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Dai Y, Huang W, Xu L, Zhang Q, Huang X. Machine learning models and nomogram based on clinical, laboratory profiles and skeletal muscle index to predict pancreatic fistula after pancreatoduodenectomy. Gland Surg 2024; 13:164-177. [PMID: 38455348 PMCID: PMC10915431 DOI: 10.21037/gs-23-410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/17/2023] [Indexed: 03/09/2024]
Abstract
Background Postoperative pancreatic fistula (POPF) is a perilous complication that may arise subsequent to pancreaticoduodenectomy (PD). In recent times, there has been an escalating interest in employing machine learning (ML) techniques to aid in treatment decision-making. The purpose of this research is to assess the effectiveness of ML in comparison to conventional models, while also conducting an initial evaluation of the predictive capability of skeletal muscle index (SMI) concerning POPF. Methods This retrospective observational study was carried out at The First Affiliated Hospital of Wenzhou Medical University from January 2012 to January 2021, encompassing data from 269 patients who underwent PD. After identifying independent factors associated with the condition, a logistic regression model was employed to construct a nomogram, alongside the establishment of five ML models. To assess their effectiveness, the best-performing ML model and nomogram were evaluated on a separate test group comprising 77 additional patients. The evaluation involved comparing the area under the curve (AUC) and Brier score. Results Among the 269 patients studied, the incidence of POPF was found to be 56.9%, with 106 patients (69.3%) experiencing clinically-relevant POPF. We identified six independent factors associated with POPF, including body mass index (BMI), SMI, pancreatic duct dilatation, tumor size, triglyceride levels, and the ratio of aspartate aminotransferase to alanine aminotransferase (AST/ALT) on the first postoperative day. When evaluated on the test set, the Gaussian Naive Bayes (GNB) model, which was the best-performing ML model, achieved an AUC of 0.824 and a Brier score of 0.175. The corresponding performance indicators for the nomogram were 0.844 for AUC and 0.165 for the Brier score. Conclusions This study found that there is minimal difference between ML and the nomogram based on logistic regression in predicting POPF. Additionally, SMI shows promise as a potential and practical tool for assessing the risk of POPF.
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Affiliation(s)
- Yile Dai
- The First School of Clinical Medicine, Wenzhou Medical University, Wenzhou, China
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenqian Huang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Liming Xu
- Department of Hepatobiliary Surgery, Wenzhou Central Hospital, Wenzhou, China
| | - Qiyu Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaming Huang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Zhang B, Li L, Liu H, Li L, Wang H, Li Y, Wang Y, Sun B, Chen H. A modified single-needle continuous suture of duct-to-mucosa pancreaticojejunostomy in pancreaticoduodenectomy. Gland Surg 2023; 12:1642-1653. [PMID: 38229848 PMCID: PMC10788565 DOI: 10.21037/gs-23-340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/17/2023] [Indexed: 01/18/2024]
Abstract
Background The pancreatic reconstruction technique decides the incidence of postoperative pancreatic fistulas (POPF) in pancreaticoduodenectomy (PD). This study aims to evaluate the safety of modified single-needle continuous suture (SNCS) of duct-to-mucosa and compare the efficacy with double-layer continuous suture (DLCS) of duct-mucosa pancreaticojejunostomy (PJ) in open PD (OPD). Methods A total of 266 patients that received PD between January 2019 and May 2023 were retrospectively analyzed. Among them, 130 patients underwent DLCS, and 136 patients underwent SNCS [73 OPD and 63 laparoscopic PD (LPD)]. The primary outcome was clinically relevant POPF (CR-POPF) according to the definition of the revised 2016 International Study Group of Pancreatic Fistula (ISGPF). Propensity score matching (PSM) was conducted to reduce confounding bias. Results A total of 66 pairs were successfully matched using PSM in OPD. No significant difference was observed in the occurrence of CR-POPF between the two groups (9.1% vs. 21.2%, P=0.052). However, the median duration of operation and PJ was shorter in the SNCS group. The incidence of CR-POPF in LPD was 9.5%. Furthermore, regarding the alternative fistula risk score (a-FRS), the CR-POPF rate were 2.1%, 10.5%, and 15.6% in low-, intermediate-, and high-risk groups (P=0.067). Conclusions The SNCS is a facile, safe, and effective PJ technique and does not increase the incidence of POPF, regardless of a-FRS stratification, pancreatic texture, and main pancreatic duct (MPD) size.
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Affiliation(s)
- Binru Zhang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Le Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongyang Liu
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Linfeng Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Haonian Wang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yilong Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yongwei Wang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hua Chen
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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Dermanis AA, Halle-Smith J, Powell-Brett S, Roberts JK, Sutcliffe RP, Chatzizacharias N. Arterial resection during operative management of pancreatic head and uncinate process adenocarcinoma: a systematic review. Transl Gastroenterol Hepatol 2023; 8:41. [PMID: 38021362 PMCID: PMC10643219 DOI: 10.21037/tgh-23-33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 09/25/2023] [Indexed: 12/01/2023] Open
Abstract
Background Surgical resection is a part of the treatment pathways for the management of pancreatic cancer with arterial involvement. Arterial resection in this context is however not widely supported due to the paucity and diversity of the reported evidence in the literature. The aim of this systematic review is the presentation and analysis of the current evidence in the field. Methods A systematic literature search of PubMed, MEDLINE and the Cochrane Library was performed for eligible studies, following the PRISMA guidelines. Information on baseline characteristics, peri-operative outcomes, survival outcomes and histopathological findings were extracted for pooling and analysis. Results Eight studies with a total of 170 patients were included in the analysis. One hundred and thirty-five patients had a pancreaticoduodenectomy (PD) and 35 had a total pancreatectomy (TP) with arterial resection. Perioperative morbidity was 43.5% and mortality was 4.5%. Median overall survival (OS) was 12.7 months (range, 10.5-22.2 months). Overall 3- and 5-year survival for this cohort was reported at 6.6% (range, 0-42.4%) and 3.3% (range, 0-6.6%) respectively. Resection margins were clear (R0) in a median of 75% of patients. Only a median of 45% of patients received neo-adjuvant chemotherapy. Conclusions Arterial resection can be performed with an acceptable peri-operative morbidity and mortality. However, survival outcomes are still not convincing and future efforts should concentrate on patient and disease biology selection.
