Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units. UK Pancreatic Cancer Group

Surgical management of early-stage pancreatic cancer

BACKGROUND

Pancreatic cancer remains a difficult disease to treat. Diagnosis at an early stage may allow curative treatment with resection. In the past, the mortality associated with surgical treatment of pancreatic carcinoma was prohibitive but mortality associated with resection is now commensurate with all other major oncologic resections. Thus, the focus of surgical management has shifted to address several issues: the diagnosis and evaluation of patients with suspected pancreatic cancer, the role of preoperative endobiliary stenting, the role of laparoscopy, the extent of resection, the role of adjuvant and neoadjuvant treatment, and the role of specialized centers in treating the disease.

METHODS

The current literature is reviewed to address these issues and help guide physicians who first encounter patients with suspected pancreatic cancer as well as surgeons who ultimately resect them. Practical evidence-based information to guide the decision-making process is provided.

RESULTS

Surgical morbidity and mortality have achieved parity with other types of major oncologic resection, and a distinct survival advantage is possible when such therapy is applied early in the disease stage. Issues regarding the use of stents, extent of resection, and pre- vs post-operative chemoradiation therapy are becoming clearer as our collective experience broadens.

CONCLUSIONS

Surgical treatment of pancreatic cancer should be aggressively pursued given the clearly established survival advantage and relief of symptoms achieved when it is applied appropriately.

Fast track--different implications in pancreatic surgery

Concepts in "fast-track" surgery, which provide optimal perioperative care, have been proven to significantly reduce complication rates and decrease hospital stay. This study explores whether fast-track concepts can also be safely applied and improve the outcomes of major pancreatic resections. Perioperative data from 255 consecutive patients, who underwent pancreatic resection by means of fast-track surgery in a high-volume medical center, were analyzed using univariate and multivariate models. Of the 255 patients, 180 received a pancreatic head resection and 51 received distal, 15 received total, and 9 received segmental pancreatectomies. The patients were discharged on median day 10 with a 30-day readmission rate of 3.5%. The in-hospital mortality was 2%, whereas medical and surgical morbidities were 17 and 25%, respectively. Fast-track parameters, such as first stools, normal food, complete mobilization, and return to normal ward, correlated significantly with early discharge (p < 0.05). Patients' age, operation time, and early extubation proved to be independent factors of early discharge, shown through multivariate analysis (odds ratio: 4.0, 2.0, and 2.8, respectively; p < 0.05). Low readmission, mortality, and morbidity rates demonstrate that fast-track surgery is in fact feasible and safe and promotes earlier discharge without compromising patient outcomes.

Delayed recovery after pancreaticoduodenectomy: a major factor impairing the delivery of adjuvant therapy?

BACKGROUND

Delayed recovery after pancreaticoduodenectomy (PD) is believed to preclude adjuvant therapy for approximately 30% of patients who undergo elective PD as initial treatment for pancreatic adenocarcinoma. This study reexamined the frequency of delayed recovery and assessed other factors associated with adjuvant therapy administration after PD at a high-volume center.

STUDY DESIGN

Preoperative and perioperative variables were reviewed in a consecutive series of 85 patients with pancreatic adenocarcinoma undergoing PD without preoperative chemotherapy or radiotherapy from 1990 to 2004.

RESULTS

Study groups included patients undergoing emergency PD (group 1, n=13); elective PD with good preoperative Eastern Cooperative Oncology Group (ECOG) performance status (PS) (group 2, ECOG PS: 0 to 1, n=63); and elective PD with marginal preoperative PS (group 3, ECOG PS: 2 to 3, n=9). Delayed recovery of PS precluded adjuvant therapy in 23% of patients in group 1, 6% of patients in group 2, and 44% of patients in group 3 (p=0.0001).

CONCLUSIONS

The impact of delayed recovery after PD on the delivery of adjuvant therapy depends on the urgency of surgery and the preoperative PS. For patients with good preoperative PS who undergo elective PD at a high-volume center, it is uncommon for delayed recovery to preclude delivery of adjuvant therapy.

Middle segmental pancreatic resection: An option to treat benign pancreatic body lesions

OBJECTIVE

To clarify whether middle segmental pancreatic resection can be performed with comparable morbidity and mortality to classic pancreatic resections for lesions in the mid-portion of the pancreas.

SUMMARY BACKGROUND DATA

Pancreaticoduodenectomies or distal pancreatectomy, traditionally used to treat lesions of the pancreatic body, sacrifice a significant amount of normal pancreatic tissue. Middle segmental pancreatic resection has therefore been introduced to minimize loss of functioning pancreatic tissue.

PATIENTS AND METHODS

In a prospective 4-year single-center study, 40 consecutive patients with lesions of the neck or the body of the pancreas underwent a middle segmental pancreatic resection. A matched-pairs analysis comparing middle segmental pancreatic resection with pp-Whipple and distal pancreatectomy was included.

RESULTS

Seventeen patients had neoplastic lesions (4 solid malignancies, 9 cystic lesions, 4 neuroendocrine tumors) and 23 patients had focal chronic pancreatitis. Postoperative surgical morbidity was 27.5% and mortality 2.5%. The reoperation rate was 5.0%. Three patients (7.5%) developed pancreatic fistula. Median postoperative hospital stay was 11 days (range, 6-62 days). After a median follow-up of 29 months, 97.4% (38 patients) of the patients were satisfied with the operation. The mean quality of life status (EORTC QLQ-C30) was comparable to a normal control population. Matched-pairs analysis revealed no differences of perioperative parameters (except operation time), morbidity, and mortality. However, endocrine pancreatic function was better preserved (P < 0.05) in patients with middle segmental pancreatic resection.

CONCLUSIONS

Middle segmental pancreatic resection is an appropriate procedure for selected patients with tumorous lesions in the mid-portion of the pancreas. It preserves pancreatic parenchyma and function and has a mortality and morbidity rate comparable to other pancreatic resection procedures.

Analysis of closure of the pancreatic remnant after distal pancreatic resection

BACKGROUND

The appropriate management of the pancreatic remnant following distal pancreatic resection remains a clinically relevant problem. We carried out a retrospective analysis which focused on this issue and compared the two favored techniques of suture and staple closure.

PATIENTS AND METHODS

Forty-six patients underwent distal pancreatectomy between October 1999 and January 2006. The patients were retrospectively analysed based on the management of the remaining pancreatic gland. Thirty-seven patients had suture and nine patients had staple closure. The morbidity, mortality, incidence of pancreatic fistula, necessity of secondary surgical intervention, and the duration of hospital stay for the two groups were compared. Pancreatic fistula was considered according to the novel international standard definition (ISGPF). In addition, subgroup analysis of patients receiving octreotide was carried out.

RESULTS

Overall, postoperative morbidity due to pancreatic fistula occurred in seven patients (19%) after suture and in one patient (11%) after staple closure (p = 0.54), with no deaths. The number of patients with surgical revision related to pancreatic leakage was two (5%) after suture closure vs no revision after staple closure (p = 0.65). The median number of total hospital days for the suture group was 19 (range 7-78 days) vs 21 (range 12-96 days) for the stapler group (p = 0.21). No significant benefit for the octreotide application could be determined.

CONCLUSION

According to the data, no significant difference for either suture or stapler closure was observed, with the tendency for staple closure to be superior.

Pancreaticoduodenectomy with mesentericoportal vein resection for adenocarcinoma of the pancreatic head

BACKGROUND

The value of mesentericoportal vein resection (VR) associated with pancreaticoduodenectomy (PD) for pancreatic-head adenocarcinoma still remains controversial.

