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Kotecha K, Tree K, Ziaziaris WA, McKay SC, Wand H, Samra J, Mittal A. Centralization of Pancreaticoduodenectomy: A Systematic Review and Spline Regression Analysis to Recommend Minimum Volume for a Specialist Pancreas Service. Ann Surg 2024; 279:953-960. [PMID: 38258578 DOI: 10.1097/sla.0000000000006208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center. BACKGROUND The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable. MATERIALS AND METHODS Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a "zero-crossing" technique was used, which produced "first and second derivatives" to identify volume thresholds. RESULTS Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df 5.154 ( P <0.001) and 8.254 ( P <0.001), respectively. The threshold value for mortality was ~45 PDs/year (model 9.219 ( P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost ( edf =2, P =0.989) and length of stay ( edf =2.04, P =0.099). CONCLUSIONS There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year.
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Affiliation(s)
- Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Tree
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - William A Ziaziaris
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Siobhan C McKay
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Cancer and Genomic Science, University of Birmingham, Edgbaston, Birmingham United Kingdom
| | - Handan Wand
- Kirby Institute (formerly National Center in HIV Epidemiology and Clinical Research), University of New South Wales, Sydney, NSW
| | - Jaswinder Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Center, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Center, Sydney, Australia
- University of Notre Dame, Sydney
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Skalicky P, Knapkova K, Tesarikova J, Gregorik M, Klos D, Lovecek M. Preoperative nutritional support in patients undergoing pancreatic surgery affects PREPARE score accuracy. Front Surg 2023; 10:1275432. [PMID: 38046103 PMCID: PMC10690825 DOI: 10.3389/fsurg.2023.1275432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/06/2023] [Indexed: 12/05/2023] Open
Abstract
Background This study aimed to validate the accuracy of the Preoperative Pancreatic Resection (PREPARE) risk score in pancreatic resection patients. Patients and methods This prospective study included 216 patients who underwent pancreatic resection between January 2015 and December 2018. All patients in our cohort with weight loss or lack of appetite received dietary advice and preoperative oral nutritional supplementation (600 kcal/day). Demographic, clinicopathological, operative, and postoperative data were collected prospectively. The PREPARE score and the predicted risk of major complications were computed for each patient. Differences in major postoperative complications were analyzed using a multivariate Cox proportional hazards regression model. The predicted and observed risks of major complications were tested using the C-statistic. Results The study included 216 patients [117 men (54.2%)] with a median age of 65.0 (30.0-83.0) years. The majority of patients were classified as American Society of Anesthesiologists (ASA)' Physical Status score II (N = 164/216; 75.9%) and as "low risk" PREPARE score (N = 185/216; 85.6%) before the surgery. Only 4 (1.9%) patients were malnourished, with albumin levels of less than 3.5 g/dl. The most common type of pancreatic resection was a pylorus-preserving pancreaticoduodenectomy (N = 122/216; 56.5%). Major morbidity and 30-day mortality rates were 11.1% and 1.9%, respectively. The type of surgical procedure (hazard ratio [HR]: 3.849; 95% confidence interval [CI]: 1.208-12.264) and ASA score (HR: 3.089; 95% CI: 1.067-8.947) were significantly associated with the incidence of major postoperative complications in multivariate analysis. The receiver operating characteristic curve was 0.657 for incremental values and 0.559 for risk categories, indicating a weak predictive model. Conclusion The results of the present study suggest that the PREPARE risk score has low accuracy in predicting the risk of major complications in patients with consistent preoperative nutritional support. This limits the use of PREPARE risk score in future preoperative clinical routines.
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Affiliation(s)
- Pavel Skalicky
- Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Katerina Knapkova
- Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Jana Tesarikova
- Department of Surgery I, University Hospital Olomouc, Olomouc, Czech Republic
| | - Michal Gregorik
- Department of Surgery I, University Hospital Olomouc, Olomouc, Czech Republic
| | - Dusan Klos
- Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Martin Lovecek
- Department of Surgery I, University Hospital Olomouc, Olomouc, Czech Republic
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Perri G, van Hilst J, Li S, Besselink MG, Hogg ME, Marchegiani G. Teaching modern pancreatic surgery: close relationship between centralization, innovation, and dissemination of care. BJS Open 2023; 7:zrad081. [PMID: 37698977 PMCID: PMC10496870 DOI: 10.1093/bjsopen/zrad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Pancreatic surgery is increasingly moving towards centralization in high-volume centres, supported by evidence on the volume-outcome relationship. At the same time, minimally invasive pancreatic surgery is becoming more and more established worldwide, and interest in new techniques, such as robotic pancreatoduodenectomy, is growing. Such recent innovations are reshaping modern pancreatic surgery, but they also represent new challenges for surgical training in its current form. METHODS This narrative review presents a chosen selection of literature, giving a picture of the current state of training in pancreatic surgery, together with the authors' own views, and in the context of centralization and innovation towards minimally invasive techniques. RESULTS Centralization of pancreatic surgery at high-volume centres, volume-outcome relationships, innovation through minimally invasive technologies, learning curves in both traditional and minimally invasive surgery, and standardized training paths are the different, but deeply interconnected, topics of this article. Proper training is essential to ensure quality of care, but innovation and centralization may represent challenges to overcome with new training models. CONCLUSION Innovations in pancreatic surgery are introduced with the aim of increasing the quality of care. However, their successful implementation is deeply dependent on dissemination and standardization of surgical training, adapted to fit in the changing landscape of modern pancreatic surgery.
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Affiliation(s)
- Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Shen Li
- Department of Surgical Oncology, University of Chicago, Chicago, Illinois, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Melissa E Hogg
- Department of HPB Surgery, NorthShore Health System, Evanston, Illinois, USA
| | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
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Balzano G, Guarneri G, Pecorelli N, Partelli S, Crippa S, Vico A, Falconi M, Baglio G. Geographical Disparities and Patients' Mobility: A Plea for Regionalization of Pancreatic Surgery in Italy. Cancers (Basel) 2023; 15:cancers15092429. [PMID: 37173896 PMCID: PMC10177179 DOI: 10.3390/cancers15092429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Patients requiring complex treatments, such as pancreatic surgery, may need to travel long distances and spend extended periods of time away from home, particularly when healthcare provision is geographically dispersed. This raises concerns about equal access to care. Italy is administratively divided into 21 separate territories, which are heterogeneous in terms of healthcare quality, with provision generally decreasing from north to south. This study aimed to evaluate the distribution of adequate facilities for pancreatic surgery, quantify the phenomenon of long-distance mobility for pancreatic resections, and measure its effect on operative mortality. Data refer to patients undergoing pancreatic resections (in the period 2014-2016). The assessment of adequate facilities for pancreatic surgery, based on volume and outcome, confirmed the inhomogeneous distribution throughout Italy. The migration rate from Southern and Central Italy was 40.3% and 14.6%, respectively, with patients mainly directed towards high-volume centers in Northern Italy. Adjusted mortality for non-migrating patients receiving surgery in Southern and Central Italy was significantly higher than that for migrating patients. Adjusted mortality varied greatly among regions, ranging from 3.2% to 16.4%. Overall, this study highlights the urgent need to address the geographical disparities in pancreatic surgery provision in Italy and ensure equal access to care for all patients.
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Affiliation(s)
- Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
| | - Giovanni Guarneri
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
| | - Nicolò Pecorelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | | | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Giovanni Baglio
- Head of the Research and International Relations Unit, Italian National Agency for Regional Healthcare Services, 00187 Rome, Italy
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Marchegiani G, Di Gioia A, Giuliani T, Lovo M, Vico E, Cereda M, Bassi C, Gianotti L, Salvia R. Delayed gastric emptying after pancreatoduodenectomy: One complication, two different entities. Surgery 2023; 173:1240-1247. [PMID: 36702659 DOI: 10.1016/j.surg.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/09/2022] [Accepted: 12/13/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy associated with a low complication burden but a prolonged hospital stay. The present study aimed to characterize DGE, with a particular focus on its subtypes and related predictors. METHODS A 2-center retrospective analysis was performed including consecutive pancreatoduodenectomy over 5 years. Primary delayed gastric emptying (pDGE) and secondary delayed gastric emptying (sDGE) were defined according to the presence of concomitant causing factors. Predictors of DGE, pDGE and sDGE were assessed through logistic regression. RESULTS Out of 1,170 patients considered, 188 developed delayed gastric emptying (16.1%). Most DGE (71.8%) were secondary. sDGE resolved later (P = .007), with hospital stay, duration of total parenteral nutrition, and of enteral nutrition being longer than for pDGE (all P < .005). Smoking status, total operative time, indication for surgery other than pancreatic cancer, estimated blood loss, and soft pancreatic texture were independent predictors of DGE. In the subgroup analysis of pDGE, smoking was the only independent predictor, whereas pylorus-preservation was a protective factor. Smoking, indication for surgery, estimated blood loss, soft gland texture, and main pancreatic duct diameter were independent predictors of sDGE. CONCLUSION DGE after pancreatoduodenectomy consists of 2 different subtypes. The primary form resolves earlier, and its occurrence might be reduced by pylorus preservation. For the secondary form, clinicians should focus on preventing and treating other trigger complications. The diagnosis of the DGE subtype has critical therapeutic implications and paves the way for further systematic studies.
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Affiliation(s)
- Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy. https://twitter.com/Gio_Marchegiani
| | - Anthony Di Gioia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy. https://twitter.com/Anth_DiGioia
| | - Tommaso Giuliani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy. https://twitter.com/Tom_Giuliani_MD
| | - Michela Lovo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy
| | - Eleonora Vico
- Unit of Hepatobiliary Pancreatic Surgery, Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Marco Cereda
- Unit of Hepatobiliary Pancreatic Surgery, Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy.
| | - Luca Gianotti
- Unit of Hepatobiliary Pancreatic Surgery, Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy. https://twitter.com/SalviaRobi
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Fischer C, Alvarico SJ, Wildner B, Schindl M, Simon J. The relationship of hospital and surgeon volume indicators and post-operative outcomes in pancreatic surgery: a systematic literature review, meta-analysis and guidance for valid outcome assessment. HPB (Oxford) 2023; 25:387-399. [PMID: 36813680 DOI: 10.1016/j.hpb.2023.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Available evidence on the volume-outcome relationship after pancreatic surgery is limited due to the narrow focus of interventions, volume indicators and outcomes considered as well as due to methodological differences of the included studies. Therefore, we aim to evaluate the volume-outcome relationship following pancreatic surgery following strict study selection and quality criteria, to identify aspects of methodological variation and to define a set of key methodological indicators to consider when aiming for comparable and valid outcome assessment. METHODS Four electronic databases were searched to identify studies on the volume-outcome relationship in pancreatic surgery published between the years 2000-2018. Following a double-screening process, data extraction, quality appraisal, and subgroup analysis, results of included studies were stratified and pooled using random effects meta-analysis. RESULTS Consistent associations were found between high hospital volume and both postoperative mortality (OR 0.35, 95% CI: 0.29-0.44) and major complications (OR 0.87, 95% CI: 0.80-0.94). A significant decrease in the odds ratio was also found for high surgeon volume and postoperative mortality (OR 0.29, 95%CI: 0.22-0.37). DISCUSSION Our meta-analysis confirms a positive effect for both hospital and surgeon volume indicators for pancreatic surgery. Further harmonization (e.g. surgery types, volume cut-offs/definition, case-mix adjustment, reported outcomes) are recommended for future empirical studies.