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Affiliation(s)
- Alexander A. Dermanis
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - James Halle-Smith
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sarah Powell-Brett
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - J. Keith Roberts
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Robert P. Sutcliffe
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Nikolaos Chatzizacharias
- HPB and Liver Transplant Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Tonelli F, Marini F, Giusti F, Iantomasi T, Giudici F, Brandi ML. Pancreatic Neuroendocrine Tumors in MEN1 Patients: Difference in Post-Operative Complications and Tumor Progression between Major and Minimal Pancreatic Surgeries. Cancers (Basel) 2023; 15:4919. [PMID: 37894286 PMCID: PMC10605506 DOI: 10.3390/cancers15204919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/29/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023] Open
Abstract
Pancreatic neuroendocrine neoplasms (PNENs) affect over 80% of patients with multiple endocrine neoplasia type 1 (MEN1). Surgery is usually the therapy of choice, but the real immediate and long-term therapeutic benefit of a partial extensive pancreatic resection remains controversial. We analyzed, in 43 PNEN MEN1 patients who underwent 19 pancreaticoduodenectomies (PD), 19 distal pancreatectomies (DP), and 5 minimal pancreatectomies, the prevalence of surgery-derived early complications and post-operative pancreatic sequelae, and the PNEN relapse-free survival time after surgery, comparing major (PD+DP) and minimal pancreatic surgeries. No post-operative mortality was observed. Metastatic cancers were found in 12 cases, prevalently from duodenal gastrinoma. Long-term cure of endocrine syndromes, by the 38 major pancreatic resections, was obtained in 78.9% of gastrinomas and 92.9% of insulinomas. In only one patient, hepatic metastases, due to gastrinoma, progressed to death. Out of the 38 major surgeries, only one patient was reoperated for the growth of a new PNEN in the remnant pancreas. No functioning PNEN persistence was reported in the five minimal pancreatic surgeries, PNEN relapse occurred in 60% of patients, and 40% of cases needed further pancreatic resection for tumor recurrence. No significant difference in PNEN relapse-free survival time after surgery was found between major and minimal pancreatic surgeries.
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Affiliation(s)
- Francesco Tonelli
- Fondazione F.I.R.M.O. Onlus, Fondazione Italiana per la Ricerca sulle Malattie dell’Osso (Italian Foundation for the Research on Bone Diseases), 50129 Florence, Italy; (F.T.)
- Donatello Bone Clinic, Villa Donatello Hospital, 50019 Sesto Fiorentino, Italy
| | - Francesca Marini
- Fondazione F.I.R.M.O. Onlus, Fondazione Italiana per la Ricerca sulle Malattie dell’Osso (Italian Foundation for the Research on Bone Diseases), 50129 Florence, Italy; (F.T.)
| | - Francesca Giusti
- Donatello Bone Clinic, Villa Donatello Hospital, 50019 Sesto Fiorentino, Italy
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50139 Florence, Italy
| | - Teresa Iantomasi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50139 Florence, Italy
| | - Francesco Giudici
- Department of Clinical and Experimental Medicine, Surgical Unit, University of Florence, 50139 Florence, Italy
| | - Maria Luisa Brandi
- Fondazione F.I.R.M.O. Onlus, Fondazione Italiana per la Ricerca sulle Malattie dell’Osso (Italian Foundation for the Research on Bone Diseases), 50129 Florence, Italy; (F.T.)
- Donatello Bone Clinic, Villa Donatello Hospital, 50019 Sesto Fiorentino, Italy
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Sommier L, Panaro F. Decision-making in high-risk leakage duodenopancreatectomy: pancreatic anastomosis or total pancreatectomy? Hepatobiliary Surg Nutr 2023; 12:567-569. [PMID: 37600989 PMCID: PMC10432310 DOI: 10.21037/hbsn-23-193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 05/15/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Lazare Sommier
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, School of Medicine, Montpellier, France
| | - Fabrizio Panaro
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, School of Medicine, Montpellier, France
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Yamaguchi T, Halkic N. Preservation of aberrant right hepatic artery during pancreaticoduodenectomy. Hepatobiliary Surg Nutr 2023; 12:465-467. [PMID: 37351130 PMCID: PMC10282686 DOI: 10.21037/hbsn-23-146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/29/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Takamune Yamaguchi
- Department of Hepato-Biliary and Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland
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Yin J, Zhu Q, Zhang K, Gao W, Wu J, Lu Z, Jiang K, Miao Y. Development and validation of risk prediction nomogram for pancreatic fistula and risk-stratified strategy for drainage management after pancreaticoduodenectomy. Gland Surg 2022; 11:42-55. [PMID: 35242668 PMCID: PMC8825517 DOI: 10.21037/gs-21-550] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/18/2021] [Indexed: 08/10/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the major complication following pancreaticoduodenectomy (PD). We sought to develop and validate a risk prediction model for POPF after PD with the aim of determining personal risk probability and proposing a novel strategy for intraoperative placement and/or early-removal of prophylactic drainage. METHODS Data from 993 patients undergoing PD from January 2012 to December 2016 were retrospectively analyzed. Patients were randomly assigned to either training cohort or validation cohort. A nomogram was formulated based on the results from multivariable regression model for prediction of POPF. Internal and external validation were carried out with calibration plot respectively. RESULTS POPF occurred in 162 (16.3%) patients. The final pre-/intra-operative prediction model included alanine transaminase level [odds ratio (OR) 1.00, 95% confidence interval (CI): 1.00-1.00, P=0.023], combined portal-superior mesenteric vein resection (OR 0.22, 95% CI: 0.05-0.95, P=0.043), pancreatic duct diameter (OR 1.48, 95% CI: 1.11-1.96, P=0.007), intraoperative colloid infusion (OR 1.00, 95% CI: 1.00-1.00, P=0.001), pathology (OR 1.71, 95% CI: 1.09-2.66, P=0.018). The area under the curve (AUC) was 0.667 in the training cohort and 0.621 in the validation cohort. The final postoperative prediction model included pancreatic duct diameter (OR 1.58, 95% CI: 1.14-2.19, P=0.006), intraoperative colloid infusion (OR 2.52, 95% CI: 1.26-5.06, P=0.009), drainage fluid amylase on postoperative day 3 (POD3) (OR 4.70, 95% CI: 3.30-6.70, P<0.001), and neutrophil count on POD3 (OR 2.83, 95% CI: 1.63-4.93, P<0.001). The AUC was 0.809 in the training cohort and 0.797 in the validation cohort. Based on these variables, two nomogram prediction models were developed respectively. The calibration plot of the two models showed a good correlation between the expected risk and the actual risk in the low-risk range. Our risk-stratified strategy for drain management according to nomograms may be beneficial for 34.5% of patients. CONCLUSIONS Our study formulated and validated two nomogram models for predicting POPF that performed particularly well in the low-risk range. This tool may allow surgeons to propose a risk stratified strategy for intraoperative drain placement and early drain removal, which may be beneficial for a substantial proportion of patients.