METHODS

From 1989 to 2003, 45 consecutive patients with pancreatic-head adenocarcinoma underwent PD with mesentericoportal VR due to intraoperative macroscopic involvement of the superior mesenteric or portal vein (VR+ group). They were compared with 88 patients who underwent PD for adenocarcinoma without VR over the same time period (VR- group) and matched for age, American Society of Anesthesiologists (ASA) score, pathological diagnosis, and nodal involvement. Preoperative features, intraoperative parameters, postoperative course, and survival were compared between the VR+ group and VR- group. Factors that may influence survival were determined by univariate and multivariate analyses.

RESULTS

Mortality, morbidity, and mean hospital stay did not differ between the two groups (VR+ 4.4%, 56%, and 22.6 days, respectively; VR- 5.7%, 64%, 24.6 days, respectively). In the group VR+, vein invasion was histologically proven in 29 (64%) patients. Three-year global survival and 3-year disease-free survival did not differ between the two groups: VR+ 22% and 14%, respectively; VR- 25% and 21%, respectively (log-rank: P=0.69 and P=0.39, respectively). Neither VR nor histologically proven vein involvement significantly impacted survival duration. On multivariate analysis, tumor-free margin was the most important prognostic factor.

CONCLUSIONS

Vein resection during PD can be performed safely. Patients with adenocarcinoma who require VR during PD have a survival not different from that of patients who undergo standard PD. Macroscopic isolated mesentericoportal vein involvement is not a contraindication for PD in patients with adenocarcinoma provided disease-free margins can be obtained.

Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection

BACKGROUND

Delayed gastric emptying (DGE) is one of the most troublesome postoperative complications following pancreatic resection. Not only does it contribute considerably to prolonged hospitalization, but it is also associated with increased postoperative morbidity and mortality.

METHODS

We performed an electronic and manual search of the international literature for studies dealing with the treatment of DGE following pancreatic resection using the Medline database. The search items used were "delayed gastric emptying," "pancreaticoduodenectomy," "Whipple procedure," "pylorus-preserving pancreaticoduodenectomy," and "complications following pancreatic resection" in various combinations.

RESULTS

A number of studies were identified regarding possible therapeutic alternatives for the treatment of DGE. From the class of prokinetic regimens, most studies seem to support the use of erythromycin. However, its use has not gained wide acceptance. Regarding the operative technique, both standard Whipple and pylorus-preserving pancreatic resection carry similar rates of DGE. Billroth II type-like gastrointestinal reconstruction is the most widely accepted method and is associated with lower rates of DGE. Reoperations for managing severe DGE were very rarely reported.

CONCLUSIONS

The incidence of DGE in high-volume centers specialized in pancreatic surgery is well below 20%, thus following the improved rates that have been reported in the last decade regarding mortality and length of hospital stay after pancreatic surgery. DGE mandates a uniform definition and method of evaluation to achieve homogeneity among studies. Standardization of the operative technique, as well as "centralizing" pancreatic resections in high-volume centers, should aid to improve the occurrence of this bothersome postoperative complication.

Effect of Jejunal and Biliary Decompression on Postoperative Complications and Pancreatic Leakage Arising from Pancreatojejunostomy after Pancreatoduodenectomy

BACKGROUND

Since its introduction, reconstruction after pancreatoduodenectomy has undergone numerous modifications, leading to a dramatic decline in the mortality rate. However, the reported morbidity rate, due mainly to pancreatic leakage, still remains high.

METHODS

Between January 1999 and April 2005, 102 consecutive patients underwent pancreatojejunostomy after pancreatoduodenectomy. Patients treated by biliary decompression alone (n = 58) were compared with patients treated by jejunal decompression alone (n = 40). Four patients who underwent both biliary and jejunal decompression were excluded from the study.

RESULTS

Patients who underwent jejunal decompression had a significantly lower incidence of overall postoperative complications (P = 0.028), pancreatic leakage (P = 0.009), and infection (P = 0.011) than patients who underwent biliary decompression. Only one patient who underwent biliary decompression died as a direct result of pancreatic leakage.

CONCLUSIONS

Discontinuation of biliary decompression with postoperative jejunal decompression using tube jejunostomy may be a good option in patients undergoing pancreatoduodenectomy, because it appears to reduce the incidence of overall postoperative complications, pancreatic leakage, and infection.

Surveillance and management of upper gastrointestinal disease in Familial Adenomatous Polyposis

Almost all patients affected by Familial Adenomatous polyposis (FAP) will develop foregut as well as hindgut polyps, and following prophylactic colectomy duodenal cancer constitutes one of the leading causes of death in screened populations. Without prophylactic colectomy, FAP patients predictably develop colorectal cancer, but the lifetime risk of upper gastrointestinal cancer is lower, estimated at approximately 5%. Management of the upper gastrointestinal cancer risk is one of the greatest challenges facing clinicians involved in the care of Polyposis families, and with improved survival following prophylactic colectomy, the burden of foregut disease (particularly duodenal adenomatosis) will increase. Until recently, the value of upper gastrointestinal surveillance in FAP populations has been contentious, but with improved understanding of the natural history coupled with developments in surgery, interventional endoscopy and medical therapy, treatment algorithms for duodenal adenomatosis in FAP are becoming clearer.

Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients

OBJECTIVE

The aim of this study was designed to determine whether the period of drain insertion influences the incidence of postoperative complications.

BACKGROUND DATA

The significance of prophylactic drains after pancreatic head resection is still controversial. No report discusses the association of the period of drain insertion and postoperative complications.

METHODS

A total of 104 consecutive patients who underwent pancreatic head resection were enrolled in this study. To assess the value of prophylactic drains, we prospectively assigned the patients into 2 groups: group I underwent resection from January 2000 to January 2002 (n = 52, drain to be removed on postoperative day 8); group II underwent resection from February 2002 to December 2004 (n = 52, drain to be removed on postoperative day 4). Postoperative complications in the 2 groups were compared.

RESULTS

The rate of pancreatic fistula was significantly lower in group II (3.6%) than in group I (23%) (P = 0.0038). The rate of intra-abdominal infections, including intra-abdominal abscess and infected intra-abdominal collections, was significantly reduced in group II (7.7%) compared with group I (38%) (P = 0.0003). Eighteen of 52 (34.6%) patients in group I had an inserted drain beyond 8 days, whereas only 2 of 52 (3.7%) patients in group II had an inserted drain beyond 4 days (P = 0.0002). Cultures of drainage fluid were positive in 16 of 52 (30.8%) patients in group I, and in 2 of 52 (3.7%) patients in group II (P = 0.0002). Intraoperative bleeding (> 1500 mL), operative time (> 420 minutes, and the period of drain insertion were significant risk factors for intra-abdominal infections (P = 0.043, 0.025, 0.0003, respectively). The period of drain insertion was the only independent risk factor for intra-abdominal infections by multivariate analysis (odds ratio, 6.7).

CONCLUSION

Drain removal on postoperative day 4 was shown to be an independent factor in reducing the incidence of complications with pancreatic head resection, including intra-abdominal infections.

Risk factors for mortality and intra-abdominal complications after pancreatoduodenectomy: multivariate analysis in 300 patients

BACKGROUND

Studies of risk factors after pancreatoduodenectomy are few: some concern restricted populations and others are based on administrative data.

METHODS

Multicenter clinical data were collected for 300 patients undergoing pancreatoduodenectomy to determine (by univariate and multivariate analysis) preoperative and intraoperative risk factors for mortality and intra-abdominal complications (IACs), including pancreatic fistula. Fourteen factors including the center and volume effect were analyzed.