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Affiliation(s)
- Claudia Fischer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria.
| | - Stefanie J Alvarico
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - B Wildner
- University Library, Medical University of Vienna, Vienna, Austria
| | - Martin Schindl
- Department of Surgery, Comprehensive Cancer Center (CCC), Medical University and Pancreatic Cancer Unit, Vienna, Austria
| | - Judit Simon
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria; Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom; Ludwig Boltzmann Institute Applied Diagnostics, Vienna, Austria
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Byun Y, Choi YJ, Han Y, Kang JS, Kim H, Kwon W, Jang JY. Outcomes of 5000 pancreatectomies in Korean single referral center and literature reviews. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:1327-1335. [PMID: 33636051 DOI: 10.1002/jhbp.933] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/06/2021] [Accepted: 02/14/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pancreatic resection has higher postoperative mortality and morbidity rates than other abdominal operations. Some centers have reported remarkable postoperative outcomes of minimally invasive surgery. This study investigated the chronological trends of pancreatectomies by analyzing a large-scale database. METHODS The medical records of 5175 patients who underwent pancreatic resection between 1961 and 2019 at a single institution were reviewed. To investigate the chronological change in survival outcomes of periampullary cancer, the survival data of 3,108 patients were analyzed. RESULTS Patient age and the proportion with pancreatic cancer have increased over time. From 2015 to 2019, pancreatic cancer was the most common cause for resection (35.9%), followed by pancreatic cysts (24.8%) and common bile duct cancer (13.4%). The incidence of postoperative complications tended to decrease over time (26.0% from 2000 to 2004; 20.8% from 2015 to 2019). A comparison of survival outcomes of periampullary malignancies by period revealed that patients with pancreatic cancer significantly improved (5-year survival rate: 14.4% before 2000% vs 15.2% from 2000 to 2009% vs 29.0% after 2009, P < .001). CONCLUSIONS Postoperative outcomes of pancreatic resection have improved over the past few decades. To improve outcomes in the future, an active multidisciplinary approach and postoperative management are required.
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Affiliation(s)
- Yoonhyeong Byun
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Korea
| | - Yoo Jin Choi
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Korea
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Zwart ES, Yilmaz BS, Halimi A, Ahola R, Kurlinkus B, Laukkarinen J, Ceyhan GO. Venous resection for pancreatic cancer, a safe and feasible option? A systematic review and meta-analysis. Pancreatology 2022; 22:803-809. [PMID: 35697587 DOI: 10.1016/j.pan.2022.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 02/28/2022] [Accepted: 05/02/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND In pancreatic ductal adenocarcinoma patients with suspected venous infiltration, a R0 resection is most of the time not possible without venous resection (VR). To investigate this special kind of patients, this meta-analysis was conducted to compare mortality, morbidity and long-term survival of pancreatic resections with (VR+) and without venous resection (VR-). METHODS A systematic search was performed in Embase, Pubmed and Web of Science. Studies which compared over twenty patients with VR + to VR-for PDAC with ≥1 year follow up were included. Articles including arterial resections were excluded. Statistical analysis was performed with the random effect Mantel-Haenszel test and inversed variance method. Individual patient data was compared with the log-rank test. RESULTS Following a review of 6403 papers by title and abstract and 166 by full text, a meta-analysis was conducted of 32 studies describing 2216 VR+ and 5380 VR-. There was significantly more post-pancreatectomy hemorrhage (6.5% vs. 5.6%), R1 resections (36.7% vs. 28.6%), N1 resections (70.3% vs. 66.8%) and tumors were significantly larger (34.6 mm vs. 32.8 mm) in patients with VR+. Of all VR + patients, 64.6% had true pathological venous infiltration. The 90-day mortality, individual patient data for overall survival and pooled multivariate hazard ratio for overall survival were similar. CONCLUSION VR is a safe and feasible option in patients with pancreatic cancer and suspicion of venous involvement, since VR during pancreatic surgery has comparable overall survival and complication rates.
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Affiliation(s)
- E S Zwart
- Amsterdam UMC, Amsterdam, Cancer Center Amsterdam, Netherlands Department of Surgery, the Netherlands
| | - B S Yilmaz
- Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - A Halimi
- Division of Surgery, CLINTEC, Karolinska Institute, Sweden; Department of Surgical and Perioperative Sciences, Umeå University Hospital, Sweden
| | - R Ahola
- Tampere University Hospital and Tampere University, Tampere, Finland
| | - B Kurlinkus
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - J Laukkarinen
- Tampere University Hospital and Tampere University, Tampere, Finland
| | - G O Ceyhan
- Department of General Surgery, HPB Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.
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Cawich SO, Pearce NW, Naraynsingh V, Shukla P, Deshpande RR. Whipple’s operation with a modified centralization concept: A model in low-volume Caribbean centers. World J Clin Cases 2022; 10:7620-7630. [PMID: 36158490 PMCID: PMC9372853 DOI: 10.12998/wjcc.v10.i22.7620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 05/05/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors’ opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.
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Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Neil W Pearce
- University Surgical Unit, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Parul Shukla
- Department of Surgery, Weill Cornell Medical College, New York, NY 10065, United States
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
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Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis. Langenbecks Arch Surg 2022; 407:2801-2810. [PMID: 35752718 DOI: 10.1007/s00423-022-02599-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications. METHODS Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed. RESULTS A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations. CONCLUSIONS Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.
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Robertson R, Russell K, Pandanaboyana S, Wu D, Windsor J. Postoperative nutritional support after pancreaticoduodenectomy in adults. Hippokratia 2022. [DOI: 10.1002/14651858.cd014792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rachel Robertson
- Department of General Surgery; Whangarei Hospital, Northland District Health Board; Whangarei New Zealand
| | - Kylie Russell
- Nutrition and Dietetics; Auckland District Health Board; Auckland New Zealand
- Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences; The University of Auckland; Auckland New Zealand
| | - Sanjay Pandanaboyana
- HPB and Liver Transplant Surgery; Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | - Dong Wu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences; Beijing China
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences; The University of Auckland; Auckland New Zealand
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12
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Di Gioia A, Giuliani T, Marchegiani G, Andrianello S, Bonamini D, Secchettin E, Esposito A, Bassi C, Salvia R. Pancreatoduodenectomy in obese patients: surgery for nonmalignant tumors might be deferred. HPB (Oxford) 2022; 24:885-892. [PMID: 34801400 DOI: 10.1016/j.hpb.2021.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/09/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Obesity has traditionally been considered a cause of increased surgical complexity and poor outcomes following pancreatoduodenectomy (PD). This study aimed at evaluating the role of obesity in terms of mortality and failure to rescue (FTR), with a particular focus on nonmalignant tumors. METHODS All patients undergoing elective PD over 10 consecutive years were analyzed. Patients were stratified according to their BMI and categorized into two groups. Predictors of mortality and FTR were assessed through logistic regression. RESULTS Out of 1865 patients included, 151 were obese (8.1%). Overall mortality and FTR were 3.1% and 14.1%, respectively. In obese patients, mortality was 6.0% and FTR 26.5%, significantly higher compared to nonobese (p < 0.05). In the multivariable analysis, obesity, age > 70 years, and ASA-PS score were independent predictors of mortality and FTR. Postoperative pancreatic fistula (35.8% vs. 25.8%), postpancreatectomy acute pancreatitis (24.5% vs. 12.5%), and chyle leak (6.0% vs. 3.2%) were more frequent among obese patients. In the subgroup of patients with nonmalignant tumors (n = 443), obesity was the only independent predictor of FTR. CONCLUSION PD performed in obese patients was associated with higher surgical morbidity and mortality. When dealing with nonmalignant tumors, deferring surgery in obese patients should be strongly considered.
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Affiliation(s)
- Anthony Di Gioia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Tommaso Giuliani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy.
| | - Stefano Andrianello
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Deborah Bonamini
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Erica Secchettin
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
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13
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Hunger R, Seliger B, Ogino S, Mantke R. Mortality factors in pancreatic surgery: A systematic review. How important is the hospital volume? Int J Surg 2022; 101:106640. [PMID: 35525416 PMCID: PMC9239346 DOI: 10.1016/j.ijsu.2022.106640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND How the extent of confounding adjustment impact (hospital) volume-outcome relationships in published studies on pancreatic cancer surgery is unknown. METHODS A systematic literature search was conducted for studies that investigated the relationship between volume and outcome using a risk adjustment procedure by querying the following databases: PubMed, Cochrane Central Register of Controlled Trials, Livivo, Medline and the International Clinical Trials Registry Platform (last query: 2020/09/16). Importance of risk-adjusting covariates were assessed by effect size (odds ratio, OR) and statistical significance. The impact of covariate adjustment on hospital (or surgeon) volume effects was analyzed by regression and meta-regression models. RESULTS We identified 87 studies (75 based on administrative data) with nearly 1 million patients undergoing pancreatic surgery that included in total 71 covariates for risk adjustment. Of these, 33 (47%) had statistically significant effects on short-term mortality and 23 (32%) did not, while for 15 (21%) factors neither effect size nor statistical significance were reported. The most important covariates for short term mortality were patient-specific factors. Concerning the covariates, single comorbidities (OR: 4.6, 95% CI: 3.3 to 6.3) had the strongest impact on mortality followed by hospital volume (OR: 2.9, 95% CI: 2.5 to 3.3) and the procedure (OR: 2.2, 95% CI: 1.9 to 2.5). Among the single comorbidities, coagulopathy (OR: 4.5, 95% CI: 2.8 to 7.2) and dementia (OR: 4.2, 95% CI: 2.2 to 8.0) had the strongest influence on mortality. The regression analysis showed a significant decrease hospital volume effect with an increasing number of covariates considered (OR: 0.06, 95% CI: 0.10 to -0.03, P < 0.001), while such a relationship was not observed for surgeon volume (P = 0.35). CONCLUSIONS This analysis demonstrated a significant inverse relationship between the extent of risk adjustment and the volume effect, suggesting the presence of unmeasured confounding and overestimation of volume effects. However, the conclusions are limited in that only the number of included covariates was considered, but not the effect size of the non-included covariates.
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Affiliation(s)
- Richard Hunger
- Department of General Surgery, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Barbara Seliger
- Martin Luther University Halle-Wittenberg, Institute of Medical Immunology, Halle, Germany; Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Shuji Ogino
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA; Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Rene Mantke
- Department of General Surgery, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany; Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany.
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14
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Marchegiani G, Perri G, Giovinazzo F, Zanini S, Turri G, Innamorati G, Salvia R, Bassi C. High Values of Drain Fluid Epidermal Growth Factor and Transforming Growth Factor-Beta Are Associated with the Development of Pancreatic Fistula after Pancreatoduodenectomy. Dig Surg 2022; 39:125-132. [PMID: 35468606 DOI: 10.1159/000524678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 04/04/2022] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Postoperative inflammatory response may act as a major determinant of anastomotic failure after pancreaticoduodenectomy. In this pilot study, we investigated the potential role of drain fluid cytokines in predicting postoperative pancreatic fistula (POPF). METHODS Drain fluid TGF-β, IGF-1, EGF, and IL-6, together with serum amylase and drain fluid amylase, were measured on POD1 and correlated with the development of POPF. RESULTS The study population consisted of 66 patients. POPF and Clavien-Dindo ≥3 morbidity rates were 12.1% and 9.1%, respectively. Patients developing POPF presented significantly higher values of POD1 serum amylase level (477 vs. 54 UI/L, p < 0.001), drain fluid amylase (7,500 vs. 127 UI/L, p < 0.001), TGFβ (94 vs. 40 pg/g, p = 0.045), and EGF (17 vs. 13, p = 0.015). There were no differences in terms of IGF-1 and IL-6 values. CONCLUSION Assessing the local inflammatory response after pancreatoduodenectomy could represent a promising field of research since both TGFβ and EGF seem to be associated with the occurrence of POPF.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Francesco Giovinazzo
- Liver Transplant and General Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sara Zanini
- Translational Surgery Lab, LURM, University of Verona Hospital Trust, Verona, Italy
| | - Giulia Turri
- Department of General and Hepatobiliary Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giulio Innamorati
- Translational Surgery Lab, LURM, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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15
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Giuliani A, Avella P, Segreto AL, Izzo ML, Buondonno A, Coluzzi M, Cappuccio M, Brunese MC, Vaschetti R, Scacchi A, Guerra G, Amato B, Calise F, Rocca A. Postoperative Outcomes Analysis After Pancreatic Duct Occlusion: A Safe Option to Treat the Pancreatic Stump After Pancreaticoduodenectomy in Low-Volume Centers. Front Surg 2022; 8:804675. [PMID: 34993230 PMCID: PMC8725883 DOI: 10.3389/fsurg.2021.804675] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/25/2021] [Indexed: 12/07/2022] Open
Abstract
Background: Surgical resection is the only possible choice of treatment in several pancreatic disorders that included periampullar neoplasms. The development of a postoperative pancreatic fistula (POPF) is the main complication. Despite three different surgical strategies that have been proposed–pancreatojejunostomy (PJ), pancreatogastrostomy (PG), and pancreatic duct occlusion (DO)–none of them has been clearly validated to be superior. The aim of this study was to analyse the postoperative outcomes after DO. Methods: We retrospectively reviewed 56 consecutive patients who underwent Whipple's procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit. After pancreatic resection in open surgery, we performed DO of the Wirsung duct with Cyanoacrylate glue independently from the stump characteristics. The mean follow-up was 24.5 months. Results: In total, 29 (60.4%) were men and 19 were (39.6%) women with a mean age of 62.79 (SD ± 10.02) years. Surgical indications were in 95% of cases malignant diseases. The incidence of POPF after DO was 31 (64.5%): 10 (20.8%) patients had a Grade A fistula, 18 (37.5%) Grade B fistula, and 3 (6.2%) Grade C fistula. No statistical differences were demonstrated in the development of POPF according to pancreatic duct diameter groups (p = 0.2145). Nevertheless, the POPF rate was significantly higher in the soft pancreatic group (p = 0.0164). The mean operative time was 358.12 min (SD ± 77.03, range: 221–480 min). Hospital stay was significantly longer in patients who developed POPF (p < 0.001). According to the Clavien-Dindo (CD) classification, seven of 48 (14.58%) patients were classified as CD III–IV. At the last follow-up, 27 of the 31 (87%) patients were alive. Conclusions: Duct occlusion could be proposed as a safe alternative to pancreatic anastomosis especially in low-/medium-volume centers in selected cases at higher risk of clinically relevant POPF.
