pancreatectomy. Methods: We examined the aberrant expression of over 20 genes identified using transcript profiling or known to be important in carcinogenesis using immunohistochemistry and in-situ hybridisation in a cohort of 124 patients with pancreatic cancer to identify potential biomarkers of prognosis and response to operative resection. Results: Aberrant expression of p53, p21WAF1/CIP1, p27KIP1, p16INK4A, cyclin D1, cyclin E, DPC4/Smad4, EGFR, beta-catenin, sfrp4, LMO4, HOXB2, S100P, S100A6, S100A2, RAI3 and CRBP1 were identified in a significant proportion of PC. Multivariate analysis of clinicopathological variables (tumor size, differentiation, subtype, lymph node metastases, perineural invasion and vascular space invasion), treatment parameters (margin involvement, adjuvant therapy, resection type), and aberrant expression of the above candidate biomarkers identified that HOXB2 expression and resection margin involvement by tumor were the only 2 independent prognostic factors. Patients who had absent HOXB2 expression and had clear margins after pancreaticoduodenectomy (48%) had an actual survival of 40% at 3 years and 21% at 5 years, compared to those with HOXB2 expression and/or positive surgical margins who had all died by 28 months. Conclusion: HOXB2 expression may represent a surrogate marker of advanced disease, can potentially be assessed preoperatively using FNAB, and is currently the best predictor of outcome and response to operative resection to be reported. Preoperative assessment of HOXB2 expression has potential clinical utility in predicting response to operative resection for PC to allow better selection of patients for operative intervention.

No significant financial relationships to disclose.

Skills acquired on virtual reality laparoscopic simulators transfer into the operating room in a blinded, randomised, controlled trial

Virtual reality surgical simulators have proven value in the acquisition and assessment of laparoscopic skills. In this study, we investigated skill transfer from a virtual reality laparoscopic simulator into the operating room, using a blinded, randomised, controlled trial design. Surgical trainees using the LapSim System performed significantly better at their first real-world attempt at a laparoscopic task than their colleagues who had not received similar training, as measured independently by a number of expert surgical observers using four criteria.

Bacteremia associated with operative decompression of a small bowel obstruction

BACKGROUND

Intraoperative decompression of the small bowel has been advocated as a method of aiding recovery of both the patient and the intestine. However, the methods proposed (retrograde stripping or enterotomy) require vigorous handling of bacteria-laden small bowel, possibly giving rise to a bacteremia.

STUDY DESIGN

A small bowel obstruction was created in 31 rats by means of a ligature. Twenty-four hours later, the obstruction was relieved, and the rats were divided into three groups: relief of obstruction alone, relief with retrograde stripping, and relief with enterotomy plus suction. Blood cultures were taken before and after manipulation of the bowel.

RESULTS

In blood cultures taken before and after manipulation there was a significant increase of Escherichia coli bacteremia in the two manipulation groups compared with the relief of obstruction only group.

CONCLUSIONS

Bacteremia may be an effect of operative decompression of obstructed bowel, which at times outweighs its supposed benefits.

Repair of giant inguinoscrotal inguinal hernia using marlex mesh and scrotal skin flaps

A new technique for the repair of giant inguinoscrotal hernia is described. It consists of: reduction of the hernia; repair of the hernial orifices with marlex mesh; creation of a midline anterior wall defect to increase intra-abdominal capacity; covering this defect with marlex mesh; then covering the midline marlex mesh with a rotation flap of inguinoscrotal skin. This technique increases intra-abdominal capacity and allows reduction of the hernia without compromising respiratory function, in patients with chronic airflow limitation, by using skin that would otherwise be discarded.

Left lateral laparoscopic cholecystectomy and its relevance to choledocholithiasis

One of the current challenges to the laparoscopic biliary surgeon is the management of bile duct stones. While laparoscopic bile duct exploration is in its infancy, pre- and postoperative endoscopic retrograde cholangiopancreatography with or without endoscopic papillotomy (ERCP/EP) currently plays a significant role. Intra-operative ERCP/EP has advantages over pre- and postoperative ERCP/EP; however it has not gained popularity due, partly, to the difficulties associated with ERCP/EP being performed with the patient in the supine position. This study prospectively assessed, in 10 consecutive patients, the feasibility of performing laparoscopic cholecystectomies in the left lateral position, a position amenable to intra-operative ERCP/EP if necessary. It is concluded that laparoscopic cholecystectomy in the left lateral position can be performed safely, with similar ease and results as in the supine position, increasing the options available to manage choledocholithiasis.

A totally diverting loop colostomy

A technique is described where the distal limb of a loop colostomy is tied with nylon or polydioxanone. This ensures total faecal diversion and dispenses with the supporting rod, enabling early application of stoma appliances. The technique does not interfere with the traditional transverse closure of a loop colostomy.

Ischaemic complications of graduated compression stockings in the treatment of deep venous thrombosis

Graduated compression stockings are frequently used in the prevention of deep venous thrombosis and the treatment of venous insufficiency. Two patients are discussed who sustained ischaemic complications after application of graduated compression stockings. Review of the literature demonstrates that low cutaneous pressures significantly decrease local blood flow and that the amount of pressure exerted by graduated compression stockings increases significantly with increases in leg girth. Ischaemic complications associated with the use of these stockings also appears to be more common than previously thought and any policy of routine prescription to patients should be questioned.

Torsion of the vermiform appendix: a case report and review of literature

A case of torsion of the vermiform appendix is described. It is a rare cause of an acute abdomen with a clinical presentation that is indistinguishable from acute appendicitis.