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Affiliation(s)
- Jie Yin
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Qicong Zhu
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
| | - Kai Zhang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Wentao Gao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Junli Wu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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Chen W, Zhang K, Zhang Z, Lu Z, Zhang D, Liu J, Yang Y, Leng Y, Zhang Y, Zhang W, Jiang K, Zhuang G, Miao Y, Liu Y. Pancreatoduodenectomy within 2 weeks after endoscopic retrograde cholangio-pancreatography increases the risk of organ/space surgical site infections: a 5-year retrospective cohort study in a high-volume centre. Gland Surg 2021; 10:1852-1864. [PMID: 34268070 PMCID: PMC8258873 DOI: 10.21037/gs-20-826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/18/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Organ/space surgical site infections (OSSI) after pancreaticoduodenectomy (PD) are not rare events. The role of diagnosis and treatment for pancreatic and biliary diseases with an endoscopic retrograde cholangio-pancreatography (ERCP) procedure is currently controversial. However, the ERCP procedure might play a role in surgical outcomes after PD. METHODS We conducted a retrospective cohort study for patients who underwent PD in the First Affiliated Hospital with the Nanjing Medical University from 1st September 2012 to 31st January 2018. The relationship between ERCP exposure and OSSI after PD was analyzed by univariate and forward stepwise multivariate logistic regression model. RESULTS Of the 1,365 patients who underwent PD, 136 developed OSSI (10.0%). We found that ERCP exposure before PD (EEBPD) was significantly associated with an increased incidence rate of post-operative pancreas fistula (POPF) [24.2% (23/95) vs. 14.9% (189/1,270), risk ratio (RR) =1.63, 95% confidence interval (CI), 1.11-2.38, P=0.015]. Hypertension, a higher level of preoperative low-density lipoprotein (LDL) and creatinine (Cr) were associated with elevated risks of post-operative OSSI [adjusted odds ratio (Adj-OR) (95% CI) were 1.59 (1.09-2.32), 1.70 (1.16-2.51), 1.99 (1.36-2.92)], whereas a preoperatively higher level of aspartate aminotransferase (AST) would decrease the risk [Adj-OR (95% CI), 0.62 (0.42-0.91)]. Remarkably, EEBPD would significantly increase and more than double the OSSI risk [Adj-OR (95% CI), 2.56 (1.46-4.47)] especially if it was within 14 days before surgery (Spearman =-0.698, P<0.001). CONCLUSIONS ERCP, as an independent risk factor, significantly increased the risk of post-operative OSSI after PD if it is performed within 14 days prior to surgery. Our findings would assist clinical decision-making, and improve OSSI control and prevention.
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Affiliation(s)
- Wensen Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kai Zhang
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zipeng Lu
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Daoquan Zhang
- Department of Endoscopy, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Juan Liu
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yue Yang
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yinzhi Leng
- Department of Infection, Nanjing Traditional Chinese Medicine Hospital, Nanjing, China
| | - Yongxiang Zhang
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weihong Zhang
- Office of Infection Management, Jiangsu Province Hospital & Jiangsu Shengze Hospital, Suzhou, China
| | - Kuirong Jiang
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Guihua Zhuang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Yi Miao
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Yun Liu
- Department of Geriatrics Endocrinology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Medical Informatics, School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
- Institute of Medical Informatics and Management, Nanjing Medical University, Nanjing, China
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Han P, Yang Y, He Y, Wu H, Wang D, Liu K, Guan C, Zhang X, Guo W, Zhang Z. The effect of atrial fibrillation on perioperative outcomes in patients with pancreatic cancer undergoing open pancreaticoduodenectomy: analysis of the National Inpatient Sample. Gland Surg 2021; 10:1951-1961. [PMID: 34268079 DOI: 10.21037/gs-21-116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/27/2021] [Indexed: 11/06/2022]
Abstract
Background To assess the role of atrial fibrillation on perioperative outcomes in patients with pancreatic cancer undergoing open pancreaticoduodenectomy (OPD). Methods We investigated patients with pancreatic cancer undergoing OPD during 2012-2014 within National Inpatient Sample database. The study population was divided into two groups based on the presence of atrial fibrillation. In-hospital mortality, length of stay, cost of hospitalization, and in-hospital complications were compared between the two groups. Logistic regression models and linear regression were used to adjust for potential confounders. Propensity score matching was also utilized. Results Of the 12,785 patients aged ≥18 years undergoing OPD during years 2012-2014, 11,469 (90%) had no atrial fibrillation and 1,316 (10%) had atrial fibrillation. Patients with atrial fibrillation were found to have significantly higher cost, but similar mortality and LOS compared to those without atrial fibrillation. The risk of gastrointestinal anastomotic leakage, cardiac complications, respiratory complications, pulmonary embolism, and perioperative shock were found to be significantly higher in atrial fibrillation group than non-atrial fibrillation group in both multivariate regression model and propensity score matching model. In older patients (>65 years), atrial fibrillation was found to be associated with a significantly higher cost, longer hospital stays, higher incidence of cardiac complications, respiratory complications, and postoperative shock, yet similar mortality. Conclusions Atrial fibrillation was found to be associated with higher cost in pancreatic cancer patients undergoing OPD, as well as increased occurrence of cardiac complications, respiratory complications, pulmonary embolism, and perioperative shock. Surgeons should pay special attention to patients with atrial fibrillation, and consider working together with cardiologists and anesthesiologists to jointly develop a management plan.