RESULTS

In univariate analysis, mortality was increased with age 70 years or more, extended resection(s), and volume and center effects. IACs occurred more often with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, extended resection(s), and the center effect. Pancreatic fistula was more frequent with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, and the center effect. In multivariate analysis, independent risk factor(s) for mortality were age greater than 70 years (odds ratio [OR], 3; 95% confidence interval [CI], 1.3-8) and extended resection (OR, 5; 95% CI, 1.2-22), risk factors for IACs were extended resection (OR, 5; 95% CI, 1.2-22) and main pancreatic duct diameter of 3 mm or less (OR, 2; 95% CI, 1.1-3), and the risk factor for pancreatic fistula was main pancreatic duct diameter of 3 mm or less (OR, 2.5; 95% CI, 1.2-4.6).

CONCLUSIONS

Age more than 70 years, extended resections, and main pancreatic duct diameter less than 3 mm are independent risk factors that should be considered in indications for and techniques of pancreatoduodenectomy.

Toward zero pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy

BACKGROUND

Postoperative morbidity after pancreaticoduodenectomy has been associated mainly with the development of pancreatic fistula. However, postoperative complications unrelated to pancreatic fistula cannot be disregarded after pancreaticoduodenectomy. The aim of the present study was to investigate the postoperative morbidity in a large series of pancreaticoduodenectomies with pancreaticogastrostomies without pancreatic fistula.

METHODS

The present study analyzed the data from 194 consecutive patients undergoing a pancreaticoduodenectomy with a pancreaticogastrostomy between July 1997 and June 2003 in whom no postoperative pancreatic fistula occurred.

RESULTS

The overall rate of postoperative morbidity was 33.5%. Specific and general complications occurred in 16% and 17.5% of the patients, respectively. An American Society of Anesthesiologists (ASA) score of 3 and blood transfusion were the only independent factors associated with postoperative morbidity.

CONCLUSIONS

Our study found that the overall morbidity after a pancreaticoduodenectomy with a pancreaticogastrostomy still remains high even in the absence of pancreatic fistula and is associated with the preoperative medical condition (ASA score) of the patients and with blood transfusion.

Outcome of surgical treatment of pancreatic, peri-ampullary and ampullary cancer diagnosed in the south of The Netherlands: A cancer registry based study

AIMS

To gain insight into the quality of pancreatic cancer surgery in 10 low-volume (median sized) hospitals, each serving 150,000-250,000 people, in the Comprehensive Cancer Centre South (CCCS) area and of referred patients to academic centres to determine the need for further regionalization.

METHOD

The population-based Eindhoven Cancer Registry was used to select all patients in the CCCS area with pancreatic, peri-ampullary and ampullary cancer diagnosed between January 1, 1995 and April 30, 2000 (N = 1130). Of those, 124 patients (11%) underwent surgical resection (of which 40 were treated in university hospitals outside the region).

RESULTS

For all pancreatic carcinoma resections, the 3-month survival rate was 82%, varying from 95% for referred patients to 76% for patients treated within the region (p = 0.014). One- and two-year survival rates showed no difference between both groups (p = 0.36 and p = 0.55, respectively). Surgically treated patients who were referred to university hospitals outside the CCCS area were younger, more often male, more often diagnosed with pTNM stage III, exhibited less comorbidity and had a higher socio-economic status than patients surgically treated within the region.

CONCLUSION

Although the results are based on small numbers and patient selection probably influenced these outcomes, these data seem to support further hospital specialisation, to which the surgeons of the CCCS area have committed themselves.

Complications after pancreaticoduodenectomy: the problem of current definitions

Pancreaticoduodenectomy nowadays represents a complex procedure and a challenge for the surgeon. Even though mortality is reported to be below 5% for experienced surgeons, morbidity is still around 30%-50%, often leading to prolongation of hospital stay, demanding postoperative investigations and procedures, and outpatient monitoring of the patients with complications. In the literature there is no agreement on the definitions of postoperative complications following pancreaticoduodenectomy, leading to a wide range of complication rates in different specialist units, particularly regarding the source of every complication, postoperative pancreatic fistula, and others such as delayed gastric emptying. Some authors have demonstrated that applying different definitions in homogeneous, single-center series, the incidence of a complication varied with statistical significance, implying the impossibility of correctly comparing different experiences. It seems essential to organize a Consensus Meeting among expert surgeons to prepare world-wide accepted definitions. The aim of this article is to review the current controversial definitions and to suggest a new clinical-based approach to the problem of the feasibility and reliability of the definitions themselves.

Improvement of delayed gastric emptying in pylorus-preserving pancreaticoduodenectomy: results of a prospective, randomized, controlled trial

OBJECTIVE

To determine if an antecolic or a retrocolic duodenojejunostomy during pylorus-preserving pancreaticoduodenectomy (PpPD) was associated with the least incidence of delayed gastric emptying (DGE), in a prospective, randomized, controlled trial.

SUMMARY BACKGROUND DATA

The pathogenesis of DGE after PpPD has been speculated to be related to factors such as inflammation, ischemia, gastric atony, motilin levels, and type of surgical procedure. Previous retrospective studies have shown a lower incidence of DGE after antecolic duodenojejunostomy. A prospective trial is needed.

METHODS

Forty patients were enrolled in this trial between May 2002 and April 2004. Just before duodenojejunostomy during PpPD, the patients were randomly assigned to undergo either an antecolic or a retrocolic duodenojejunostomy.

RESULTS

DGE occurred in 5% of patients with the antecolic route for duodenojejunostomy versus 50% with the retrocolic route (P = 0.0014). Those with the antecolic route had a significantly shorter duration of postoperative nasogastric tube drainage than did those with the retrocolic route (4.2 days versus 18.9 days, respectively, P = 0.047). By postoperative day 14, all patients with the antecolic route could take solid foods, while only 55% (11 of 20) of the patients with the retrocolic route could take solid foods (P = 0.0007). The length of stay in the hospital was 28 days for the antecolic group versus 48 days for the retrocolic group (P = 0.018).

CONCLUSIONS

Antecolic reconstruction for duodenojejunostomy during PpPD decreases postoperative morbidity and length of hospital stay by decreasing DGE. Our data suggest that PpPD with antecolic duodenojejunostomy is a safer operation.

The inherited genetics of pancreatic cancer and prospects for secondary screening

It is estimated that pancreatic cancer has a familial component in approximately 5-10% of cases. Some of these cases are part of a defined cancer syndrome with a known gene mutation but in the remaining the causative gene remains unknown. In recent years, a better understanding of the molecular events that occur in the progression model of pancreatic cancer has lead to the development of secondary screening programmes with the aim of identifying early precursor lesions or pre-invasive cancer at a stage amenable to curative resection. High-risk groups who have an inherited predisposition for pancreatic cancer form the ideal group to study in developing a robust screening programme. Multimodality screening using computed tomography and endoluminal ultrasound in combination with molecular analysis of pancreatic juice are proving promising as diagnostics tools or at least serving as predictors of risk over a defined period.

The case for adjuvant chemotherapy in pancreatic cancer

Pancreatic cancer is a difficult cancer to treat effectively. Only a small proportion of patients are suitable for resection. The long-term survival following resection alone is between 10 and 18%. Adjuvant therapy aims to improve this outcome. There have been five fully reported adjuvant trials in pancreatic cancer. The largest study is the ESPAC-1 trial which demonstrated a significant survival benefit for 5-fluorouracil chemotherapy and no survival benefit for adjuvant chemoradiotherapy. A meta-analysis of these trials has confirmed the survival benefit for chemotherapy and thus adjuvant chemotherapy is recommended as the standard of care following pancreatic resection. There are further large studies which will also help to further define the optimum adjuvant chemotherapy in these patients.