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Affiliation(s)
- Antonio Giuliani
- Unit of General and Emergency Surgery, AOR "San Carlo", Potenza, Italy.,Unit of Hepatobiliary Surgery and Liver Transplant Centre, "Cardarelli" Hospital, Naples, Italy
| | - Pasquale Avella
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Anna Lucia Segreto
- Department of General Surgery "SS. Antonio e Biagio e Cesare Arrigo" Hospital, Alessandria, Italy
| | - Maria Lucia Izzo
- Unit of General and Emergency Surgery, AOR "San Carlo", Potenza, Italy
| | - Antonio Buondonno
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | | | - Micaela Cappuccio
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Maria Chiara Brunese
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Roberto Vaschetti
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Andrea Scacchi
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Germano Guerra
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Fulvio Calise
- Unit of Hepatobiliary Surgery and Liver Transplant Centre, "Cardarelli" Hospital, Naples, Italy.,HPB Surgery Unit, Pineta Grande Hospital, Campania, Italy
| | - Aldo Rocca
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy.,HPB Surgery Unit, Pineta Grande Hospital, Campania, Italy
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16
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Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures. Cir Esp 2021; 99:745-756. [PMID: 34794902 DOI: 10.1016/j.cireng.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms. METHOD Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded. RESULTS 631 patients were analyzed. The values obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02). CONCLUSIONS The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.
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17
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Birrer DL, Golcher H, Casadei R, Haile SR, Fritsch R, Hussung S, Brunner TB, Fietkau R, Meyer T, Grützmann R, Merkel S, Ricci C, Ingaldi C, Di Marco M, Guido A, Serra C, Minni F, Pestalozzi B, Petrowsky H, DeOliveira M, Bechstein WO, Bruns CJ, Oberkofler CE, Puhan M, Lesurtel M, Heinrich S, Clavien PA. Neoadjuvant Therapy for Resectable Pancreatic Cancer: A New Standard of Care. Pooled Data From 3 Randomized Controlled Trials. Ann Surg 2021; 274:713-720. [PMID: 34334656 DOI: 10.1097/sla.0000000000005126] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to pool data from randomized controlled trials (RCT) limited to resectable pancreatic ductal adenocarcinoma (PDAC) to determine whether a neoadjuvant therapy impacts on disease-free survival (DFS) and surgical outcome. SUMMARY BACKGROUND DATA Few underpowered studies have suggested benefits from neoadjuvant chemo (± radiation) for strictly resectable PDAC without offering conclusive recommendations. METHODS Three RCTs were identified comparing neoadjuvant chemo (± radio) therapy vs. upfront surgery followed by adjuvant therapy in all cases. Data were pooled targeting DFS as primary endpoint, whereas overall survival (OS), postoperative morbidity, and mortality were investigated as secondary endpoints. Survival endpoints DFS and OS were compared using Cox proportional hazards regression with study-specific baseline hazards. RESULTS A total of 130 patients were randomized (56 in the neoadjuvant and 74 in the control group). DFS was significantly longer in the neoadjuvant treatment group compared to surgery only [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.4-0.9] (P = 0.01). Furthermore, DFS for the subgroup of R0 resections was similarly longer in the neoadjuvant treated group (HR 0.6, 95% CI 0.35-0.9, P = 0.045). Although postoperative complications (Comprehensive Complication Index, CCI®) occurred less frequently (P = 0.008), patients after neoadjuvant therapy experienced a higher toxicity, but without negative impact on oncological or surgical outcome parameters. CONCLUSION Neoadjuvant therapy can be offered as an acceptable standard of care for patients with purely resectable PDAC. Future research with the advances of precision oncology should now focus on the definition of the optimal regimen.
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Affiliation(s)
- Dominique L Birrer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Henriette Golcher
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Sarah R Haile
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Ralph Fritsch
- Department of Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Saskia Hussung
- Department of Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas B Brunner
- Department of Radiation Oncology, University Hospital Magdeburg, Magdeburg, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Thomas Meyer
- Department of Surgery, Hospital Ansbach, Ansbach, Germany
| | - Robert Grützmann
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Claudio Ricci
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Mariacristina Di Marco
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
- Medical Oncology, IRCCS Azienda Ospedaliero, University of Bologna, Bologna, Italy
| | - Alessandra Guido
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Carla Serra
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Francesco Minni
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Michelle DeOliveira
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Wolf O Bechstein
- Department of General, Visceral- and Transplantation Surgery, University Hospital Frankfurt am Main, Frankfurt, Germany
| | - Christiane J Bruns
- Department of General and Transplantation Surgery, University Hospital Cologne, Köln, Germany
| | - Christian E Oberkofler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Milo Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, University Lyon I, Lyon, France
| | - Stefan Heinrich
- Department of General, Visceral and Transplantation Surgery, University Hospital of Mainz, Mainz, Germany
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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18
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Marchegiani G, Perri G, Bianchi B, Esposito A, Landoni L, Casetti L, Tuveri M, Malleo G, Paiella S, Fontana M, Pea A, De Pastena M, Salvia R, Bassi C. Pancreatic surgery during COVID-19 pandemic: major activity disruption of a third-level referral center during 2020. Updates Surg 2021; 74:953-961. [PMID: 34689316 PMCID: PMC8541802 DOI: 10.1007/s13304-021-01197-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/18/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The COVID-19 pandemic has severely limited the access to cancer surgery, but it is not known to what extent referral centers for pancreatic diseases were affected by its outbreak. The aim of this study is to describe the effect of COVID-19 pandemic on a third-level referral center for pancreatic surgery in Italy. METHODS The 2020 activity of The Pancreas Institute of the University of Verona was reviewed, comparing different phases of the COVID-19 pandemic outbreaks using the pre-COVID era as a control. Endpoints were the overall caseload of pancreatic resections, surgical waiting list, administration of preoperative therapy, major morbidity and mortality, residents' training; number of inpatients beds, outpatient visits/procedures/diagnostics. RESULTS In 2020, there was an overall significant reduction of pancreatic resections performed (394 vs. 506 in 2019), particularly during the first (March-May) and second (October-December) COVID-19 outbreaks, with an all-time-low of 16 resections/months in April (compared to 43 average resection/month in 2019). The rates of major morbidity (Clavien-Dindo ≥ 3) and mortality were similar to 2019 (16 vs 12%, p = 0.11 and 3 vs 2%, p = 0.29, respectively). During the first and second outbreaks resident's training, inpatient beds, outpatient visits, diagnostics, and procedures were severely impaired, while the waiting list for up-front cancer resections and the use of preoperative chemotherapy concomitantly raised. CONCLUSION The COVID-19 pandemic has severely disrupted the activity of a third-level referral center for pancreatic surgery, affecting the access to cancer surgical procedures and raising concerns regarding the solidity of the current centralization model.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy.
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Beatrice Bianchi
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Luca Landoni
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Luca Casetti
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Massimiliano Tuveri
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Martina Fontana
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Antonio Pea
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Matteo De Pastena
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery-The Pancreas Institute, Verona University Hospital Trust, Piazzale Scuro 10, 37134, Verona, Italy
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19
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Luijten JCHBM, Nieuwenhuijzen GAP, Sosef MN, de Hingh IHJT, Rosman C, Ruurda JP, van Duijvendijk P, Heisterkamp J, de Steur WO, van Laarhoven HWM, Besselink MG, Groot Koerkamp B, van Santvoort HC, Lemmens VEP, Vissers PAJ. Impact of nationwide centralization of oesophageal, gastric, and pancreatic surgery on travel distance and experienced burden in the Netherlands. Eur J Surg Oncol 2021; 48:348-355. [PMID: 34366174 DOI: 10.1016/j.ejso.2021.07.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study aims to assess the impact of nationwide centralization of surgery on travel distance and travel burden among patients with oesophageal, gastric, and pancreatic cancer according to age in the Netherlands. As centralization of care increases to improve postoperative outcomes, travel distance and experienced burden might increase. MATERIALS AND METHODS All patients who underwent surgery between 2006 and 2017 for oesophageal, gastric and pancreatic cancer in the Netherlands were included. Travel distance between patient's home address and hospital of surgery in kilometres was calculated. Questionnaires were used to assess experienced travel burden in a subpopulation (n = 239). Multivariable ordinal logistic regression models were constructed to identify predictors for longer travel distance. RESULTS Over 23,838 patients were included, in whom median travel distance for surgical care increased for oesophageal cancer (n = 9217) from 18 to 28 km, for gastric cancer (n = 6743) from 9 to 26 km, and for pancreatic cancer (n = 7878) from 18 to 25 km (all p < 0.0001). Multivariable analyses showed an increase in travel distance for all cancer types over time. In general, patients experienced a physical and social burden, and higher financial costs, due to traveling extra kilometres. Patients aged >70 years travelled less often independently (56% versus 68%), as compared to patients aged ≤70 years. CONCLUSION With nationwide centralization, travel distance increased for patients undergoing oesophageal, gastric, and pancreatic cancer surgery. Younger patients travelled longer distances and experienced a lower travel burden, as compared to elderly patients. Nevertheless, on a global scale, travel distances in the Netherlands remain limited.
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Affiliation(s)
- J C H B M Luijten
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | | | - M N Sosef
- Department of Surgery, Zuyderland Hospital, Heerlen, the Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - C Rosman
- Department of Surgery, Radboudumc, Nijmegen, the Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - J Heisterkamp
- Department of Surgery, Elisabeth Tweesteden Hospital, Tilburg, Embraze Regional Cancer Network, the Netherlands
| | - W O de Steur
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - H W M van Laarhoven
- Department of Medical Oncology, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - H C van Santvoort
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Surgery, Sint. Antonius, Nieuwegein, the Netherlands
| | - V E P Lemmens
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; Department of Public Health, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - P A J Vissers
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands.