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Affiliation(s)
- Pu Han
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yifeng Yang
- Department of Internal Medicine, University of Iowa Hospitals and Clinic, Iowa, USA
| | - Yanjie He
- Department of Surgery, NYU Langone Medical Center, New York, USA
| | - Hongwei Wu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Dong Wang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Kun Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Chengjian Guan
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Xiaodong Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Wei Guo
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Cancer Invasion and Metastasis Research & National Clinical Research Center for Digestive Diseases, Beijing, China
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10
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Huang H, Wang C, Ji F, Han Z, Xu H, Cao M. Nomogram based on albumin and neutrophil-to-lymphocyte ratio for predicting postoperative complications after pancreaticoduodenectomy. Gland Surg 2021; 10:877-891. [PMID: 33842233 DOI: 10.21037/gs-20-789] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background The aim of this study was to identify a preoperative inflammatory marker with the most predictive value for postoperative complications after pancreaticoduodenectomy (PD). We then combined it with other perioperative variables to construct and validate a nomogram for complications after PD. Methods A total of 223 patients who received PD from January 2014 to July 2019 at a high-volume (>60 PDs/year) pancreatic centers in China were included in this retrospective study. All of the PDs were performed by the same surgeon who is beyond the learning curve with more than 100 PDs over the previous 3 years before 2014. 15 preoperative inflammatory markers were collected, including neutrophils, lymphocytes, high-sensitivity C-reactive protein and lactic dehydrogenase. The inflammatory markers' predicting abilities for complications were analyzed by calculating the values of an area under the curve (AUC). The complications included surgical complications (such as pancreatic fistula, delayed gastric emptying and bile leakage) and medical complications (such as sepsis, pneumonia, urinary tract infection, acute heart failure and acute liver failure) in this study. Univariable and multivariable logistic regression analyses were performed to investigate the perioperative features for independent risk factors for complications after PD. Nomograms with or without the most predictive inflammatory for complications were subsequently developed based on multivariable logistic regression using Akaike information criterion. Nomograms' performance was quantified and compared in terms of calibration and discrimination. We studied the utility of the nomograms using decision curve analysis. Results The albumin/ NLR score (ANS) exhibited the highest AUC value (0.616) for predicting postoperative complications. ANS and approach method were identified as independent risk factors for complications. The nomogram with ANS had higher C-index (0.725) and better calibration. The NRI compared between nomograms was 0.160 (95% CI: 0.023-0.296; P=0.022). By decision curve analysis, the model with ANS had higher clinical value. Conclusions The ANS is a useful predictor and an independent risk factor for postoperative complications after PD. The nomogram with ANS was constructed with better performance and more clinical benefit for predicting postoperative complications.
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Affiliation(s)
- Haoquan Huang
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Chengli Wang
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Fengtao Ji
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhixiao Han
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hui Xu
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Minghui Cao
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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Honda M, Hioki M, Sadamori H, Monden K, Wakabayashi G, Takakura N. Advance ligation to facilitate pancreaticojejunostomy following pancreaticoduodenectomy by dilating the main pancreatic duct. Gland Surg 2021; 10:59-64. [PMID: 33633962 DOI: 10.21037/gs-20-501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Duct-to-mucosa pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) is technically challenging, particularly in cases of soft pancreas with a nondilated main pancreatic duct (MPD). We propose a novel procedure that involves ligating the pancreas in advance to allow for MPD dilation. Methods We compared the data of 16 patients who underwent PD followed by PJ with advance ligation (AL) for soft pancreas with a nondilated MPD with that of 17 patients who underwent a conventional procedure (conventional group) without AL at a single institution between January 2015 and April 2017. MPD diameters were assessed using preoperative computed tomography and intraoperative ultrasonography. Pancreatic consistency was judged intraoperatively. The pancreatic parenchyma and MPD were ligated in advance to allow time for MPD dilation. After AL, we divided the pancreatic parenchyma. AL led to MPD dilation and facilitated PJ. Results There were significantly fewer complications in the AL group than in the conventional group (P=0.005). There were no cases of pancreatitis or death in either group. The mean procedural time for occluding the MPD was 43 min (range, 21-134 min). The median MPD dilation rate after AL was 1.6 (0.9-3.8). Conclusions AL is a simple, safe, and useful procedure for facilitating PJ.
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Affiliation(s)
- Masayuki Honda
- Department of Surgery, Fukuyama City Hospital, Zaocho, Fukuyama, Hiroshima, Japan.,Department of Surgery, Sainokuni Higashiomiya Medical Center, Torocho, Kitaku, Saitama, Japan.,Department of Surgery, Ageo Central General Hospital, Kashiwaza, Ageo, Saitama, Japan
| | - Masayoshi Hioki
- Department of Surgery, Fukuyama City Hospital, Zaocho, Fukuyama, Hiroshima, Japan
| | - Hiroshi Sadamori
- Department of Surgery, Fukuyama City Hospital, Zaocho, Fukuyama, Hiroshima, Japan
| | - Kazuteru Monden
- Department of Surgery, Fukuyama City Hospital, Zaocho, Fukuyama, Hiroshima, Japan
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Kashiwaza, Ageo, Saitama, Japan
| | - Norihisa Takakura
- Department of Surgery, Fukuyama City Hospital, Zaocho, Fukuyama, Hiroshima, Japan
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12
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Lin R, Lin X, Lu F, Yang Y, Wang C, Fang H, Wen S, Chen Y, Huang H. Combination of anterior superior mesenteric vein-first and right posterior superior mesenteric artery-first approaches for uncinate process dissection in minimally invasive pancreaticoduodenectomy. Gland Surg 2020; 9:1396-1405. [PMID: 33224815 DOI: 10.21037/gs-20-228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background Uncinate process dissection is a key step in minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic and robotic procedures, which increase the intraoperative blood loss and operative time and decrease the R0 resection rate if improperly handled. However, few studies have reported the operative skills in detail. Methods We performed uncinate process dissection using a combination of the anterior superior mesenteric vein (SMV)-first approach and the right posterior superior mesenteric artery (SMA)-first approach in MIPD for 138 patients with periampullary tumors between March 2017 and October 2019. The demographic and perioperative data of all the patients were collected to evaluate the efficacy of this method. Results All patients underwent an uneventful operation. An assistant incision was performed to separate extensive adhesion between the tumor and the SMV in 3 patients. The combined approach had a notably shorter operation time and resection time, less intraoperative blood loss and a shorter postoperative hospital stay than the traditional approach (P<0.05). There were no significant differences in conversion rate, numbers of harvested lymph node or postoperative complications, including postoperative pancreatic fistula, bile leakage, delayed gastric emptying, postoperative bleeding and reoperation between the two groups (P>0.05). There were no deaths during the perioperative period. Conclusions The combination of the anterior SMV-first approach and the right posterior SMA-first approach is a safe and feasible technique for uncinate process dissection in MIPD.