Surgical treatment of patients with intermediate-terminal pancreatic cancer

AIM: To investigate the surgical treatment of patients with intermediate–terminal pancreatic cancer.

METHODS: A retrospective analysis was made of the clinical data of 163 patients with intermediate–terminal pancreatic cancer who were surgically treated between August 1994 and August 2003.

RESULTS: A total of 149 patients underwent palliative surgery. The mortality rate of those who underwent cholecystojejunostomy alone was 14.2%, the icterus or cholangitis recurrence rate was 61.9% with an average survival period of 7.1 mo. The mortality rate for those who received hepatic duct-jejunostomy (HDJS) was 5.7%, the icterus or cholangitis recurrence rate was 6.8% with an average survival period of 7.1 mo. But 31.8% of the patients developed duodenum obstruction within 6 mo after the surgery, six of seven patients with severe pain were given peri-abdominal aorta injection with absolute alcohol and their pain was alleviated. The other patients underwent percutaneous transhepatic cholangial drainage (PTCD) and their icterus index returned to normal level within 40 d with an average survival period of 7.5 mo.

CONCLUSION: Roux-en-y HDJS combined with prophylactic gastrojejunostomy is recommended for patients with intermediate–terminal pancreatic cancer, and biliary prosthesis can partly relieve biliary obstruction in a short term.

[Surgical treatment of pancreatic and periampullary carcinoma in a specialized unit: a decade later]

INTRODUCTION

Results of surgical treatment for pancreatic and periampullary carcinoma have improved in recent years owing to several factors, particularly the concentration of these patients in specialised surgical units.

MATERIAL AND METHODS

Retrospective-prospective comparative study of results in 2 groups of patients treated over 2 different periods of time and with different surgical policy: group A, which included 80 patients treated from 1982 to 1992 in a general surgery unit, and group B, which comprised 151 patients treated from 1998 to 2003 in a specialised hepato-biliary-pancreatic surgery unit.

RESULTS

Surgical treatment in patients of groups A and B, respectively, was: resection in 20% and 53.6% and by-pass in 62.5% and 36.4%. Postoperative morbidity after resection was similar (75% vs 74.1%) but higher after by-pass in group B (41.8% vs 34%). Postoperative mortality after surgical resection and by-pass was 25% and 14.1%, respectively, for group A and 3.7% and 16.3%, respectively, for group B. Mean survival for all patients was 7.0 +/- 7.1 months for group A and 14.1 +/- 15.3 months for group B. Mean survival for patients with surgical resection was 11.8 +/- 9.8 months and 18.7 +/- 15.8 months for groups A and B, respectively.

CONCLUSIONS

Pancreatic and periampullary carcinoma should be surgically treated in specialised pancreatic surgery units in order to offer the best outcome to patients.

Microscopically incomplete resection offers acceptable palliation in pancreatic cancer

BACKGROUND

Because mortality and morbidity of pancreatic surgery have decreased to acceptable levels, the complex question arises whether pancreatic resection should be performed in patients with preoperatively doubtful resectable pancreatic cancer.

METHODS

Perioperative parameters and outcome of 80 patients who underwent a microscopically incomplete (R1) resection were compared with those of 90 patients who underwent a bypass for locally advanced disease for pancreatic adenocarcinoma. All patients initially underwent exploratory laparotomy with the intention to perform a resection. Quality of life was assessed by analyzing readmissions and their indications.

RESULTS

Groups were similar with respect to age, presenting symptoms, and preoperative health status. Tumors were significantly larger in the bypass group (3.5 cm vs 2.9 cm, P < .01). Hospital mortality was comparable: zero after R1 resection and 2% after bypass. Of all severe complications, only intra-abdominal hemorrhage occurred significantly more frequently after resection (10% vs 2%; P = .03). Hospital stay after resection was significantly longer than after bypass (16 vs 10 days; P < .01). Survival was significantly longer after R1 resection (15.8 vs 9.5 months, P < .01). Sixty-one percent of patients were readmitted for a total of 215 admissions, equally distributed between groups. After R1 resection, 0.58% of the total survival time after initial discharge was spent in the hospital, after bypass, 0.69%, which was not significantly different.

CONCLUSIONS

R1 pancreatic resection and bypass for locally advanced disease can be performed with comparable low mortality and morbidity rates. Readmission rates are also comparable between groups and time spent in the hospital after initial discharge is low. Because resection offers adequate palliation in pancreatic cancer, a more aggressive surgical approach in patients who are found to have a doubtfully resectable tumor could be advocated, even if only an R1 resection can be achieved.

Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands

OBJECTIVES

To evaluate the best available evidence on volume-outcome effect of pancreatic surgery by a systematic review of the existing data and to determine the impact of the ongoing plea for centralization in The Netherlands.

SUMMARY BACKGROUND DATA

Centralization of pancreatic resection (PR) is still under debate. The reported impact of hospital volume on the mortality rate after PR varies. Since 1994, there has been a continuous plea for centralization of PR in The Netherlands, based on repetitive analysis of the volume-outcome effect.

METHODS

A systematic search for studies comparing hospital mortality rates after PR between high- and low-volume hospitals was used. Studies were reviewed independently for design features, inclusion and exclusion criteria, cutoff values for high and low volume, and outcome. Primary outcome measure was hospital or 30-day mortality. Data were obtained from the Dutch nationwide registry on the outcome of PR from 1994 to 2004. Hospitals were divided into 4 volume categories based on the number of PRs performed per year. Interventions and their effect on mortality rates and centralization were analyzed.

RESULTS

Twelve observational studies with a total of 19,688 patients were included. The studies were too heterogeneous to allow a meta-analysis; therefore, a qualitative analysis was performed. The relative risk of dying in a high-volume hospital compared with a low-volume hospital was between 0.07 and 0.76, and was inversely proportional to the volume cutoff values arbitrarily defined. In 5 evaluations within a decade, hospital mortality rates were between 13.8% and 16.5% in hospitals with less than 5 PRs per year, whereas hospital mortality rates were between 0% and 3.5% in hospitals with more than 24 PRs per year. Despite the repetitive plea for centralization, no effect was seen. During 2001, 2002, and 2003, 454 of 792 (57.3%) patients underwent surgery in hospitals with a volume of less than 10 PRs per year, compared with 280 of 428 (65.4%) patients between 1994 and 1996.

CONCLUSIONS

The data on hospital volume and mortality after PR are too heterogeneous to perform a meta-analysis, but a systematic review shows convincing evidence of an inverse relation between hospital volume and mortality and enforces the plea for centralization. The 10-year lasting plea for centralization among the surgical community did not result in a reduction of the mortality rate after PR or change in the referral pattern in The Netherlands.

Prospectively randomized trial using perioperative low-dose octreotide to prevent organ-related and general complications after pancreatic surgery and pancreatico-jejunostomy

The aim of the present study was to evaluate the influence of low-dose perioperative octreotide on the prevention of complications (pancreatic fistula and general complications) in patients undergoing pancreatic surgery followed by pancreaticojejunostomy. A total of 105 patients were randomized to receive either octreotide 0.1 mg subcutaneously 3 times/day for a total of 7 days or no octreotide. The primary endpoints were the occurrence of a pancreatic fistula and or general complications, including extended length of hospital stay. There were 25 surgical draining procedures performed and 80 duodenopancreatectomies with or without preservation of the pylorus. In all, 25 (23.8%) of the patients were treated for chronic pancreatitis, 8 (7.6%) for benign tumoral disease, and 72 (68.6%) for carcinoma. All patients underwent pancreaticojejunostomy.