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A four-step method to centralize pancreatic surgery, accounting for volume, performance and access to care. HPB (Oxford) 2021; 23:1095-1104. [PMID: 33257170 DOI: 10.1016/j.hpb.2020.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/16/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adequate criteria for pancreatic surgery centralization are debated. This retrospective study aimed to define a reproducible method for complex care centralization, accounting for hospital performance and access to care. METHODS The method consisted in: 1. Analysis of overall outcome and mortality-related factors. 2. Assessment of volume and adjusted mortality of each hospital. 3. Definition of different centralization models. 4. Final adjustments to guarantee access to care, evaluating travel times and waiting lists. This method was tested on Lombardy, the most populous Italian region (about 10 million inhabitants, 24 000 km2). RESULTS According to Ministry of Health data, 79 hospitals performed 3037 resections in 2014-2016. Mean overall mortality was 5.0%, increasing from 2.3%, of seven high-volume facilities (>30 resections/year) to 10.7% of 56 low-volume facilities (<10 resections/year). Five centralization models were tested (range: 7-23 hospitals): the best performing model included seven high-volume facilities, providing both low mortality (<2%), and easy access to care, namely reasonable travel time (≤60 min for >90% of the population), and limited impact on waiting list (1.1 extra-resection/hospital/week). CONCLUSION The four-step method appears as a flexible tool to centralize pancreatic surgery, allowing regulatory institutions to estimate the effect of different models.
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21
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Friend or foe? Feeding tube placement at the time of pancreatoduodenectomy: propensity score case-matched analysis. Surg Endosc 2021; 36:2994-3000. [PMID: 34165639 DOI: 10.1007/s00464-021-08594-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 06/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The role of concomitant gastrostomy or jejunostomy feeding tube (FT) placement during pancreatoduodenectomy (PD) and its impact on patient outcomes remain controversial. METHODS NSQIP database was surveyed for patients undergoing PD between 2014 and 2017. FT placement was identified using CPT codes. Propensity scores were used to match the two groups (1:1) on baseline characteristics and intraoperative variables including pancreas specific ones (duct size, gland texture, underlying disease, wound class, use of wound protector, drain placement, type of pancreatic reconstruction and vascular reconstruction). Outcomes were compared. Finally, a subset analyses for patients with delayed gastric emptying (DGE) or postoperative pancreatic fistula (POPF) were performed. RESULTS Out of 15,224 PD, 1,104 (7.5%) had FT. POPF and DGE rates were 17% and 18%, respectively, for the entire cohort. Feeding jejunostomy was the most placed FT (88.2%). Patients with FT placement were more likely to be older (mean, 65.8 vs. 64.6 y), smokers (22.6% vs. 17.8%) who had preoperative weight loss (22.5% vs. 15.3%), ASA class ≥ 3 (80.8% vs. 77.5%), preoperative transfusion (1.5% vs. 0.84%), chemotherapy (22.8% vs. 17.5%), and radiation (14.5% vs. 6.8%, p < 0.05). The matched cohort included 880 patients in each group with completely balanced preoperative and intraoperative characteristics. In the matched cohort, patients with FT placement had higher overall morbidity (52.2% vs. 44.3%, p = 0.001), major morbidity (28.4% vs. 22.5%, p = 0.004), organ/space infection (14.4% vs. 10.9%, p = 0.026), re-operation (8.6% vs. 5.1%, p = 0.003), DGE (26.8% vs. 16.4%, p < 0.001), and longer mean hospital length of stay (12.9 vs. 11.2 days, p = 0.001) than those without FT. There was no difference in mortality (1.7% vs. 2.2%, p = 0.488) or readmission rate (20.2% vs. 17.2%, p = 0.099). In patients with DGE and POPF, FT placement was not associated with morbidity, mortality, length of stay, or readmission rate (p > 0.05). CONCLUSION Patients with FT placement during PD tend to have higher postoperative morbidity and delayed recovery.
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Moya-Herraiz AA, Dorcaratto D, Martin-Perez E, Escrig-Sos J, Poves-Prim I, Fabregat-Prous J, Larrea Y Olea J, Sanchez-Bueno F, Botello-Martinez F, Sabater L. Non-arbitrary minimum threshold of yearly performed pancreatoduodenectomies: National multicentric study. Surgery 2021; 170:910-916. [PMID: 33875253 DOI: 10.1016/j.surg.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/11/2021] [Accepted: 03/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Annual hospital volume of pancreatoduodenectomies could influence postoperative outcomes. The aim of this study is to establish with a non-arbitrary method the minimum threshold of yearly performed pancreatoduodenectomies in order to improve several postoperative quality outcomes. METHOD Prospective follow-up of patients submitted to pancreatoduodenectomy in participating hospitals during 1 year. The influence of hospital volume on quality outcomes was analyzed by univariable and multivariable models. The minimum threshold of yearly performed pancreatoduodenectomies to improve outcomes was established by Akaike's information criteria. RESULTS Data from 877 patients operated in 74 hospitals were analyzed. Of 12 quality outcomes, 9 were influenced by hospital pancreatoduodenectomy volume on multivariable analysis. To decrease the risk of complications and the risk of retrieving an insufficient number of lymph nodes at least 31 pancreatoduodenectomies per year should be performed. To decrease the risk of prolonged length of stay, postoperative death, and affected surgical margins, at least 37, 6, and 14 pancreatoduodenectomies per year should be performed, respectively. CONCLUSION Several postoperative quality outcomes are influenced by the number of yearly performed pancreatoduodenectomies and could be improved by establishing a minimum threshold of procedures. Number of procedures needed to improve quality outcomes has been established by a non-arbitrary method.
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Affiliation(s)
- Angel Antonio Moya-Herraiz
- Department of Surgery, HPB unit, Hospital General Universitario de Castelló, Castelló de la Plana, Castellón, Spain
| | - Dimitri Dorcaratto
- Department of Surgery, Liver, Biliary and Pancreatic Unit, Hospital Clínico, University of Valencia, Biomedical Research Institute (INCLIVA), Valencia, Spain.
| | | | - Javier Escrig-Sos
- Department of Surgery, Hospital General Universitario de Castelló, Castelló de la Plana, Castellón, Spain
| | | | - Joan Fabregat-Prous
- Department of Surgery, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Javier Larrea Y Olea
- Department of Surgery, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | | | - Luis Sabater
- Department of Surgery, Liver, Biliary and Pancreatic Unit, Hospital Clínico, University of Valencia, Biomedical Research Institute (INCLIVA), Valencia, Spain
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Salvia R, Andrianello S, Ciprani D, Deiro G, Malleo G, Paiella S, Casetti L, Landoni L, Tuveri M, Esposito A, Marchegiani G, Bassi C. Pancreatic surgery is a safe teaching model for tutoring residents in the setting of a high-volume academic hospital: a retrospective analysis of surgical and pathological outcomes. HPB (Oxford) 2021; 23:520-527. [PMID: 32859493 DOI: 10.1016/j.hpb.2020.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Academic hospitals must train future surgeons, but whether residents could negatively affect the outcomes of major procedures is a matter of concern. The aim of this study is to assess if pancreatic surgery is a safe teaching model. METHODS Outcomes of 1230 major pancreatic resections performed at a high-volume pancreatic teaching hospital between 2015 and 2018 were compared according to the first surgeon type, attending vs resident. RESULTS Residents performed a selection of 132 (16%) pancreaticoduodenectomies (PD) and 46 (11%) distal pancreatectomies (DP). For PD, pancreatic fistula (25% vs 0, p < 0.001), biliary fistula (7.1% vs 3.5%, p = 0.04) and operative time (400 vs 390 min, p < 0.001) were lower for residents but post-pancreatectomy hemorrhage was higher (20.5% vs 13% p = 0.024). For DP, pancreatic fistula rate was lower for residents (31.7% vs 17.5% p = 0.046). There was no difference in terms of lymph nodes retrieval both for PDs and DPs, while the R1 resections were more frequent among PDs performed by attending surgeons (31.5% vs 15.7%, p = 0.023). CONCLUSION The active participation of residents does not negatively affect outcomes of major pancreatic resections in a high-volume center. By means of case selection and continuous tutoring, pancreatic surgery represents a safe and valid teaching model.
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Affiliation(s)
- Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Debora Ciprani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giacomo Deiro
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Capretti G, Donisi G, Gavazzi F, Nappo G, Pansa A, Piemonti L, Zerbi A. Total pancreatectomy as alternative to pancreatico-jejunal anastomosis in patients with high fistula risk score: the choice of the fearful or of the wise? Langenbecks Arch Surg 2021; 406:713-719. [PMID: 33783612 DOI: 10.1007/s00423-021-02157-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/22/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE Patients with fistula risk score (FRS) ≥7 are at the highest risk of developing clinically relevant post-operative pancreatic fistula (CR-POPF). There is no agreement on the management of this subpopulation. The primary outcome of the study was the definition of the role of intraoperative completion pancreatectomy (ICP) in patients at high risk for CR-POPF, as an alternative to high-risk pancreaticoduodenectomy (PD). METHODS This is an observational study set in a single tertiary referral center. Patients scheduled for PD in our center between 2010 and 2019 with FRS ≥7 were included in the study. Data were prospectively collected. RESULTS A total of 738 patients were scheduled for between 2010 and 2019, and 62 had FRS ≥7. Thirty-five patients were managed with PD and pancreatico-jejunal anastomosis (group A), and 27 with ICP (group B). Overall complication rate was significantly higher in group A than group B (95 versus 59%; p=0.005) and there was a not significantly higher rate of major complications (Clavien-Dindo ≥3) (43 versus 26%; p=0.192). In group A, 49% of patients had a CR-POPF. Median post-operative length of stay was 15 days in group A and 12 in group B (p=0.043). Readmission was observed only in group A (26%). In multivariate analysis, PD was an independent predictive factor of major post-operative morbidity (RR 9.27; CI 1.74-49.31). No patients in either group suffered major adverse events related to endocrine and exocrine insufficiency. CONCLUSION In high-FRS patients, ICP has good short-term outcomes relative to PD without major long-term events related to endocrine and exocrine insufficiency. ICP could be considered as a feasible alternative in selected cases.
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Affiliation(s)
- Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy. .,Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy.
| | - Greta Donisi
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Francesca Gavazzi
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Andrea Pansa
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Lorenzo Piemonti
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, MI, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy.,Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
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Archibugi L, Mariani A, Ciambriello B, Petrone MC, Rossi G, Testoni SGG, Carlucci M, Aldrighetti L, Falconi M, Balzano G, Doglioni C, Capurso G, Arcidiacono PG. High sensitivity of ROSE-supported ERCP-guided brushing for biliary strictures. Endosc Int Open 2021; 9:E363-E370. [PMID: 33655035 PMCID: PMC7895655 DOI: 10.1055/a-1322-2638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/21/2020] [Indexed: 01/15/2023] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in biliary strictures, with brushing being a cheap and fast method to acquire a cytological specimen, despite a sensitivity around 45 %. Rapid on-site evaluation (ROSE) is widely used for endoscopic ultrasound-acquired cytological specimen adequacy, improving its sensitivity and specificity. Nevertheless, no study has evaluated its role for ERCP-guided brushing. Our aim was to assess the diagnostic yield of ERCP-guided brushing of biliary strictures when supported by ROSE. Patients and methods This was a retrospective single-center study that included patients undergoing ERCP-guided brush cytology supported by ROSE for biliary strictures. Recorded data included patient clinical-radiological and ERCP features. Final diagnosis was determined after surgery, intraductal biopsy or adequate follow-up. The diagnostic yield was calculated and a subgroup analysis for factors associated with false-negative or true-positive results was performed. Results Two hundred six patients were included, 57.3 % males, median age 72 years, 77.2 % having extrahepatic biliary strictures. Of the patients, 99 % had an adequate sample at ROSE after a mean of 2.6 passages. The diagnostic yield was accuracy 83 %, sensitivity 74.6 %, and specificity 98 %, positive and negative predictive values 98 % and 71 % respectively, with an area under the curve of 0.86. A diagnosis of cholangiocarcinoma was significantly more frequent among true-positive cases (68 % vs 46.8 %; P = 0.04). Conclusions This is the first study evaluating the use of ROSE as support for ERCP-guided brushing of biliary strictures, with a sensitivity far higher than those reported for brushing alone and at least comparable to those of more expensive and invasive techniques.