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Affiliation(s)
- Ronggui Lin
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xianchao Lin
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Fengchun Lu
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuanyuan Yang
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Congfei Wang
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Haizong Fang
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Shi Wen
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yanchang Chen
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Heguang Huang
- Department of General surgery, Fujian Medical University Union Hospital, Fuzhou, China
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13
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Kwak BJ, Choi HJ, You YK, Kim DG, Hong TH. Comparative long-term outcomes for pancreatic volume change, nutritional status, and incidence of new-onset diabetes between pancreatogastrostomy and pancreatojejunostomy after pancreaticoduodenectomy. Hepatobiliary Surg Nutr 2020; 9:284-295. [PMID: 32509814 DOI: 10.21037/hbsn.2019.04.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background The difference in volume change in a pancreatic remnant according to the type of pancreaticoenterostomy after pancreaticoduodenectomy (PD) for long-term follow-up is unknown. Also, there are few studies that evaluate the difference in general nutritional status and pancreatic endocrine function, including new-onset diabetes mellitus (NODM) depending on the type of pancreaticoenterostomy. This study aimed to compare serial pancreatic volume changes in pancreatic remnants between pancreatogastrostomy (PG) and pancreatojejunostomy (PJ) after PD and to evaluate the difference in general nutritional status and incidence of NODM between PG and PJ. Methods This study enrolled 115 patients who had survived for more than 3 years after PD. They were divided into the PG group and the PJ group. Their clinicopathologic factors were collected and analyzed. We calculated serial pancreas volume and pancreatic duct size precisely from preoperative stage to 5 years after surgery by image-processing software specifically designed for navigation and visualization of multimodality and multidimensional images. Consecutive changes of albumin and body mass index (BMI) as related to general nutritional status were compared between the PG and PJ groups. To evaluate the incidence and risk factors of NODM following PD, subgroup analysis was performed in 88 patients who did not have diabetes preoperatively. Results Most patient demographics were not significantly different between the PG group (n=45) and PJ group (n=70). There was no significant difference in volume reduction between the groups from postoperative 1 month to 5 years (PG group -18.21±14.66 mL versus PJ group -14.43±13.05 mL, P=0.209). But there was a significant difference in increased pancreatic duct size between the groups from postoperative 1 month to 5 years (PG group 1.66±2.20 mm versus PJ group 0.54±1.54 mm, P=0.007). There was no significant difference in the increase of total serum albumin between the groups for 5 years after surgery (PG group 0.51±0.47 g/dL, 14.3% versus PJ group 0.42±0.60 g/dL, 11.3%, P=0.437). There was also no significant difference in BMI decrease between the groups (PG group -1.13±3.12, -4.9% versus PJ group -1.97±2.01, -8.7%, P=0.206). On the whole, NODM was diagnosed in 19 patients out of the 88 patients (21.6%) who did not have DM preoperatively. The incidence of NODM was not significantly different between the groups (PG group 21.6% versus PJ group 21.5%, P=0.995). In addition, pancreaticoenterostomy was not an independent risk factor for NODM by logistic regression analysis (odds ratio, 0.997, 95% CI: 0.356-0.2.788, P=0.995). No other risk factors for NODM were found. Conclusions PG and PJ following PD induced similar pancreatic volume reduction during long-term follow-up. There was no difference in general nutritional status or incidence of NODM between the groups after PD.
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Affiliation(s)
- Bong Jun Kwak
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kyoung You
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Goo Kim
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae Ho Hong
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Pu N, Mu S, Fang Y, Yin H, Liu G, Zhao G, Zhang L, Wu W, Lou W. Survival outcomes of pancreaticoduodenectomy versus extended pancreaticoduodenectomy procedure for pancreatic head carcinoma: a propensity score matching study. Transl Cancer Res 2020; 9:1476-1486. [PMID: 35117495 PMCID: PMC8798580 DOI: 10.21037/tcr.2020.01.38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/26/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND It is unclear if the modified extended pancreaticoduodenectomy (PD) has better outcome superior the conventional PD for patients with pancreatic head carcinoma (PHC). The objective of this study is to compare the survival outcomes of the classic PD procedure and the modified extended PD procedure for PHC. METHODS A total of 7,084 resected PHC patients with PD and extended PD procedure from the SEER database from 2004 to 2014 were stratified. With the utilization of propensity score matching (PSM), patient baseline characteristics were balanced to decrease the bias. Overall survival (OS) and cancer-specific survival (CSS) were analyzed in both groups. RESULTS Of the 7,084 patients, 6,541 (92.3%) and 543 (7.7%) patients received PD and extended PD surgical procedures, respectively. After 2:1 ratio of PSM, 543 patients with extended PD procedure and 1,084 patients with PD procedure were completely matched. The median CSS and OS for PD and extended PD group were 20.0 and 19.0 months, and 19.0 and 18.0 months, respectively. The 5-year CSS and OS rates for PD and extended PD group were 17.5% and 16.1%, and 13.9% and 13.1%, respectively. CONCLUSIONS There is no distinct difference in survival outcomes between PD and extended PD procedure in patients with PHC.
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Affiliation(s)
- Ning Pu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Sucheng Mu
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yuan Fang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Hanlin Yin
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Gao Liu
- Department of Liver Surgery and Transplantation, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guochao Zhao
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Lei Zhang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Wenchuan Wu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Wenhui Lou
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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15
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Rozich NS, Jones CE, Morris KT. Malnutrition, frailty, and sarcopenia in pancreatic cancer patients: assessments and interventions for the pancreatic surgeon. ACTA ACUST UNITED AC 2019; 2. [PMID: 33554109 DOI: 10.21037/apc.2019.02.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The objective of this article is to review the available literature examining the impact of malnutrition, frailty, and sarcopenia on surgical morbidity among pancreatic cancer patients. We examine definitions used to diagnose and quantify these conditions and review the differences between them with regards to preoperative assessment and postoperative outcomes. The most relevant scoring systems are summarized. Lastly, we summarize current knowledge regarding effectiveness of specific interventions aimed at malnutrition, frailty, and sarcopenia for patients undergoing pancreatic cancer surgery.