High operative risk of cool-tip radiofrequency ablation for unresectable pancreatic head cancer

BACKGROUND AND OBJECTIVES

To report and discuss the effect, complications and mortality of cool-tip radiofrequency ablation (RFA) for unresectable pancreatic cancer.

METHODS

During October 2003 to July 2004, sixteen patients with unresectable pancreatic cancer were treated by open cool-tip RFA. One-half of the 16 patients had tumors located in the pancreatic head. A 5-mm minimum safe distance between RFA site and major peripancreatic vessels was kept to avoid injury to the vessels.

RESULTS

Six of twelve patients with back pain got pain relief postoperatively. Pancreatic fistula occurred in three patients (18.8%) and healed smoothly in 7-10 days with routine abdominal drainage. The mortality was 25% (4/16). In the four death cases, tumors were all located in the pancreatic head; three patients with tumor close to portal vein died suddenly of massive gastrointestinal hemorrhage on the 4th, 30th, 40th postoperative day respectively and a 79-year-old patient died of acute renal failure on the 2nd postoperative day.

CONCLUSIONS

Standard use of cool-tip RFA was dangerous for pancreatic head cancer close to portal vein, in which a 5-mm minimum safe distance between RFA site and major peripancreatic vessels might not be enough to avoid injury to the vessels.

Effect of neoadjuvant chemoradiation on operative mortality and morbidity for pancreaticoduodenectomy

BACKGROUND

Neoadjuvant chemoradiotherapy (neo-CRT) is being used with increasing frequency for periampullary tumors, but how it alters the complication rate of pancreaticoduodenectomy (PD) is unclear.

METHODS

A retrospective analysis was conducted of 79 patients with periampullary malignancies who received 5-fluorouracil-based neo-CRT followed by PD.

RESULTS

There was no difference in mortality between PD after neo-CRT (3.8%) and conventional PD for either malignant (4.5%) or benign (2.2%) disease. Focusing only on patients with malignancy, the neo-CRT group had a significantly lower pancreatic leak rate than the conventional group (10% vs. 43%; P < .001). Intra-abdominal abscesses were less common in the neo-CRT group (8.8% vs. 21%; P = .019), and there was one (1.2%) amylase-rich abscess in neo-CRT group, compared with eight (12%) in the conventional group. In addition, two patients in the conventional group died of leak-associated sepsis, compared with none in the neo-CRT group. Multivariate analysis revealed that neoadjuvant chemoradiation (odds ratio, .15) was the most significant factor associated with a reduced risk of pancreatic leak.

CONCLUSIONS

Neo-CRT does not increase the mortality or morbidity of PD. In contrast, neo-CRT was associated with a marked reduction in the incidence of pancreatic leak, as well as leak-associated morbidity and mortality.

Adjuvant treatment

Exocrine pancreatic cancer (pancreatic ductal adenocarcinoma) is one of the leading causes of cancer deaths in the western world, accounting for 5% of all cancer-related deaths. Only a small percentage of patients with pancreatic cancer are able to undergo potentially curative resection, even in specialized centres, and prognosis remains poor after successful surgery. Over the last few years efforts have been directed towards the development of adjuvant therapies in attempts to improve outcome. The main trials of adjuvant chemotherapy, chemoradiotherapy and chemoradiotherapy with follow-on chemotherapy are described in this paper, followed by the results of the ESPAC-1 trial and the status of ESPAC-2 and -3 trials.

Pancreatoduodenectomy for tumors of Vater's ampulla: report on 94 consecutive patients

Evaluation of prognostic factors of adenocarcinoma of Vater's ampulla is still a matter of debate. The aim of this study was to evaluate retrospectively factors that influence early and long-term outcomes in a 20-year single-institution experience on ampullary carcinoma. A total of 94 consecutive patients with ampullary carcinoma or adenoma with severe dysplasia were managed from 1981 to 2002. Among them, 64 underwent pancreatoduodenectomy, and the remaining 30 submitted to surgical (n = 5) or endoscopic (n = 25) palliative treatment. Demographic, clinical, and pathologic data were collected, and a comparison was made between patients who did or did not undergo resection. Standard statistical analyses were carried out in an attempt to establish a correlation between clinical variables, intraoperative and pathologic factors, and survival in patients with resection. A total of 85 (90.4%) patients had potentially resectable lesions due to the extent of the tumor, but only 64 (68%) underwent curative resection. The surgical morbidity rate was 34.3%. Postoperative mortality was 9.3%, with no deaths among the 38 more recently treated patients. Median survivals were 9 and 54 months for nonresected and resected patients, respectively. The overall 5-year survival was 64.4% for patients undergoing pancreatoduodenectomy. Survival was found to be significantly affected by resection, tumor size, tumor grade, and tumor infiltration. Patients with negative lymph nodes show a trend toward longer survival. In a multivariate analysis, only the depth of tumor infiltration influenced patient survival. Pancreatoduodenectomy is the treatment of choice for ampullary carcinoma and adenomas with high-grade dysplasia, with a good chance of long-term survival. Surgical resection remains the most important factor influencing outcome.

Complications with Reconstruction Procedures in Pylorus-preserving Pancreaticoduodenectomy

This study was conducted retrospectively to examine the efficacy of Traverso reconstruction compared with Billroth I reconstruction after pylorus-preserving pancreaticoduodenectomy, in the prevention of several complications. Pylorus-preserving pancreaticoduodenectomy is an aggressive surgery, and insufficiency of the pancreaticoenterostomy plays an important role in the postoperative progression. However, reports examining the correlation between pancreatic fistula and the type of reconstruction after pylorus-preserving pancreaticoduodenectomy have been limited. Sixty-four patients who underwent pylorus-preserving pancreaticoduodenectomy (33 reconstructed by the Traverso technique and 31 reconstructed by the Billroth I technique) were entered into this study to investigate whether the complications were related to the type of reconstruction procedure employed. Insufficiency of the pancreaticojejunostomy, including major leakage and pancreatic fistula, occurred in 18.2% of the reconstructions by Billroth I and 0% of the reconstructions by Traverso (p < 0.05). In addition, jejunal obstruction by recurrent tumor in the remnant pancreas was observed in 3 patients reconstructed by Billroth I, and required palliative bypass surgery. Reconstruction by the Traverso procedure after pylorus-preserving pancreaticoduodenectomy is a safe surgical method and has an advantage for advanced pancreatic cancer, which has high risk of jejunal obstruction by recurrent tumor in the remnant pancreas.

Risk factors of pancreatic leakage after pancreaticoduodenectomy

AIM: To analyze the risk factors for pancreatic leakage after pancreaticoduodenectomy (PD) and to evaluate whether duct-to-mucosa pancreaticojejunostomy could reduce the risk of pancreatic leakage.

METHODS: Sixty-two patients who underwent PD at our hospital between January 2000 and November 2003 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, and gastric cancer. Standard PD was performed for 25 cases, PD with extended lymphadenectomy for 27 cases, pylorus-preserving PD for 10 cases. A duct-to-mucosa pancreaticojejunostomy was performed for patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy for patients with a soft pancreas and a non-dilated duct. Patients were divided into two groups according to the incidence of postoperative pancreaticojejunal anastomotic leakage: 10 cases with leakage and 52 cases without leakage. Seven preoperative and six intraoperative risk factors with the potential to affect the incidence of pancreatic leakage were analyzed with SPSS10.0 software. Logistic regression was then used to determine the effect of multiple factors on pancreatic leakage.