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Affiliation(s)
- Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gemma Rossi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Gloria Giulia Testoni
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Carlucci
- Department of General and Emergency Surgery, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Doglioni
- Pathology Unit, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Nicholas E, van Roessel S, de Burlet K, Hore T, Besselink MG, Connor S. Using Textbook Outcomes to benchmark practice in pancreatic surgery. ANZ J Surg 2021; 91:361-366. [PMID: 33475226 DOI: 10.1111/ans.16555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 12/25/2020] [Accepted: 12/26/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Textbook Outcome (TO) is a novel composite measure of clinical outcomes that can be used to measure the quality of surgical outcomes. TOs for pancreatic surgery were published by the Dutch Pancreatic Cancer Group (DPCG) in 2020. The aim of this study was to explore how a medium volume hepatopancreaticobiliary unit could use TO to benchmark local outcomes following pancreatic surgery. METHODS Retrospective analysis of prospectively collected data from patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between March 2005 and February 2020 at Christchurch Hospital (CH). Analysis of TO items as defined by the DPCG was performed and compared to nationwide Dutch outcomes (2014-2017), including cumulative analysis using CuSum. RESULTS In total, 273 patients were included (median age 63 years; 51% female) of which 182 (67%) underwent PD and 91 (33%) underwent DP (median annual volume 12 PDs/6 DPs). Overall, 58% of patients undergoing PD and 74% of patients undergoing DP achieved TO, compared with 58% and 67%, P = 0.944 and P = 0.231, respectively, for the Netherlands (median annual volume 33 PDs/8 DPs per hospital). CONCLUSIONS TO offers a useful quality measure to benchmark local outcomes following pancreatic surgery against an external nationwide analysis. The results show that as a medium volume centre performance was comparable to previously published Dutch results, which included high volume centres. Applying CuSum methodology to the TO metric allows a continuous measure of performance. This offers the potential to provide feedback for quality improvement strategies.
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Affiliation(s)
- Ella Nicholas
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Stijn van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kirsten de Burlet
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Todd Hore
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Saxon Connor
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
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Castillo Tuñón JM, Valle Rodas ME, Botello Martínez F, Rojas Holguín A, López Guerra D, Santos Naharro J, Jaén Torrejímeno I, Blanco Fernández G. Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures. Cir Esp 2020; 99:S0009-739X(20)30313-4. [PMID: 33342520 DOI: 10.1016/j.ciresp.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The main objective of this study is to determine if our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms. METHOD Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded. RESULTS 631 patients were analyzed. The values ??obtained in the quality standards are in range. The most frequent surgery was cephalic duodenopancreatectomy, which associated higher peri-operative morbidity and mortality rates (p ≤ 0.05). The extended vascular resections impacted the cephalic duodenopancreatectomy group, associating a longer mean stay (p = 0.01) and a higher rate of re-interventions (p = 0.02). CONCLUSIONS The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbi-mortality.
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Yamashita M, Adachi T, Ono S, Matsumura N, Adachi T, Natsuda K, Hidaka M, Eguchi S. Pancreaticoduodenectomy can be indicated for elderly patients: risk prediction using the estimation of physiologic ability and surgical stress (E-PASS) system. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:165-173. [PMID: 33058480 DOI: 10.1002/jhbp.840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/06/2020] [Accepted: 08/31/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Pancreaticobiliary malignant diseases are primarily treated by surgical resection. However, the surgical indications for elderly patients, especially for pancreaticoduodenectomy (PD), must be carefully considered due to patient compliance. Whether PD can contribute to better prognoses in elderly patients remains unclear. Therefore, we aimed to evaluate the complications, compliance, and survival of elderly and non-elderly patients who underwent PD in our department. METHODS We retrospectively analyzed 282 patients who underwent PD from 2000 to 2017 and divided them into non-elderly (aged ≤ 79 years, n = 238) and elderly (aged ≥ 80 years, n = 44) groups. The estimation of physiologic ability and surgical stress (E-PASS) system was used to evaluate morbidity and mortality using preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS). RESULTS Preoperative risk score was higher in the elderly group than in the non-elderly group, although SSS and CRS were similar. No significant differences were detected in the occurrence of postoperative complications. In the elderly group, CRS was higher in patients with complications than in those without. Long-term outcomes evaluated by overall and disease-specific survival were not significantly different. CONCLUSIONS In the elderly patients, E-PASS especially CRS can predict the occurrence of complications. The safety and prognoses of elderly patients after PD are comparable with those of non-elderly patients.
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Affiliation(s)
- Mampei Yamashita
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomohiko Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shinichiro Ono
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Naomi Matsumura
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Toshiyuki Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Koji Natsuda
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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The experience of the minimally invasive (MI) fellowship-trained (FT) hepatic-pancreatic and biliary (HPB) surgeon: could the outcome of MI pancreatoduodenectomy for peri-ampullary tumors be better than open? Surg Endosc 2020; 35:5256-5267. [PMID: 33146810 DOI: 10.1007/s00464-020-08118-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/21/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although early series focused on benign disease, minimally invasive pancreatoduodenectomy (MIPD) might be particularly suited for malignancy. Unlike their predecessors, fellowship-trained (FT) Hepatic-Pancreatic and Biliary (HPB) surgeons usually have equal skills in approaching peri-ampullary tumors (PT) either openly or via minimally invasive (MI) techniques. METHOD We retrospectively reviewed a MI-HPB-FT surgeon's 10-year experience with PD. A sub-analysis of malignant PT was also done (MIPD-PT vs. OPD-PT). The primary endpoint was to assess postoperative mortality and morbidity. Secondary endpoints included operative parameters, length of hospital stay, and survival analysis. Moreover, we addressed practice pattern changes for a surgeon straight out of training with no previous experience of independent surgery. RESULTS From December 2007-February 2018, one MI-HPB-FT performed a total of 100 PDs, including 57 MIPDs and 43 open PDs (OPDs). In both groups, over 70% of PDs were undertaken for malignancy. Eight patients with borderline resectable pancreatic ductal cancer (PDC) were in the OPD-PT group (as compared to only 2 in the MIPD-PT group) (p = 0.07). Estimated mean blood loss and length of stay were less in the MIPD-PT group (345 mL and 12 days) as compared to the OPD-PT group (971 mL and 16 days), p < 0.001 and p = 0.007, respectively. However, the mean operative time was longer for the MIPD-PT (456 min) as compared to the OPD-PT (371 min), p < 0.001. Thirty and 90-day mortality was 2.6%/5.1% after MIPD-PT compared to 0%/3.2% after OPD-PT, respectively, p = 1. Overall 30-/90-day morbidity rates were similar at 41.0%/43.6% after MIPD-PT and 35.5%/41.9% after OPD-PT, respectively, p = 0.8 and 1. Complete resection (R0) rates were not statistically different, 97.4% after MIPD-PT compared to 87.0% after OPD-PT (p = 0.2). After MIPD and OPD for malignant PT, overall 1, 3 and 5-year survival rates, and median survival were 82.5%, 59.6% and 46.3% and 38 months as compared to 52.5%, 15.7% and 10.5% and 13 months, respectively (p = 0.01). In the MIDP-PT group, recurrence free survival (RFS) at 1, 3 and 5 years and median RFS were 69.1%, 41.9% and 33.5% and 26 months as compared to 50.4%, 6.3% and 6.3% and 13 months, in the OPD-PT group, respectively (p = 0.03). CONCLUSION FT HPB Surgeons who begin their practice with the ability to do both MI and OPD may preferentially approach resectable peri-ampullary tumors minimally invasively. This may result in decreased blood loss decreased length of hospital stays. Despite longer operative time, the improved visualization of MI techniques may enable superior R0 rates when compared to historical open controls. Moreover, combined with quicker initiation of adjuvant chemotherapeutic treatments, this may eventually result in improved survival.
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Pecorelli N, Guarneri G, Alagol K, Mazza M, Quattromani R, Partelli S, Crippa S, Castoldi R, Balzano G, Falconi M. The impact of minimally invasive surgery on hospital readmissions, emergency department visits and functional recovery after distal pancreatectomy. Surg Endosc 2020; 35:5740-5751. [DOI: 10.1007/s00464-020-08051-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 09/26/2020] [Indexed: 12/19/2022]
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In-hospital mortality and failure to rescue following hepatobiliary surgery in Germany - a nationwide analysis. BMC Surg 2020; 20:171. [PMID: 32727457 PMCID: PMC7388497 DOI: 10.1186/s12893-020-00817-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 07/08/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Recent observational studies on volume-outcome associations in hepatobiliary surgery were not designed to account for the varying extent of hepatobiliary resections and the consequential risk of perioperative morbidity and mortality. Therefore, this study aimed to determine the risk-adjusted in-hospital mortality for minor and major hepatobiliary resections at the national level in Germany and to examine the effect of hospital volume on in-hospital mortality, and failure to rescue. METHODS All inpatient cases of hepatobiliary surgery (n = 31,114) in Germany from 2009 to 2015 were studied using national hospital discharge data. After ranking hospitals according to increasing hospital volumes, five volume categories were established based on all hepatobiliary resections. The association between hospital volume and in-hospital mortality following minor and major hepatobiliary resections was evaluated by multivariable regression methods. RESULTS Minor hepatobiliary resections were associated with an overall mortality rate of 3.9% and showed no significant volume-outcome associations. In contrast, overall mortality rate of major hepatobiliary resections was 10.3%. In this cohort, risk-adjusted in-hospital mortality following major resections varied widely across hospital volume categories, from 11.4% (95% CI 10.4-12.5) in very low volume hospitals to 7.4% (95% CI 6.6-8.2) in very high volume hospitals (risk-adjusted OR 0.59, 95% CI 0.41-0.54). Moreover, rates of failure to rescue decreased from 29.38% (95% CI 26.7-32.2) in very low volume hospitals to 21.38% (95% CI 19.2-23.8) in very high volume hospitals. CONCLUSIONS In Germany, patients who are undergoing major hepatobiliary resections have improved outcomes, if they are admitted to higher volume hospitals. However, such associations are not evident following minor hepatobiliary resections. Following major hepatobiliary resections, 70-80% of the excess mortality in very low volume hospitals was estimated to be attributable to failure to rescue.
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Should all pancreatic surgery be centralized regardless of patients' comorbidity? HPB (Oxford) 2020; 22:1057-1066. [PMID: 31784212 DOI: 10.1016/j.hpb.2019.10.2443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND It remains to be established whether centralization to high volume centers is essential for all patients undergoing pancreatic surgery. The aims of this study were to identify the optimal cut-off volume to optimize patient outcomes and to determine if patient comorbidity affected the volume-outcome relationship. METHODS Patients undergoing pancreatectomy from 2012 to 2015 were retrospectively identified (n = 12 333) in the French nationwide database. The 90-day Post-Operative Mortality (POM) was analyzed according to hospital volume of pancreatectomy (very low:<10, Low:10-19, High:20-49 and very high:≥50 resections/year) and Charlson Comorbidity Index (ChCI). RESULTS The overall POM was 6.9%. The cut-off of 20 pancreatic resections per year was identified as predictor of POM. Compared to high volume centers, POM was significantly higher in low and very low volume centers whatever the ChCl. Regarding surgical procedures, there was a significant decrease in POM with increasing hospital volume only after pancreaticoduodenectomy regardless of the ChCl. On multivariable analysis, low and very low volume centers were independently associated with increased mortality rates. CONCLUSION The optimal cut-off of annual caseload was 20 pancreatic resections. POM following pancreaticoduodenectomy is high in low and very low volume centers independently of ChCl, suggesting that this procedure should be centralized.
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Balzano G, Guarneri G, Pecorelli N, Paiella S, Rancoita PMV, Bassi C, Falconi M. Modelling centralization of pancreatic surgery in a nationwide analysis. Br J Surg 2020; 107:1510-1519. [DOI: 10.1002/bjs.11716] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/26/2020] [Accepted: 04/29/2020] [Indexed: 12/31/2022]
Abstract
Abstract
Background
The benefits of centralization of pancreatic surgery have been documented, but policy differs between countries. This study aimed to model various centralization criteria for their effect on a nationwide cohort.