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Affiliation(s)
- Noah S Rozich
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Caitlin E Jones
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Katherine T Morris
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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16
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Wang W, Shen Z, Shi Y, Zou S, Fu N, Jiang Y, Xu Z, Chen H, Deng X, Shen B. Accuracy of Nodal Positivity in Inadequate Lymphadenectomy in Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Population Study Using the US SEER Database. Front Oncol 2019; 9:1386. [PMID: 31867282 PMCID: PMC6909429 DOI: 10.3389/fonc.2019.01386] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/25/2019] [Indexed: 12/24/2022] Open
Abstract
Objectives: The optimal number of the examined lymph nodes (ELNs) in pancreaticoduodenectomy for pancreatic ductal adenocarcinoma has been widely studied. However, the accuracy of nodal positivity for the patients with inadequate lymphadenectomy is still unclear. The purpose of our study was to determine the accuracy of the number of positive nodes reported for patients with 1-3 positive nodes and the probability that 4 or more nodes could be positive along with tumor size and number of nodes examined. Methods: We obtained data on patients who underwent pancreaticoduodenectomy for resectable pancreatic ductal adenocarcinoma diagnosed during 2004-2013 from the US Surveillance, Epidemiology, and End Results registry. An mathematical model based on Hypergeometric Distribution and Bayes' Theorem was used to estimate the accuracy. Results: Among the 9,945 patients, 55.6% underwent inadequate lymphadenectomy. Of them, 1,842, 6,049, and 2,054 had T1, T2, and T3 stage disease, respectively. The accuracy of the number of observed positive nodes increased as the number of ELNs increased and the tumor size decreased. To rule out the possibility of N2 stage (4 and more positive nodes), there should be at least 13 ELNs for the patients with 1 observed positive lymph node and 14 for the patients with 2. Conclusion: Inadequate lymphadenectomy could result in underestimation of the N stage, and this would have adverse impact on recurrence, efficacy of postoperative treatment, and even overall survival. This model combined with the observed positive lymph nodes, the number of ELNs, and tumor size could provide a more accurate determination of nodal positivity of these patients.
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Gu L, Khadaroo PA, Chen M, Qian H, Zhu H, Li X, Pan J, Zhong X, Wang X. Surgical management and outcomes of duodenal gastrointestinal stromal tumors. Acta Gastroenterol Belg 2019; 82:11-18. [PMID: 30888748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND STUDY AIMS This retrospective study purports to examine these characteristics and compare the surgical procedures available and appropriate for the treatment of patients affected by duodenal GISTs. PATIENTS AND METHODS A retrospective examination of reports and studies carried out between May 2012 and March 2017, and covering patients with primary GISTs of the duodenum was performed using modules from the SPSS package. Comparisons of treatment effects resulting from the administration of two differential methods of surgical treatment namely pancreaticoduodenectomy (PD), and limited resection (LR), were effected on the reports of the GIST patients thus selected. RESULTS Out of these 62 patients who had undergone resection of duodenal GISTs, 47 (76%) had limited resection (LR) and 15 (24%) underwent pancreaticoduodenectomy (PD). In Multivariate analyses, tumor size was an independent predictive factor for recurrence (p=0.008). ASA, tumor size, and PD were independent and significant prognostic factors on OS (p=0.021, p=0.024, and p=0.030, respectively). In the very low and low risk group, and high-risk group, there were no significant differences in the RFS (recurrence-free survival) and OS (overall survival) between the LR and PD groups. CONCLUSIONS When technically feasible, LR should be given due consideration as a reliable and curative option for duodenal GISTs achieving satisfactory RFS and OS.
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Affiliation(s)
- L Gu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - P A Khadaroo
- Zhejiang University School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - M Chen
- The Fourth Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - H Qian
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - H Zhu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - X Li
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - J Pan
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - X Zhong
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - X Wang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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18
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Zhang S, Lan Z, Zhang J, Chen Y, Xu Q, Jiang Q, Zhao Y, Wang C, Bi X, Huang X. Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis. Oncotarget 2017; 8:46449-60. [PMID: 28521286 DOI: 10.18632/oncotarget.17503] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 04/11/2017] [Indexed: 12/12/2022] Open
Abstract
Objective We aimed to compare the two most commonly used pancreatico-jejunostomy reconstruction techniques—duct-to-mucosa and invagination. Methods Databases, including MEDLINE, EMBASE, Cochrane Library, and several clinical trial registration centers were searched. Randomized controlled trials that compared duct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were included and analyzed. Results In total, seven RCTs were included, involving 850 patients. The difference in postoperative pancreatic fistula rate between the duct-to-mucosa and invagination pancreaticojejunostomy was not significant (RR = 1.03, 95% CI = 0.76-1.39, P = 0.86). There was no significant difference in clinically relevant postoperative pancreatic fistula between the two groups (RR = 0.78, 95% CI = 0.15-3.96, P = 0.77). The overall morbidity, overall mortality, delayed gastric emptying, intra-abdominal collection, reoperation rate, and length of hospital stay between the two groups were not significantly different. Sensitivity analysis showed that the meta-analysis was stable. Further, no significant publication bias was seen. Conclusions Duct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were comparable in terms of postoperative pancreatic fistula incidence and other parameters.