RESULTS: Of the 62 patients, 10 (16.13%) were identified as having pancreatic leakage after operation. Other major postoperative complications included delayed gastric emptying (eight patients), abdominal bleeding (four patients), abdominal abscess (three patients) and wound infection (two patients). The overall surgical morbidity was 43.5% (27/62). The hospital mortality in this series was 4.84% (3/62), and the mortality associated with pancreatic fistula was 10% (1/10). Sixteen cases underwent duct-to-mucosa pancreaticojejunostomy and 1 case (1/16, 6.25%) devel-oped postoperative pancreatic leakage, 46 cases underwent invagination pancreaticojejunostomy and 9 cases (9/46, 19.6%) developed postoperative pancreatic leakage. General risk factors including patient age, gender, history of jaundice, preoperative nutrition, pathological diagnosis and the length of postoperative stay were similar in the two groups. There was no statistical difference in the incidence of pancreatic leakage between the patients who received the prophylactic use of octreotide after surgery and the patients who did not undergo somatostatin therapy. Moreover, multivariate logistic regression analysis showed that none of the above factors seemed to be associated with pancreatic fistula. Two intraoperative risk factors, pancreatic duct size and texture of the remnant pancreas, were found to be significantly associated with pancreatic leakage. The incidence of pancreatic leakage was 4.88% in patients with a pancreatic duct size greater than or equal to 3 mm and was 38.1% in those with ducts smaller than 3 mm (P = 0.002). The pancreatic leakage rate was 2.94% in patients with a hard pancreas and was 32.1% in those with a soft pancreas (P = 0.004). Operative time, blood loss and type of resection were similar in the two patient groups. The incidence of pancreatic leakage was 6.25% (1/16) in patients with duct-to-mucosa anastomosis, and was 19.6% (9/46) in those with traditional invagination anastomosis. Although the difference of pancreatic leakage between the two groups was obvious, no statistical signific-ance was found. This may be due to the small number of patients with duct-to-mucosa anastomosis. By further analyzing with multivariate logistic regression, both pancreatic duct size and texture of the remnant pancreas were demonstrated to be independent risk factors (P = 0.007 and 0.017, OR = 11.87 and 15.45). Although anastomotic technique was not a significant factor, pancreatic leakage rate was much less in cases that underwent duct-to-mucosa pancreaticojejunostomy.

CONCLUSION: Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Duct-to-mucosa pancreaticojejunostomy, as a safe and useful anastomotic technique, can reduce pancreatic leakage rate after PD.

Surgical treatment of metastases to the pancreas

BACKGROUND AND AIMS

Metastases to the pancreas are rare and their surgical treatment is not well reported. We present a considerable experience from a single centre analysing various prognostic factors.

METHODS

Data were collected on 13 cases who underwent surgery between 1988 and 2002. Since 1997, data have been recorded prospectively on a dedicated database. Clinical and histopathological factors were reviewed.

RESULTS

There were two women and 11 men with a median age of 62 years (range 40-73). There were seven cases of renal cell carcinomas, three colorectal carcinomas, two sarcomas and one lung carcinoma. A prolonged disease-free interval from primary surgery was characteristic for renal cell carcinoma cases (median = 10.8 years). The operative procedures performed included seven pancreatoduodenectomies, four total and two distal pancreatectomies. The operative mortality and morbidity was 7.7% and 46.1% respectively. The overall one- and two-year survival was 78.8% and 54% respectively. Median survival for renal cell carcinoma was 30.5 months and for non-renal cell carcinoma was 26.4 months (p = 0.76).

CONCLUSIONS

Pancreatectomy should be considered for metastases to the pancreas in the absence of generalised metastatic disease. However, decision making and experience should be concentrated in centres with significant familiarity of this approach.

Analysis of long-term survivors after surgical resection for invasive pancreatic cancer

Pancreatic cancer remains a lethal disease. Although there are many reports on the survival rates of pancreatic cancer patients after surgical resection, the clinicopathological characteristics that influence long-term survival over 5 years remain controversial. Here, we clarify the favourable prognostic factors for long-term survival. One hundred and eighty-two patients with pancreatic cancer underwent surgical resections from 1981 to 1997 in our department. Among them, eight patients survived for at least 5 years after the surgery. The clinicopathological characteristics of the eight long-term survivors who underwent radical resections were studied retrospectively. R0 surgical resections, including five combined with portal vein resections (62.5%), were achieved in these eight patients. Negative invasions of the major regional artery (seven of eight, 87.5%) and to the extrapancreatic nerve plexus (seven of eight, 87.5%), and N0 or Nl lymph node metastasis (7 of 8, 87.5%) were detected as clinicopathological features of long-term survivors in our study. No exposure of carcinoma at the dissected surface and cut end (seven of eight, 87.5%) was characteristically confirmed by pathology. Portal vein invasion was seen in three of the eight patients (37.5%). For long-term survival in cases of pancreatic cancer, complete R0 resections should be performed and negative invasions in the major regional arteries and to the extrapancreatic plexus of the nerve were necessary. No invasion to the portal vein was not necessarily required if R0 was achieved by combined resection of the portal vein.

The surgical procedure and clinical results of the duct to mucosa pancreaticojejunostomies with resection of jejunal serosa

BACKGROUND

Pancreatic anastomotic leakage often results in severe complications of sepsis, intra-abdominal bleeding, pancreatic fistula, and is a significant cause of morbidity and mortality. An appropriate technique to minimize pancreatic leakage is very important. Recently we have performed duct to mucosa pancreaticojejunostomy with resection of jejunal serosa and obtained positive results.

PATIENTS AND METHODS

During 1999-2005, 52 patients (25 females, 27 males) underwent duct to mucosa pancreaticojejunostomy with resection of jejunal serosa after pancreatic head resections for benign (n=6) and malignant disease (n=46). The mean age was 64.0 years (range 33-80).

RESULTS

Mean post-operative hospital stay was 32.3 days. Morbidity rate due to early post-operative complication was 7.7% (pulmonary embolism in 1, pneumothorax in 1, wound infection in 2), with no pancreatic leakage.

CONCLUSIONS

There were low complication rates and an absence of pancreatic anastomotic leakage was observed in 52 patients. We consider that this pancreatic anastomotic technique is extremely favorable for pancreaticojejunostomy.

Complications of pancreatic surgery

Pancreatic resection is the only treatment option that can lead to a meaningful prolonged survival in pancreatic cancer and, in some instances, perhaps a potential chance for cure. With the advent of organ and function preserving procedures, its use in the treatment of chronic pancreatitis and other less common benign diseases of the pancreas is increasing. Furthermore, over the past two decades, with technical advances and centralization of care, pancreatic surgery has evolved into a safe procedure with mortality rates of <5%. However, postoperative morbidity rates are still substantial. This article reviews the more common procedure-related complications, their prevention and their treatment.

The Evaluation of Duct-to-mucosal Pancreaticojejunostomy in pancreaticoduodenectomy

This study was conducted to examine the efficacy of duct-to-mucosal pancreaticojejunostomy compared with external stented pancreaticojejunostomy in prevention of several complications, retrospectively. Seventy-six patients with pancreatic head resection (59 male; median age, 60.1 years) underwent pancreaticoduodenectomy at the Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan, between January 1, 1994, and March 31, 2002. In early postoperative status, the incidence of pancreatic fistula by duct-to-mucosal anastomosis (n = 45) was similar to that by external stent (n = 31); soft pancreas is a risk factor of pancreatic fistula compared with hard pancreas (p < 0.05). During the late postoperative period, however, no patients with duct-to-mucosal anastomosis showed pancreatic duct dilatation by computed tomography (CT). At the same time, 58.8% of patients with external stent followed by CT showed pancreatic duct dilatation (p < 0.01). The duct-to-mucosal anastomosis was more effective pancreaticojejunostomy than the external stent in terms of prevention of pancreatic duct dilatation, and it should be the surgical procedure of choice in pancreaticoduodenectomy.