Methods
Data on all pancreatic resections performed between 2014 and 2016 were obtained from the Italian Ministry of Health. Mortality was assessed for different hospital volume categories and for each individual facility. Observed mortality and risk-standardized mortality rate (RSMR) were calculated. Various models of centralization were tested by applying volume criteria alone or in combination with mortality thresholds.
Results
A total of 395 hospitals performed 12 662 resections; 305 hospitals were in the very low-volume category (mean 2·6 resections per year). The nationwide mortality rate was 6·2 per cent, increasing progressively from 3·1 per cent in very high-volume to 10·6 per cent in very low-volume hospitals. For the purposes of centralization, applying a minimum volume threshold of at least ten resections per year would lead to selection of 92 facilities, with an overall mortality rate of 5·3 per cent. However, the mortality rate would exceed 5 per cent in 48 hospitals and be greater than 10 per cent in 17. If the minimum volume were 25 resections per year, the overall mortality rate would be 4·7 per cent in 38 facilities, but still over 5 per cent in 17 centres and more than 10 per cent in five. The combination of a volume requirement (at least 10 resections per year) with a mortality threshold (maximum RSMR 5 or 10 per cent) would allow exclusion of facilities with unacceptable results, yielding a lower overall mortality rate (2·7 per cent in 45 hospitals or 4·2 per cent in 76 respectively).
Conclusion
The best performance model for centralization involved a threshold for volume combined with a mortality threshold.
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Affiliation(s)
- G Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - G Guarneri
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - N Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - S Paiella
- General and Pancreatic Surgery Unit — Pancreas Institute, University of Verona, Verona, Italy
| | - P M V Rancoita
- University Centre for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy
| | - C Bassi
- General and Pancreatic Surgery Unit — Pancreas Institute, University of Verona, Verona, Italy
| | - M Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
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Predictive factors for utilization of a low-volume center in pancreatic surgery: A nationwide study. J Visc Surg 2020; 158:125-132. [PMID: 32595025 DOI: 10.1016/j.jviscsurg.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE It has been demonstrated that mortality following pancreatectomy is correlated with surgical volume. However, up until now, no French study has focused on predictive factors to undergo pancreatectomy in low-volume centers. The objective of this study is to analyze the clinical characteristics, socio-economic status and medical density according to surgical volume and to analyze predictive factors for undergoing pancreatectomy in low-volume centers. PATIENTS AND METHODS All patients who underwent pancreatectomy in France from 2012 to 2015 were identified fromthe PMSI database. Hopsitals were classified as low, intermediate and high volume (<10, 11-19, ≥20 resections/year, respectively). Clinical and socioeconomic data, travel distance and rurality were assesed to identify factors associated with undergoing pancreatectomy at low-volume hospitals. RESULTS In overall, 12,333 patients were included. Those who underwent pancreatectomy in low-volume centers were more likely older, had high Charlson comorbidity index (CCI), had low socioeconomic status, and resided in rural locations.distance traveled by patients operated on in low-volume centers was significantly shorter (23 vs. 61km, P<0.001). In multivariable analysis, older age (P=0.04), CCI≥4 (P=0.008), short travel distance (P<0.001), low socio-economic status (P<0.001) and rurality (P<0.001) were associated withundergoing pancreatectomy in low-volume centers. CONCLUSION Patients continue to undergo pancreatectomy at low-volume hospitals is due not only to clinical parameters, but also to socioeconomic and environmental factors. These factors should be taken into account in process of pancreatic surgery centralization.
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Swan RZ, Niemeyer DJ, Seshadri RM, Thompson KJ, Walters A, Martinie JB, Sindram D, Iannitti DA. The Impact of Regionalization of Pancreaticoduodenectomy for Pancreatic Cancer in North Carolina since 2004. Am Surg 2020. [DOI: 10.1177/000313481408000619] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreaticoduodenectomy (PD) carries a significant risk. High-volume centers (HVCs) provide improved outcomes and regionalization is advocated. Rapid regionalization could, however, have detrimental effects. North Carolina has multiple HVCs, including an additional HVC added in late 2006. We investigated regionalization of PD and its effects before, and after, the establishment of this fourth HVC. The North Carolina Hospital Discharge Database was queried for all PDs performed during 2004 to 2006 and 2007 to 2009. Hospitals were categorized by PD volume as: low (one to nine/year), medium (10 to 19/year), and high (20/year or more). Mortality and major morbidity was assessed by comparing volume groups across time periods. Number of PDs for cancer increased 91 per cent (129 to 246 cases) at HVCs, whereas decreasing at low-volume (62 to 58 cases) and medium-volume (80 to 46 cases) centers. Percentage of PD for cancer performed at HVCs increased significantly (47.6 to 70.3%) while decreasing for low- and medium-volume centers ( P < 0.001). Mortality was significantly less at HVCs (2.8%) compared with low-volume centers (10.3%) for 2007 to 2009. Odds ratio for mortality was significantly lower at HVCs during 2004 to 2006 (0.31) and 2007 to 2009 (0.34). Mortality for PD performed for cancer decreased from 6.6 to 4.6 per cent ( P = 0.31). Major morbidity was not significantly different between groups within either time period; however, there was a significant increase in major morbidity at low-volume centers ( P = 0.018). Regionalization of PD for cancer is occurring in North Carolina. Mortality was significantly lower at HVCs, and rapid regionalization has not detracted from the superior outcomes at HVCs.
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Affiliation(s)
- Ryan Z. Swan
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David J. Niemeyer
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Ramanathan M. Seshadri
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kyle J. Thompson
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Amanda Walters
- Division of GI and Minimally-Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John B. Martinie
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David Sindram
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David A. Iannitti
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Miksch RC, D'Haese JG, Werner J. Surgical Therapy of Chronic Alcoholic Pancreatitis: A Literature Review of Current Options. Visc Med 2020; 36:191-197. [PMID: 32775349 PMCID: PMC7383250 DOI: 10.1159/000508174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/22/2020] [Indexed: 11/19/2022] Open
Abstract
Chronic pancreatitis (CP) is associated with alcohol abuse in 80% of cases. The primary treatment goals in CP are pain reduction and avoidance of pancreatitis-associated complications. CP should be treated in an interdisciplinary approach. A recent randomized clinical trial showed that early surgery compared with an endoscopy-first approach resulted in reduced pain levels. Surgical resections are, therefore, the most efficient treatment of pancreatitis-associated pain as well as other complications and should be performed early in the course of the disease. Since most of the patients pre-sent with chronic inflammation of the pancreatic head, pancreatic head resection is the most common treatment option. Duodenum-preserving pancreatic head resections are the surgical procedure of choice, but pancreaticoduodenectomies (Kausch-Whipple procedures) demonstrate similar outcome with regard to pain control, quality of life, and metabolic parameters. Other surgical procedures, including drainage procedures, pancreatic segmental resections, or left resections, are rarely indicated.
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Affiliation(s)
| | | | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilian University Munich, Munich, Germany
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Shioi I, Yokoyama N, Hirai M, Komatsu M, Kubota A, Aoki M, Sato D, Otani T. Perforation of anastomotic peptic ulcer following pancreaticoduodenectomy: a report of three cases. BMC Surg 2020; 20:79. [PMID: 32306934 PMCID: PMC7168954 DOI: 10.1186/s12893-020-00743-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 04/12/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Perforation of a marginal peptic ulcer after pancreaticoduodenectomy (PD) can lead to severe conditions, although its clinical features have not been well reported. In this article, we present three cases of marginal peptic ulcer perforation after PD that we experienced in our institute and attempt to clarify its appropriate treatment and prevention. CASE PRESENTATION Marginal ulcer perforation confirmed with computed tomography and/or surgical exploration occurred in 3 (1.8%) of 163 consecutive patients who underwent PD (including 160 patients who underwent a total or subtotal stomach-preserving procedure) at our institution. The three patients (one man and two women) had a median age of 77 (65-79) years. Two of these patients had a medical history of duodenal peptic ulcer. All three patients had biliary neoplasms. Two of the patients underwent subtotal stomach-preserving PD with antro-jejunal anastomosis, and the other patient underwent pylorus-preserving PD with duodenal jejunostomy. The perforation occurred with a sudden and severe onset of abdominal pain 34, 94, and 1204 days, respectively, after the PDs. At the time of the perforation, all of the patients had been withdrawn from postoperative prophylactic antipeptic ulcer agents, with the cessation periods ranging from 12 to 1008 days. In addition, all the patients were in fasting conditions for 1 to 13 days just before the perforation. Surgical treatment with direct suturing of the perforated ulcer was performed for two patients, while conservative therapy was performed for one patient. Their primary treatment courses were satisfactory. Chronic antisecretory agent therapy was prescribed for 562, 271, and 2370 days, respectively, from marginal ulcer perforation, and no ulcer recurrence was noted in any of the patients. CONCLUSIONS Lack of antisecretory therapy and fasting were considered an essential cause of marginal peptic ulcer perforation after PD. In addition, unlike the native duodenum, the jejunal limb used for reconstruction to a preserved stomach may be at increased risk of ulceration. Chronic permanent administration of antisecretory agents and fasting avoidance are desirable for patients who have undergone stomach-preserving PD to prevent marginal ulcer perforation.
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Affiliation(s)
- Ikuma Shioi
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chou-ku, Niigata City, 950-1197, Japan.
| | - Naoyuki Yokoyama
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chou-ku, Niigata City, 950-1197, Japan
| | - Motoharu Hirai
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chou-ku, Niigata City, 950-1197, Japan
| | - Masaru Komatsu
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chou-ku, Niigata City, 950-1197, Japan
| | - Akira Kubota
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chou-ku, Niigata City, 950-1197, Japan
| | - Makoto Aoki
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chou-ku, Niigata City, 950-1197, Japan
| | - Daisuke Sato
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chou-ku, Niigata City, 950-1197, Japan
| | - Tetsuya Otani
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chou-ku, Niigata City, 950-1197, Japan
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Park HM, Han SS, Park SJ, Kim SW. Learning curve for pancreatoduodenectomy: can it be generalized? ANZ J Surg 2020; 90:1414-1421. [PMID: 32255265 DOI: 10.1111/ans.15874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/25/2020] [Accepted: 03/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND We hypothesized that a learning curve exists for pancreatoduodenectomy (PD) and that the factors that show a learning curve and the degree of improvement over time differ among surgeons. METHODS We analysed the outcomes of PD in 300 patients operated by two surgeons between 2001 and 2014; these comprised the first 150 patients operated by each surgeon. Patients operated by each surgeon were classified into three groups according to the chronological sequence of operation (50 patients per group). RESULTS For surgeon A, the median operation time (496 versus 454 versus 418 min, P < 0.001) and the mean amount of red blood cell transfusion (3.76 versus 2.76 versus 1.26 packs, P < 0.001) showed a slight but progressive decrease from the first 50 cases to the second and the third 50 cases. For surgeon B, only the operation time, which decreased and ultimately plateaued at approximately case 100, was significantly different among the groups. There was no improvement in post-operative complications, re-operation rates, mortality, length of stay and re-admission rates over time for both surgeons. CONCLUSION We demonstrated that a learning curve for PD exists with respect to various factors. However, the factors for which learning curves were exhibited and the degree of improvement over time were different between the two surgeons.
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Affiliation(s)
- Hyeong Min Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang-si, South Korea
| | - Sung-Sik Han
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang-si, South Korea
| | - Sang-Jae Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang-si, South Korea
| | - Sun-Whe Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang-si, South Korea
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Li T, D'Cruz RT, Lim SY, Shelat VG. Somatostatin analogues and the risk of post-operative pancreatic fistulas after pancreatic resection - A systematic review & meta-analysis. Pancreatology 2020; 20:158-168. [PMID: 31980352 DOI: 10.1016/j.pan.2019.12.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is a common complication of pancreatic resection. Somatostatin analogues (SA) have been used as prophylaxis to reduce its incidence. The aim of this study is to appraise the current literature on the effects of SA prophylaxis on the prevention of POPF following pancreatic resection. METHODS The review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data from studies that reported the effects of SA prophylaxis on POPF following pancreatic resection were extracted, to determine the effect of SA on POPF morbidity and mortality. RESULTS A total of 15 studies, involving 2221 patients, were included. Meta-analysis revealed significant reductions in overall POPF (Odds ratio: 0.65 (95% CI 0.53-0.81, p < 0.01)), clinically significant POPF (Odds ratio: 0.53 (95% CI 0.34-0.83, p < 0.01)) and overall morbidity (OR: 0.69 (95% CI: 0.50-0.95, p = 0.02)) following SA prophylaxis. There is no evidence that SA prophylaxis reduces mortality (OR: 1.10 (95%CI: 0.68-1.79, p = 0.68)). CONCLUSION SA prophylaxis following pancreatic resection reduces the incidence of POPF. However, mortality is unaffected.