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Namm JP, Thakrar KH, Wang CH, Stocker SJ, Sur MD, Berlin J, Dale W, Talamonti MS, Roggin KK. A semi-automated assessment of sarcopenia using psoas area and density predicts outcomes after pancreaticoduodenectomy for pancreatic malignancy. J Gastrointest Oncol 2017; 8:936-944. [PMID: 29299352 PMCID: PMC5750184 DOI: 10.21037/jgo.2017.08.09] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/08/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Sarcopenia has been associated with increased adverse outcomes after major abdominal surgery. Sarcopenia defined as decreased muscle volume or increased fatty infiltration may be a proxy for frailty. In conjunction with other preoperative clinical risk factors, radiographic measures of sarcopenia using both muscle size and density may enhance prediction of outcomes after pancreaticoduodenectomy (PD) for malignancy. METHODS Preoperative computed tomography (CT) scans of patients undergoing PD for malignancy were analyzed from a prospective pancreatic surgery database. Sarcopenia was assessed both manually and with a semi-automated technique by measuring the total psoas area index (TPAI) and average Hounsfield units (HU) at the L3 lumbar level to estimate psoas muscle volume and density, respectively. Adjusting for known pre-operative risk factors, preoperative sarcopenia measurements were analyzed relative to perioperative outcomes. RESULTS Sarcopenia assessments of 116 subjects demonstrated good correlation between the semi-automated and the manual techniques (P<0.0001). Lower TPAI (OR 0.34, P=0.009) and HU (OR 0.84, P=0.002) measurements were predictive of discharge to skilled nursing facility (SNF), but not major complications, length of stay, readmissions or recurrence on univariate analysis. Lower TPAI was protective against the risk of organ/space surgical site infection (SSI) including pancreatic fistula (OR 3.12, P=0.019). On multivariate analysis, the semi-automated measurements of TPAI and HU remained as independent predictors of organ/space SSI including pancreatic fistula (OR 4.23, P=0.014) and discharge to SNF (OR 0.79, P=0.019) respectively. CONCLUSIONS When combined with preoperative clinical assessments in patients with pancreatic malignancy, semi-automated sarcopenia metrics are a simple, reproducible method that may enhance prediction of outcomes after PD and help guide clinical management.
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Affiliation(s)
- Jukes P. Namm
- Department of Surgery, Loma Linda University Health, Loma Linda, USA
| | - Kiran H. Thakrar
- Department of Radiology, NorthShore University HealthSystem, Evanston, USA
| | - Chi-Hsiung Wang
- Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, USA
| | - Susan J. Stocker
- Department of Surgery, NorthShore University HealthSystem, Evanston, USA
| | - Malini D. Sur
- Department of Surgery, Mount Sinai Health System, New York, USA
| | - Jonathan Berlin
- Department of Radiology, NorthShore University HealthSystem, Evanston, USA
| | - William Dale
- Department of Supportive Care Medicine, City of Hope, California, USA
| | - Mark S. Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, USA
| | - Kevin K. Roggin
- Department of Surgery, The University of Chicago Medicine, Chicago, USA
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20
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Ocuin LM, Miller-Ocuin JL, Zenati MS, Vargo JA, Singhi AD, Burton SA, Bahary N, Hogg ME, Zeh HJ, Zureikat AH. A margin distance analysis of the impact of adjuvant chemoradiation on survival after pancreatoduodenectomy for pancreatic adenocarcinoma. J Gastrointest Oncol 2017; 8:696-704. [PMID: 28890820 DOI: 10.21037/jgo.2017.04.02] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The role of adjuvant chemoradiotherapy (CRT) following pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDA) remains controversial. Recent data suggest that increased margin clearance (MC: distance between tumor and cut surface) is associated with improved survival after PD, but the role of adjuvant CRT in patients with known MC is undefined. We sought to delineate the impact of adjuvant CRT on survival based on MC following PD. METHODS Patients who underwent PD for PDA between 2002 and 2014 were retrospectively stratified into three groups based on MC: 0 mm, ≤1 mm, and >1 mm. The impact of CRT on survival in each MC group was determined by univariate and multivariate analysis. RESULTS Three hundred and ten patients with known MC were analyzed (0 mm =67, ≤1 mm =113, and >1 mm =130). Increasing MC was independently associated with improved OS (≤1 mm, HR 0.66, 95% CI 0.46-0.96, P=0.03; >1 mm, HR 0.51, 95% CI 0.35-0.75, P=0.001; compared to 0 mm). Adjuvant CRT was administered to 62 patients (20%). On margin-stratified multivariate analysis, adjuvant CRT was independently associated with increased OS in patients with ≤1 mm margins (HR 0.36; 95% CI 0.18-0.69, P=0.002) but not for 0 mm and >1 mm margins. CONCLUSIONS This analysis suggests that the benefit of adjuvant CRT may be restricted to patients with ≤1 mm MC after PD for pancreatic cancer.
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Affiliation(s)
- Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer L Miller-Ocuin
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mazen S Zenati
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Vargo
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aatur D Singhi
- Department of Anatomic Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven A Burton
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nathan Bahary
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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21
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Merdrignac A, Bergeat D, Levi Sandri GB, Agus M, Boudjema K, Sulpice L, Meunier B. Hepatic artery reinforcement after post pancreatectomy haemorrhage caused by pancreatitis. Gland Surg 2016; 5:427-30. [PMID: 27563565 DOI: 10.21037/gs.2016.02.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Post-pancreatectomy hemorrhage (PPH) is a major complication occurring in 6-8% of patients after pancreaticoduodenectomy (PD). Arterial bleeding is the most frequent cause. Mortality rate could reach 30% after grade C PPH according to ISGPS classification. Complete interruption of hepatic arterial flow has to be a salvage procedure because of the high risk of intrahepatic abscess following the procedure. We report a technique to perform an artery reinforcement after PPH caused by pancreatitis. A PD according to Whipple's procedure with child's reconstruction was performed in a 68-year-old man. At postoperative day 12, the patient presented a sudden violent abdominal pain with arterial hypotension and tachycardia. Computed tomography (CT) with intravenous contrast injection was performed. Arterial and venous phases showed a contrast extravasation on the hepatic artery. Origin of PPH was found as an erosion of hepatic artery caused by pancreatic leak. A peritoneal patch was placed around hepatic artery to reinforce damaged arterial wall. The peritoneal patch was harvested from right hypochondrium with a thin preperitoneal fat layer. The patch was sutured around hepatic artery with musculoaponeurotic face placed on the arterial wall. A CT was performed and hepatic artery was permeable with normal caliber in the portion of peritoneal patch reinforcement. The technique described in the present case consists in reinforcing directly arterial wall after occurrence of PPH. The use of a peritoneal patch during pancreatic surgery has first been described to replace a portion of portal vein after venous resection with the peritoneal layer placed on the intraluminal side of the vein. The present case describes a salvage technique to reinforce damaged artery after PPH in context of pancreatic leak. This simple technique could be useful to avoid complex arterial reconstruction and recurrent bleeding in septic context.