Cancer in the elderly: pancreatic cancer

Pancreatic cancer remains a devastating and difficult disease to diagnose and successfully treat. Its incidence increases with age, with 60% of patients being over the age of 65 at presentation. Due to the insidious nature and asymptomatic onset of pancreatic cancer approximately 85% of patients present with disseminated or locally advanced disease resulting in a very poor prognosis. In the past the elderly patient, who may be felt to be too frail for operative procedures or further therapy, may have missed out on optimal treatment. In this article we review the investigation and treatment of pancreatic cancer and examine current evidence with regard to pancreatic cancer in the elderly. The evidence suggests that surgical resection can be performed safely in patients who are fit for surgery in specialist centres but may require more intensive post-operative rehabilitation.

Conclusions from the European Study Group for Pancreatic Cancer adjuvant trial of chemoradiotherapy and chemotherapy for pancreatic cancer

Pancreatic ductal adenocarcinoma remains one of the most difficult cancers to treat. It is a tumor that tends to present late, and surgical resection is only possible in a minority of patients. After successful surgery, the prognosis is still relatively poor. Attempts at more radical pancreatic resections and extended lymphadenectomy, although feasible without excessive morbidity and mortality, have failed to produce any convincing improvement in survival. During the last few years, therefore, efforts have been directed toward the development of adjuvant therapies in an attempt to improve outcome. This article describes the main trials of adjuvant chemotherapy, chemoradiotherapy, and chemoradiotherapy with follow-on chemotherapy and presents the results of the European Study Group for Pancreatic Cancer (ESPAC) 1 trial and the status of the ESPAC 2 and 3 trials.

The influence of training level and surgical experience on survival in colorectal cancer

BACKGROUND AND AIMS

The effect of surgical training level, experience, and operation volume on complications and survival in colorectal cancer during a 10-year period in a medium-volume university hospital was retrospectively studied.

PATIENTS AND METHODS

Four hundred and fifty-six patients were resected for primary colorectal adenocarcinoma during the 10-year period of 1981-1990, and of these, 387 patients underwent resection with curative intent. The surgeons were divided into three groups according to training level and volume: group 1, surgeons in training and other surgeons operating annually on only 1-4 patients; group 2, surgeons specializing in gastrointestinal surgery (average annual volume 4-13 operations); group 3, specialists in gastrointestinal surgery (average annual volume 3-8 operations). Postoperative morbidity and mortality rates, as well as long-term survival rates, were analysed, and comparisons were made between the patients in the three groups.

RESULTS

There were no statistically significant differences between the three groups in postoperative morbidity or mortality. Cancer-specific 5-year survival rate of all patients was 57%, and that of those resected in the aforementioned three groups was 51%, 63%, and 55%, respectively, P=0.087. The 5-year survival rates for colon cancer were 59% (total), 52%, 69%, and 58%, respectively, P=0.067, and for rectal cancer were 51% (total), 42%, 53%, and 52%, respectively, P=0.585.

CONCLUSION

There were no significant differences in the rates of postoperative mortality, morbidity, and long-term overall survival between the volume groups. However, in patients with colon cancer, there was a trend for better survival for those operated on by the surgeons specializing in gastrointestinal surgery, and in rectal cancer patients, a tendency of fewer local recurrences in those operated on by the specialist surgeons.

Management of bleeding and leakage after pancreatic surgery

Pancreatic surgery has advanced considerably during the past decades. Recent studies report reduced morbidity rates and virtually no mortality after resection. However, postoperative complications are still a formidable menace. In this chapter we discuss the management of postoperative bleeding and leakages which are considered the most feared complications, and discuss the advent of minimal invasive methods for management of these complications. Patients who develop postoperative bleeding almost always present with septic complications and a sentinel bleed before onset of bleeding. These patients should undergo early diagnostic angiography followed by embolisation. If this does control the bleeding an emergency laparotomy should be performed as last resort. Patients who develop pancreatic leakage are generally managed conservatively by means of percutaneous drainage. Aggressive surgery should be performed at the first sign of severe sepsis. The condition of the pancreatic remant found during reoperation dictates the type of surgical intervention best performed.

Benefits of specialisation in the management of pancreatic cancer: results of a Scottish population-based study

Pancreatic cancer is associated with a very poor prognosis; however, in selected patients, resection may improve survival. Several recent reports have demonstrated that concentration of treatment activity for patients with pancreatic cancer has resulted in improved outcomes. The aim of this study was to ascertain if there was any evidence of benefit for specialised care of patients with pancreatic cancer in Scotland. Records of patients diagnosed with pancreatic cancer during the period 1993–1997 were identified. Three indicators of co-morbidity were calculated for each patient. Operative procedures were classified as resection, other surgery or biliary stent. Prior to analysis, consultants were assigned as specialist pancreatic surgeons, clinicians with an interest in pancreatic disease or nonspecialists. Data were analysed with regard to 30-day mortality and survival outcome. The final study population included 2794 patients. The 30-day mortality following resection was 8%, and hospital or consultant volume did not affect postoperative mortality. The 30-day mortality rate following palliative surgical operations was 20%, and consultants with higher case loads or with a specialist pancreatic practice had significantly fewer postoperative deaths (P=0.014 and 0.002, respectively). For patients undergoing potentially curative or palliative surgery, the adjusted hazard of death was higher in patients with advanced years, increased co-morbidity, metastatic disease, and was lower for those managed by a specialist (RHR 0.63, 95% CI 0.50–0.78) or by a clinician with an interest in pancreatic disease (RHR 0.63, 0.48–0.82). The risk of death 3 years after diagnosis of pancreatic cancer is higher among patients undergoing surgical intervention by nonspecialists. Specialisation and concentration of cancer care has major implications for the delivery of health services.

Pancreatic resection in the elderly1 1No competing interests declared

BACKGROUND

Elderly patients undergoing pancreatic resection present unique challenges in postoperative care. Although mortality rates among elderly patients after pancreatectomy at high-volume centers is known to be low, the anticipated decline in functional status and nutritional parameters has received little attention. Functional decline is an unrecognized but critically important consequence of pancreatic resection in older patients.

STUDY DESIGN

This study is a retrospective review, validation cohort, of older and younger patients undergoing major pancreatic resection. The setting is the state of California (database of all hospitals in the state) and The University of California, San Francisco (UCSF; a tertiary care referral center). The study population is a consecutive sample of older (greater than or equal to 75 years) and younger (16 to 74 years) patients from California (January 1990 to December 1996; n = 3,113) and UCSF (January 1993 to November 2000; n = 218), who underwent radical pancreaticoduodenectomy, distal pancreatectomy, or total pancreatectomy for neoplasia. The main outcomes measures were length of stay, complications, mortality, discharge disposition, supplemental nutrition requirement, and readmissions.

RESULTS

Elderly patients had higher mortality rates than the young statewide (10% versus 7%, p = 0.006). Although the 3% mortality at UCSF was the same for both groups, older patients were more often admitted to the ICU (47% versus 20%, p = 0.003), treated for major cardiac events (13% versus 0.5%, p < 0.001), discharged with enteral tube feedings (48% versus 16%, p < 0.001), or malnourished on readmission (17% versus 2%, p < 0.005). Older patients were more frequently discharged to skilled nursing facilities (17% versus 1% at UCSF; 24% versus 7% in California; p < 0.001, both groups).