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Affiliation(s)
- Tianpei Li
- Yong Loo Lin School of Medicine, National University, Singapore.
| | - Reuban Toby D'Cruz
- Department of General Surgery, National University Health System, Singapore
| | - Sheng Yang Lim
- Yong Loo Lin School of Medicine, National University, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Globke B, Timmermann L, Klein F, Fehrenbach U, Pratschke J, Bahra M, Malinka T. Postoperative acute necrotizing pancreatitis of the pancreatic remnant (POANP): a new definition of severe pancreatitis following pancreaticoduodenectomy. HPB (Oxford) 2020; 22:445-451. [PMID: 31431414 DOI: 10.1016/j.hpb.2019.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/21/2019] [Accepted: 07/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent studies have suggested acute pancreatitis as a separate pancreatic-specific complication following pancreaticoduodenectomy. However, data on necrotizing pancreatitis of the pancreatic remnant is limited. This study aimed to evaluate parameters of patients undergoing completion pancreatectomy (CP) after initial pancreaticoduodenectomy (PD) and compare those with or without necrosis of the pancreatic remanent. METHODS Patients who underwent CP following PD between January 2005 and December 2017 were identified from a prospectively collected database. Perioperative parameters were recorded, and patients were divided into those with or without histological evidence of necrosis of the pancreatic remnant. RESULTS Postoperative acute necrotizing pancreatitis (POANP) was histologically detected in 33 (41%) of 79 patients after CP. Serum CRP levels on POD 2 and the day of revision were significantly higher in the POANP group (p < 0.001 for each). POANP was reflected by higher APACHE II and SOFA scores after PD (P < 0.001 for each). Although patients with POANP had an earlier revision, length of ICU and total hospital stay was prolonged (p < 0.001 for each). POANP was associated with more major complications (Clavien-Dindo ≥ 3) and more often necessitated reoperations within 30 days (p < 0.001 for each). CONCLUSION Patients requiring CP following PD for POANP have an increased risk of major complications, and longer hospital stay. CRP levels, APACHE II and SOFA score, seem to correlate with the severity and might predict POANP. Universally accepted definitions with a clinically validated grading system of severity for POAP and POANP are needed to facilitate appropriate treatment strategies and enable comparison of future studies.
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Affiliation(s)
- Brigitta Globke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - Lea Timmermann
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - Fritz Klein
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - Uli Fehrenbach
- Department of Radiology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - Marcus Bahra
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - Thomas Malinka
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany.
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Hashimoto D, Mizuma M, Kumamaru H, Miyata H, Chikamoto A, Igarashi H, Itoi T, Egawa S, Kodama Y, Satoi S, Hamada S, Mizumoto K, Yamaue H, Yamamoto M, Kakeji Y, Seto Y, Baba H, Unno M, Shimosegawa T, Okazaki K. Risk model for severe postoperative complications after total pancreatectomy based on a nationwide clinical database. Br J Surg 2020; 107:734-742. [PMID: 32003458 DOI: 10.1002/bjs.11437] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/18/2019] [Accepted: 10/28/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Total pancreatectomy is required to completely clear tumours that are locally advanced or located in the centre of the pancreas. However, reports describing clinical outcomes after total pancreatectomy are rare. The aim of this retrospective observational study was to assess clinical outcomes following total pancreatectomy using a nationwide registry and to create a risk model for severe postoperative complications. METHODS Patients who underwent total pancreatectomy from 2013 to 2017, and who were recorded in the Japan Society of Gastroenterological Surgery and Japanese Society of Hepato-Biliary-Pancreatic Surgery database, were included. Severe complications at 30 days were defined as those with a Clavien-Dindo grade III needing reoperation, or grade IV-V. Occurrence of severe complications was modelled using data from patients treated from 2013 to 2016, and the accuracy of the model tested among patients from 2017 using c-statistics and a calibration plot. RESULTS A total of 2167 patients undergoing total pancreatectomy were included. Postoperative 30-day and in-hospital mortality rates were 1·0 per cent (22 of 2167 patients) and 2·7 per cent (58 of 167) respectively, and severe complications developed in 6·0 per cent (131 of 2167). Factors showing a strong positive association with outcome in this risk model were the ASA performance status grade and combined arterial resection. In the test cohort, the c-statistic of the model was 0·70 (95 per cent c.i. 0·59 to 0·81). CONCLUSION The risk model may be used to predict severe complications after total pancreatectomy.
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Affiliation(s)
- D Hashimoto
- Department of Gastroenterological Surgery, Kumamoto University, Kumamoto, Japan.,Department of Gastroenterological Surgery, Omuta Tenryo Hospital, Fukuoka, Japan
| | - M Mizuma
- Department of Surgery, Tohoku University, Miyagi, Japan
| | - H Kumamaru
- Department of Healthcare Quality Assessment, University of Tokyo, Tokyo, Japan
| | - H Miyata
- Department of Healthcare Quality Assessment, University of Tokyo, Tokyo, Japan.,Department of Health Policy and Management, Keio University, Tokyo, Japan
| | - A Chikamoto
- Department of Gastroenterological Surgery, Kumamoto University, Kumamoto, Japan
| | - H Igarashi
- Department of Medicine and Bioregulatory Science, Kyushu University, Fukuoka, Japan
| | - T Itoi
- Department of Gastroenterology, Tokyo Medical University, Tokyo, Japan
| | - S Egawa
- Division of International Cooperation for Disaster Medicine, Tohoku University, Miyagi, Japan
| | - Y Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| | - S Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - S Hamada
- Division of Gastroenterology, Tohoku University, Miyagi, Japan
| | - K Mizumoto
- Cancer Centre, Kyushu University Hospital, Fukuoka, Japan
| | - H Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - M Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Y Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University, Kobe, Japan
| | - Y Seto
- Department of Gastrointestinal Surgery, University of Tokyo, Tokyo, Japan
| | - H Baba
- Department of Gastroenterological Surgery, Kumamoto University, Kumamoto, Japan
| | - M Unno
- Department of Surgery, Tohoku University, Miyagi, Japan
| | - T Shimosegawa
- Department of Gastroenterology, South Miyagi Medical Centre, Miyagi, Japan
| | - K Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
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42
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Ahola R, Sand J, Laukkarinen J. Centralization of Pancreatic Surgery Improves Results: Review. Scand J Surg 2020; 109:4-10. [DOI: 10.1177/1457496919900411] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background and Aims: The effect of operation volume on the outcomes of pancreatic surgery has been a subject of research since the 1990s. In several countries around the world, this has led to the centralization of pancreatic surgery. However, controversy persists as to the benefits of centralization and what the optimal operation volume for pancreatic surgery actually is. This review summarizes the data on the effect of centralization on mortality, complications, hospital facilities used, and costs regarding pancreatic surgery. Materials and Methods: A systematic librarian-assisted search was performed in PubMed covering the years from August 1999 to August 2019. All studies comparing results of open pancreatic resections from high- and low-volume centers were included. In total 44, published articles were analyzed. Results: Studies used a variety of different criteria for high-volume and low-volume centers, which hampers the evaluating of the effect of operation volume. However, mortality in high-volume centers is consistently reported to be lower than in low-volume centers. In addition, failure to rescue critically ill patients is more common in low-volume centers. Cost-effectiveness has also been evaluated in the literature. Length of hospital stay in particular has been reported to be shorter in high-volume centers than in low-volume centers. Conclusion: The effect of centralization on the outcomes of pancreatic surgery has been under active research and the beneficial effect of it is associated especially with better short-term prognosis after surgery.
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Affiliation(s)
- R. Ahola
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - J. Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Tampere University Hospital, Tampere, Finland
| | - J. Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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43
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Pecorelli N, Pagnanelli M, Cinelli L, Di Salvo F, Partelli S, Crippa S, Tamburrino D, Castoldi R, Belfiori G, Reni M, Falconi M, Balzano G. Postoperative Outcomes and Functional Recovery After Preoperative Combination Chemotherapy for Pancreatic Cancer: A Propensity Score-Matched Study. Front Oncol 2019; 9:1299. [PMID: 31850203 PMCID: PMC6901953 DOI: 10.3389/fonc.2019.01299] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/11/2019] [Indexed: 12/12/2022] Open
Abstract
Introduction: Previous studies show encouraging oncologic outcomes for neoadjuvant chemotherapy (NACT) in the setting of pancreatic ductal adenocarcinoma (PDAC). However, recent literature reported an increased clinical burden in patients undergoing pancreaticoduodenectomy (PD) following NACT. Therefore, the aim of our study was to assess the impact of NACT on postoperative outcomes and recovery after PD. Methods: A retrospective propensity score-matched study was performed including all patients who underwent PD for PDAC in a single center between 2015 and 2018. Patients treated with NACT for resectable, borderline resectable or locally advanced PDAC were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients who underwent upfront resection. Propensity scores were calculated using 7 perioperative variables, including gender, age, BMI, ASA score, Charlson-Deyo comorbidity score, fistula risk score (FRS), vascular resection. Primary outcome was the number and severity of complications at 90-days after surgery measured by the comprehensive complication index (CCI). Data are reported as median (IQR) or number of patients (%). Results: Of 283 resected patients, 95 (34%) were treated with NACT. Before matching, NACT patients were younger, had less comorbidities (Charlson-Deyo score 0 vs. 1, p = 0.04), similar FRS [2 (0–3) for both groups], and more vascular resections performed [n = 28 (30%) vs. n = 26 (14%), p < 0.01]. After propensity-score matching, preoperative and intraoperative characteristics were comparable. Postoperatively, CCI was similar between groups [8.7 (0–29.6) for both groups, p = 0.59]. NACT patients had a non-statistically significant increase in superficial incisional surgical site infections [n = 12 (13%) vs. 6 (6%), p = 0.14], while no difference was found for overall infectious complications and organ-space SSI. The occurrence of clinically-relevant pancreatic fistula was similar between groups [10 (11%) vs. 13 (14%), p = 0.51]. No difference was found between groups for length of hospital stay [8 (7–15) vs. 8 (7–14) days, p = 0.62], and functional recovery outcomes. Conclusion: After propensity score adjustment for perioperative risk factors, NACT did not worsen postoperative outcomes and functional recovery following PD for PDAC compared to upfront resection.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Francesca Di Salvo
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Renato Castoldi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Michele Reni
- Department of Medical Oncology, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
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44
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"Trivial" Cysts Redefine the Risk of Cancer in Presumed Branch-Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Potential Target for Follow-Up Discontinuation? Am J Gastroenterol 2019; 114:1678-1684. [PMID: 31449158 DOI: 10.14309/ajg.0000000000000378] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The management of small and incidental branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) still is of concern. The aim is assessing the safety of a surveillance protocol through the evaluation of their progression to malignancy. METHODS All presumed BD-IPMNs observed from 2000 to 2016 were included. Only patients presenting without worrisome features (WFs) and high-risk stigmata (HRS) at diagnosis were included. Development of WF, HRS, pancreatic cancer (PC), and survival were analyzed. BD-IPMNs were defined as trivial in the continuing absence of WF/HRS after 5 years of surveillance. The age-specific standardized incidence ratio of PC in the general population was used for comparison. RESULTS A total of 1,036 BD-IPMNs without WF/HRS at diagnosis were included, 4.2% developed WF or HRS, and 1.1% developed PC after a median of 62 months. The median cyst growth rate was 0 mm/yr. A growth rate ≥2.5 mm/yr and the development of WF resulted independent predictors of PC. The standardized incidence ratio of PC for trivial BD-IPMN (n = 378) was 22.45 (95% confidence interval 8.19-48.86), but considering only patients aged >65 years (n = 198), it decreased to 3.84 (95% confidence interval 0.77-11.20). DISCUSSION Surveillance of the vast majority of presumed BD-IPMNs is safe, as the risk of PC is comparable to postoperative mortality of pancreatic surgery. A growth rate ≥2.5 mm/yr is the main predictor of PC, reinforcing the role of repeated observations. A trivial BD-IPMN in patients aged >65 years might not increase the risk of developing PC compared with general population, identifying potential targets for follow-up discontinuation.