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Affiliation(s)
- Aude Merdrignac
- Department of Hepato-Biliary and Digestive Surgery, CHU de Rennes, Rennes, France
| | - Damien Bergeat
- Department of Hepato-Biliary and Digestive Surgery, CHU de Rennes, Rennes, France
| | | | - Marina Agus
- Department of Hepato-Biliary and Digestive Surgery, CHU de Rennes, Rennes, France
| | - Karim Boudjema
- Department of Hepato-Biliary and Digestive Surgery, CHU de Rennes, Rennes, France
| | - Laurent Sulpice
- Department of Hepato-Biliary and Digestive Surgery, CHU de Rennes, Rennes, France
| | - Bernard Meunier
- Department of Hepato-Biliary and Digestive Surgery, CHU de Rennes, Rennes, France
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22
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Abstract
Pancreaticoduodenectomy (PD) is considered one of the most complex and technically challenging abdominal surgeries performed by general surgeons. With increasing use of minimally invasive surgery, this operation continues to be performed most commonly in an open fashion. Open PD (OPD) is characterized by high morbidity and mortality rates in published series. Since the early 2000s, use of robotics for PD has slowly evolved. For appropriately selected patients, robotic PD (RPD) has been shown to have less intraoperative blood loss, decreased morbidity and mortality, shorter hospital length of stay, and similar oncological outcomes compared with OPD. At our high-volume center, we have found lower complication rates for RPD along with no difference in total cost when compared with OPD. With demonstrated non-inferior oncologic outcomes for RPD, the potential exists that RPD may be the future standard in surgical management for pancreatic disease. We present a case of a patient with a pancreatic head mass and describe our institution's surgical technique for RPD.
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Affiliation(s)
- Richard Sola
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Russell C Kirks
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepato-Pancreato-Biliary Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepato-Pancreato-Biliary Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepato-Pancreato-Biliary Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
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23
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Abstract
Celiac artery (CA) stenosis is a relatively common finding in patients undergoing pancreaticoduodenectomy (PD). In the presence of CA stenosis, arterial blood supply to the celiac territory is usually sustained from the superior mesenteric artery (SMA) through well-developed collaterals. In this paper, the authors report endosonographically identified prominent gastroduodenal artery as the sign of CA stenosis for the first time. Uncovering previously unidentified vascular abnormality, endoscopic ultrasound (EUS) has improved patient management. The patient had uneventful collateral preserving PD.
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Affiliation(s)
- Can Gonen
- Department of Gastroenterology, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Ali Sürmelioğlu
- Department of General Surgery, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Metin Tilki
- Department of General Surgery, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Gamze Kiliçoğlu
- Department of Radiology, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
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24
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Ke FY, Wu XS, Zhang Y, Zhang HC, Weng MZ, Liu YB, Wolfgang C, Gong W. Comparison of postoperative complications between internal and external pancreatic duct stenting during pancreaticoduodenectomy: a meta-analysis. Chin J Cancer Res 2015; 27:397-407. [PMID: 26361409 DOI: 10.3978/j.issn.1000-9604.2015.07.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 06/16/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Two types of pancreatic duct stents are used to improve postoperative outcomes of pancreatic anastomosis. The aim of this meta-analysis was to evaluate and compare the postoperative outcomes of patients with internal or external stenting during pancreaticoduodenectomy (PD). METHODS We searched PubMed, EMBASE, the Cochrane Library and Web of Science databases until the end of December, 2014. Studies comparing outcomes of external vs. internal stent placement in PD were eligible for inclusion. Included literature was extracted and assessed by two independent reviewers. RESULTS Seven articles were identified for inclusion: three randomized controlled trials (RCTs) and four observational clinical studies (OCS). The meta-analyses revealed that use of external stents had advantage on reducing the incidences of pancreatic fistula (PF) in total [odds ratio (OR) =0.69; 95% confidence interval (CI), 0.48-0.99; P=0.04], PF in soft pancreas (OR =0.30; 95% CI, 0.16-0.56; P=0.0002) and delayed gastric emptying (DGE) (OR =0.58; 95% CI, 0.38-0.89; P=0.01) compared with internal stents. There were no significant differences in other postoperative outcomes between two stenting methods, including postoperative morbidity (OR =0.93; 95% CI, 0.39-2.23; P=0.88), overall mortality (OR =0.70; 95% CI, 0.22-2.25; P=0.55), and intra-abdominal collections (OR =0.67; 95% CI, 0.26-1.71; P=0.40). CONCLUSIONS Based upon this meta-analysis, the use of external pancreatic stents might have potential benefit in reducing the incidence of PF and DGE. Due to the limited number of original studies, more RCTs are needed to further support our result and clarify the issue.
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Affiliation(s)
- Fa-Yong Ke
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Xiang-Song Wu
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Yong Zhang
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Hong-Cheng Zhang
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ming-Zhe Weng
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ying-Bin Liu
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Christopher Wolfgang
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Wei Gong
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
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25
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Abstract
The history of pancreatic cancer surgery, though fraught with failure and setbacks, is punctuated by periods of incremental progress dependent upon the state of the art and the mettle of the surgeons daring enough to attempt it. Surgical anesthesia and the aseptic techniques developed during the latter half of the 19(th) century were instrumental in establishing a viable setting for pancreatic surgery to develop. Together, they allowed for bolder interventions and improved survival through the post-operative period. Surgical management began with palliative procedures to address biliary obstruction in advanced disease. By the turn of the century, surgical pioneers such as Alessandro Codivilla and Walther Kausch were demonstrating the technical feasibility of pancreatic head resections and applying principles learned from palliation to perform complicated anatomical reconstructions. Allen O. Whipple, the namesake of the pancreaticoduodenectomy (PD), was the first to take a systematic approach to refining the procedure. Perhaps his greatest contribution was sparking a renewed interest in the surgical management of periampullary cancers and engendering a community of surgeons who advanced the field through their collective efforts. Though the work of Whipple and his contemporaries legitimized PD as an accepted surgical option, it was the establishment of high-volume centers of excellence and a multidisciplinary approach in the later decades of the 20(th) century that made it a viable surgical option. Today, pancreatic surgeons are experimenting with minimally invasive surgical techniques, expanding indications for resection, and investigating new methods for screening and early detection. In the future, the effective management of pancreatic cancer will depend upon our ability to reliably detect the earliest cancers and precursor lesions to allow for truly curative resections.
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Affiliation(s)
- James F Griffin
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA
| | - Katherine E Poruk
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA
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