CONCLUSIONS

Older patients are more likely than younger patients to require an ICU stay, suffer a cardiac complication, and experience compromised nutritional and functional status after major pancreatic resection.

Is Reporting of Recurrence Data Important in Pancreatic Cancer?

BACKGROUND

Therapeutic approaches to patients with pancreatic cancer have undergone a paradigm shift in recent years. However, little is known about the outcome of patients with recurrent pancreatic cancer who undergo treatment. The purpose of this study was to identify patients with recurrent pancreatic cancer and to determine whether treatment after recurrence had any effect on outcome.

METHODS

A review of all patients undergoing surgical resection with curative intent revealed 70 patients with documented recurrence and complete medical records. Patients were grouped into three categories: group 1 included those who received treatment after recurrence (n = 45), group 2 included those who were not offered treatment (n = 9), and group 3 included those with poor performance status who received no treatment (n = 16).

RESULTS

The median overall survival for the three groups was 26, 18, and 14.5 months for groups 1, 2, and 3, respectively (P <.00001). The median survival after recurrence was 10 months, 6 months, and 1 month, respectively, for the three groups (P <.0001).

CONCLUSIONS

This is the first series we are aware of that compares the outcomes of patients who received treatment after recurrence of pancreatic cancer with the outcomes of those who received no treatment. In this series, it seems that patients who were well enough to tolerate additional therapy had a longer survival than those who received supportive care only. This may be important in the analysis of adjuvant therapy trials of pancreatic cancer with survival as an end point.

Concurrent chemoradiotherapy with gemcitabine and cisplatin after incomplete (R1) resection of locally advanced pancreatic carcinoma

PURPOSE

To analyze, in a prospective clinical trial, the efficacy and toxicity of concurrent radiotherapy and chemotherapy with gemcitabine and cisplatin in patients with incompletely (R1) resected pancreatic cancer.

METHODS AND MATERIALS

Between 2000 and 2002, a total of 30 pancreatic cancer patients were treated. Radiotherapy was performed in 15 patients up to a total dose of 45.0 Gy. An additional 15 patients received a total dose of 50.0 Gy according to the International Commission on Radiation Units and Measurements (ICRU) Report 50 reference point (equivalent to 45.0 Gy at the isodose, including 90% covering the former tumor area and local lymph nodes). Concurrent with radiotherapy, four applications of gemcitabine (300 mg/m(2)) and cisplatin (30 mg/m(2)) were administered. After chemoradiotherapy, patients received four additional courses of gemcitabine (1000 mg/m(2)) and cisplatin (50 mg/m(2)) on Days 1 and 15 in a 4-week cycle.

RESULTS

The median progression-free survival was 10.6 months, and the median overall survival was 22.8 months. The 1-, 2-, and 3-year survival rate was 81%, 43%, and 26%, respectively. After completion of chemoradiotherapy, distant metastasis was observed in 14 patients during a median follow-up of 15.0 months (range, 4.6-30.0). One patient developed both local recurrence and distant metastases. Hematologic toxicities were the most prominent side effects (leukopenia Grade 3 and 4 in 53% and 7% and thrombocytopenia Grade 3 and 4 in 33% and 7% of patients, respectively). Grade 3 and 4 GI toxicity was not observed.

CONCLUSION

Postoperative chemoradiotherapy with gemcitabine and cisplatin after incomplete (R1) resection of pancreatic carcinoma is safe and feasible. A prolonged progression-free survival suggests high local efficacy, translating into a benefit of overall survival. On the basis of the favorable outcome of patients receiving gemcitabine/cisplatin-based chemoradiotherapy, testing this combined treatment strategy appears warranted in a comparative trial.

T cell lymphoplasmacellular and eosinophilic infiltration of the pancreas with involvement of the gallbladder and duodenum in non-alcoholic duct-destructive chronic pancreatitis

BACKGROUND

Non-alcoholic duct destructive chronic pancreatitis is a rare entity with specific pathological features. The majority of the patients are from Japan. We report a case with involvement of the distal bile duct, the gallbladder, the duodenum and the ampulla, and present a review of patients from Europe and the USA since 1997.

CASE PRESENTATION

A 56-year-old man presented with a 3-month history of mild acute pancreatitis and obstructive jaundice, followed by increasing weight loss, lethargy and epigastric pain. CT showed a mass in the head of the pancreas. ERCP demonstrated a smooth stricture of the intra-pancreatic main bile duct and an irregular, incomplete, stricture in the main pancreatic duct. A pancreatic cancer could not be reliably excluded, and, therefore, he underwent a pylorus-preserving Kausch-Whipple's pancreatoduodenectomy.

RESULTS

Histopathology showed typical peri-ductal T cell-rich lymphoplasmacellular and eosinophilic infiltration of the pancreas, with involvement of the distal bile duct but, also, unusual inflammatory infiltration of the gallbladder, the duodenum and the ampulla.

CONCLUSION

The inflammatory process in non-alcoholic duct-destructive chronic pancreatitis can affect the entire pancreato-biliary region and mimics pancreatic cancer. Currently, there are no definitive criteria for pre-operative diagnosis, so it is very difficult for one to avoid resection.

Risk factors for complications after pancreatic head resection

BACKGROUND

Postoperative morbidity is high after pancreatic head resections. Data about risk factors are controversial. The aim of this study was to evaluate risk factors for complications after pancreatic head resection and to assess whether the complication rate changed during the study period.

METHODS

Data of 301 patients undergoing pancreatic head resection were recorded prospectively. Risk factors were assessed by multivariate analysis. The first and second part of the study period were compared.

RESULTS

Mortality was 3%. Overall and surgery-related complications occurred in 42% and 28%, respectively. Independent risk factors for postoperative morbidity were impaired renal function (odds ratio [OR] 2.7), absence of preoperative biliary drainage (OR 1.9), and resection of other organs (OR 3.2). Complication rate, duration of surgery, amount of blood transfused, and length of hospital stay decreased during the study period.

CONCLUSIONS

Increasing hospital experience decreased complication rates. Patients with risk factors should be considered for transferal to specialized centers.

Blockade of constitutively activated Janus kinase/signal transducer and activator of transcription-3 pathway inhibits growth of human pancreatic cancer

Constitutive activation of signal transducer and activator of transcription (Stat) proteins has been demonstrated in a wide variety of malignancies. In this study, we elucidated the significance of Janus kinase (JAK) and the downstream transcription factor Stat3 signals on malignant potentials of pancreatic cancer. Electrophoretic mobility shift assay and immunohistochemical analysis revealed that Stat3 was constitutively activated in subsets of human pancreatic cancer tissues and cell lines (Panc1, Kp4, AsPC-1, BxPC-3). A JAK-specific inhibitor, tyrphostin AG490, markedly inhibited Stat3 activation and expression of cyclin D1, bcl-xL and vascular endothelial growth factor mRNAs estimated by RT-PCR, as followed by growth arrest (6.3-21.3% vs controls; P<0.001) of pancreatic cancer cells. Inactivation of Stat3 by dominant-negative Stat3 adenovirus partly suppressed the growth of pancreatic cancer cells on day 4 post-inoculation (P<0.05) but not the expression of these mRNAs. These results indicate that activation of the JAK/Stat3 signaling pathway plays an important role in the progression of pancreatic cancer and that blockade of JAK/Stat3 signals may provide a novel therapeutic strategy for pancreatic cancer.