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45
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Polonski A, Izbicki JR, Uzunoglu FG. Centralization of Pancreatic Surgery in Europe. J Gastrointest Surg 2019; 23:2081-2092. [PMID: 31037503 DOI: 10.1007/s11605-019-04215-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of this article is a review and an analysis of the current state of centralization of pancreatic surgery in Europe. Numerous recent publications demonstrate higher postoperative in-hospital mortality rates in low-volume clinics after pancreatic resection than previously assumed due to their not publishing significantly worse outcomes when compared to high-volume centres. Although the benefits of centralization of pancreatic surgery in high-volume centres have been demonstrated in many studies, numerous countries have so far failed to establish centralization in their respective health care systems. METHODS A systematic literature search of the Medline database for studies concerning centralization of pancreatic surgery in Europe was conducted. The studies were reviewed independently for previously defined inclusion and exclusion criteria. We included 14 studies with a total of 117,634 patients. All data were extracted from or provided by health insurance company or governmental registry databases. RESULTS Thirteen out of the 14 studies demonstrate an improvement in their respective outcome related to volume. Twelve studies showed a significantly lower postoperative mortality rate in the highest annual volume group in comparison to overall postoperative mortality rate in the whole patient cohort. CONCLUSION As the available data indicate, most European countries have so far failed to establish centralization of pancreatic surgery to high-volume centres due to numerous reasons. Considering a plateau in survival rates of patients undergoing treatment for pancreatic cancer in Europe during the last 15 years, this review enforces the worldwide plea for centralization to lower post-operative mortality after pancreatic surgery.
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Affiliation(s)
- Adam Polonski
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany. .,Department of General Visceral and Thoracic Surgery, University of Hamburg Medical Institutions, Martinistr 52, 20252, Hamburg, Germany.
| | - Faik G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
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46
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Faraj W, Mukherji D, Zaghal AM, Nassar H, Mokadem FH, Jabbour S, Ayoub C, Rizk MS, Kanso M, Jaafar RF, Heaton N, Khalife M. Perioperative Management of Pancreaticoduodenectomy: Avoiding Admission to the Intensive Care Unit. Gastrointest Tumors 2019; 6:108-115. [PMID: 31768354 DOI: 10.1159/000502887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/23/2019] [Indexed: 01/23/2023] Open
Abstract
Introduction With the advancement in surgical expertise at high-volume centers and advances in perioperative management, pancreaticoduodenectomy is becoming safer and remains the gold standard for treating periampullary pathologies. We describe our experience in optimizing perioperative management in order to avoid admission to the intensive care unit and improve outcomes. Method Retrospective data were collected on 370 surgical patients who underwent a pancreaticoduodenectomy between the years 1994 and 2016. Results Of the 370 patients, 200 operated between 2009 and 2016 did not require intensive care admission, blood transfusion, or central line insertion. The results were compared between different time intervals: before the year 1998, between the years 1998 and 2008, and between the years 2009 and 2016. The median blood loss dropped from 800 to 400 to 300 mL, respectively. The median operative time also dropped from 360 to 335 to 215 min, respectively. In addition, the median length of hospital stay decreased from 25 to 16 to 7 days, respectively. Conclusion With the centralization of pancreaticoduodenectomy in high-volume centers and with specialized surgeons performing the surgery, there is a significant decrease in the onset of postoperative complications with a lesser need for blood transfusions and, subsequently, better recovery of patients without the need for intensive care unit admission.
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Affiliation(s)
- Walid Faraj
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Deborah Mukherji
- Department of Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ahmad M Zaghal
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hussein Nassar
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Farah H Mokadem
- Department of Anesthesia, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samar Jabbour
- Department of Anesthesia, American University of Beirut Medical Center, Beirut, Lebanon
| | - Chakib Ayoub
- Department of Anesthesia, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marwan S Rizk
- Department of Anesthesia, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mariam Kanso
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rola F Jaafar
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nigel Heaton
- Institute of Liver Studies, Kings College Hospital, London, United Kingdom
| | - Mohamad Khalife
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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Floortje van Oosten A, Smits FJ, van den Heuvel DAF, van Santvoort HC, Molenaar IQ. Diagnosis and management of postpancreatectomy hemorrhage: a systematic review and meta-analysis. HPB (Oxford) 2019; 21:953-961. [PMID: 30962134 DOI: 10.1016/j.hpb.2019.02.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/08/2019] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postpancreatectomy hemorrhage is a potentially lethal complication after pancreatic resection. The objective of this systematic review is to provide insight in the current status of incidence, detection, management and clinical outcomes of late postpancreatectomy hemorrhage. METHODS A systematic search was conducted on the literature from February 2007 to July 2018 in PubMed, Embase and the Cochrane library. Included were clinical studies with clinical outcomes on late postpancreatectomy hemorrhage defined according to the International Study Group of Pancreatic Surgery definition (i.e. occurring >24 h after pancreatic resection). RESULTS A total of 14 studies on 467 patients with late postpancreatectomy hemorrhage were included. The incidence of late postpancreatectomy hemorrhage ranged from 3% to 16% (weighted mean: 5%). Seventy-four patients received conservative treatment; 252 patients underwent primary endovascular intervention; 82 patients underwent primary relaparotomy; 56 patients underwent primary endoscopic intervention; and three patients died before any intervention could be performed. CT-scan and diagnostic angiography were able to identify the source of hemorrhage in 67% (66/98) and 69% (114/166) of patients, respectively. The most frequent origin of the hemorrhage was the gastroduodenal artery stump (79/275; 29%), followed by the common hepatic artery (51/275; 19%) and splenic artery (32/275; 12%). Overall mortality was 21% (98/464 patients; range 0%-38%). Mortality was lower after primary interventional angiography as compared to primary relaparotomy (16% vs 37% respectively). CONCLUSIONS This systematic review provides a comprehensive overview of the current literature for severe late postpancreatectomy hemorrhages. CT-scan and diagnostic angiography are equally sensitive in detecting the bleeding source. Interventional angiography appears to be associated to lower mortality as compared to relaparotomy and endoscopy as first intervention for postpancreatectomy hemorrhage.
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Affiliation(s)
- A Floortje van Oosten
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands.
| | - F Jasmijn Smits
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Daniël A F van den Heuvel
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands.
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48
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Davis SS, Babidge WJ, Kiermeier A, Maddern GJ. Regional versus metropolitan pancreaticoduodenectomy mortality in Australia. ANZ J Surg 2019; 89:1582-1586. [DOI: 10.1111/ans.15336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/23/2019] [Accepted: 05/26/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Sean S. Davis
- Discipline of Surgery, The Queen Elizabeth HospitalThe University of Adelaide Adelaide South Australia Australia
| | - Wendy J. Babidge
- Discipline of Surgery, The Queen Elizabeth HospitalThe University of Adelaide Adelaide South Australia Australia
- Australian and New Zealand Audit of Surgical MortalityRoyal Australasian College of Surgeons Adelaide South Australia Australia
| | - Andreas Kiermeier
- Statistical Process Improvement Consulting and Training Pty Ltd Adelaide South Australia Australia
| | - Guy J. Maddern
- Discipline of Surgery, The Queen Elizabeth HospitalThe University of Adelaide Adelaide South Australia Australia
- Australian and New Zealand Audit of Surgical MortalityRoyal Australasian College of Surgeons Adelaide South Australia Australia
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49
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Residual pancreatic function after pancreaticoduodenectomy is better preserved with pancreaticojejunostomy than pancreaticogastrostomy: A long-term analysis. Pancreatology 2019; 19:595-601. [PMID: 31005377 DOI: 10.1016/j.pan.2019.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/10/2019] [Accepted: 04/14/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatico-enteric anastomosis after pancreaticoduodenectomy can be performed using either a pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG). Differences in surgical outcomes are still a matter of debate, and less is known about long-term functional outcomes. METHODS Twelve years after the conclusion of a comparative study evaluating the surgical outcomes of PJ and PG (Bassi et al., Ann Surg 2005), available patients underwent morphological and functional pancreatic assessment: pancreatic volume and duct diameter measured by MRI, impaired secretion after secretin, fecal fat, fecal elastase-1 (FE-1), serum vitamin D and endocrine function. Quality of life and symptom scores were evaluated with the EORTC QLQ-C30 questionnaire. RESULTS Only 34 patients were available for assessment. No differences were found in terms of BMI variation, endocrine function, quality of life or symptoms. Exocrine function was more severely impaired after PG than after PJ (fecal fats 26.6 ± 4.1 vs 18.2 ± 3.6 g/day; FE-1 121.4 ± 6.7 vs 170.2 ± 25.5 μg/g, vitamin D 18.1 ± 1.8 vs. 23.2 ± 3.1 ng/mL). MRI assessment identified a lower pancreatic volume (26 ± 3.1 vs. 36 ± 4.1 cm3) and a more dilated pancreatic duct (4.6 ± 0.92 vs. 2.4 ± 0.18 mm) in patients with PG compared to those with PJ. CONCLUSION Compared to PJ, PG is associated with a more severely impaired exocrine function long-term, but they result similar endocrine function and quality of life. In patients with a long life expectancy, this should be taken into account.
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50
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The Number of Metastatic Lymph Nodes is a Useful Predictive Factor for Recurrence after Surgery for Nonmetastatic Nonfunctional Neuroendocrine Neoplasm of the Pancreas. Gastroenterol Res Pract 2019; 2019:6856329. [PMID: 31182959 PMCID: PMC6512048 DOI: 10.1155/2019/6856329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/28/2019] [Accepted: 03/19/2019] [Indexed: 12/15/2022] Open
Abstract
Nodal involvement (actually categorized as positive or negative) is an important prognostic factor after surgery for pancreatic neuroendocrine neoplasms (pNENs). We aim to evaluate the predictive role of the number of nodal metastases after pancreatic resection for pNENs. We analyzed from a prospectively maintained database all pancreatic resections for nonmetastatic nonfunctioning pNENs performed in our institution from 2011 to 2016. According to the number of nodal metastases, enhancing the actual categorization, we distinguished the following: N0, no nodal metastases; N1, 1-3 metastatic lymph nodes; and N2, metastases in 4 or more regional lymph nodes. Recurrence and disease-free survival (DFS) were evaluated. The predictive value in terms of recurrence for each clinicopathological data, including the number of metastatic lymph nodes, was calculated. Univariate and multivariate analyses were conducted. 77 patients underwent pancreatic surgery for pNENs. N0, N1, and N2 resections were found in 52 (67.5%), 16 (20.8%), and 9 (11.7%) cases, respectively. Mean follow-up of the entire cohort was 48 (±25) months. The recurrence rate was 11.8%, and the mean time of recurrence was 12 (±14) months. DFS was 83.7 months (76.0 - 91.5). At a univariate analysis, factors associated with recurrence were mitotic count (OR 1.19, p = 0.001), Ki67 value (OR 1.06, p = 0.001), the presence of nodal metastases (OR 11.54, p = 0.002), and metastases in 4 or more regional lymph nodes (N2) (OR 30.19, p = 0.002). At a multivariate analysis, only mitotic count (OR 1.51, p = 0.005) and N2 resection (OR 134.74, p = 0.002) were found to be predictive factors of recurrence. The number of metastatic lymph nodes and mitotic count is the most significant predictive factors of recurrence after pancreatic surgery for nonmetastatic nonfunctioning pNENs.
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