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Balaban DV, Coman LI, Balaban M, Costache RS, Jinga M. Novel Insights into Postoperative Surveillance in Resected Pancreatic Cystic Neoplasms-A Review. Diagnostics (Basel) 2024; 14:1056. [PMID: 38786354 PMCID: PMC11119521 DOI: 10.3390/diagnostics14101056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/11/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Pancreatic cystic lesions (PCL) are frequently encountered in clinical practice and some are referred to surgery due to their neoplastic risk or malignant transformation. The management of PCL involves complex decision-making, with postoperative surveillance being a key component for long-term outcomes, due to the potential for recurrence and postoperative morbidity. Unfortunately, the follow-up of resected patients is far from being optimal and there is a lack of consensus on recommendations with regard to timing and methods of surveillance. Here, we summarize the current knowledge on the postoperative surveillance of neoplastic pancreatic cysts, focusing on the mechanisms and risk factors for recurrence, the recurrence rates according to the initial indication for surgery, the final result of the surgical specimen and neoplastic risk in the remaining pancreas, as well as the postsurgical morbidity comprising pancreatic exocrine insufficiency, metabolic dysfunction and diabetes after resection, according to the type of surgery performed. We analyze postsurgical recurrence rates and morbidity profiles, as influenced by different surgical techniques, to better delineate at-risk patients, and highlight the need for tailored surveillance strategies adapted to preoperative and operative factors with an impact on outcomes.
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Affiliation(s)
- Daniel Vasile Balaban
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Laura-Ioana Coman
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Marina Balaban
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Raluca Simona Costache
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Mariana Jinga
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
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Zhang C, Zironda A, Vierkant RA, Starlinger P, Warner S, Smoot R, Kendrick M, Cleary S, Truty M, Thiels C. Quality of Life and Gastrointestinal Symptoms in Long-term Survivors of Pancreatic Cancer Following Pancreatoduodenectomy. Ann Surg 2024; 279:842-849. [PMID: 37497660 DOI: 10.1097/sla.0000000000006053] [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: 07/28/2023]
Abstract
OBJECTIVE To describe long-term quality of life (QOL) and gastrointestinal (GI) symptoms in patients who underwent pancreatoduodenectomy for pancreatic cancer in the modern era. BACKGROUND As advances in pancreatic cancer management improve outcomes, it is essential to assess long-term patient-reported outcomes after surgery. METHODS Patients who underwent curative intent pancreatoduodenectomy for pancreatic cancer between January 2011 and June 2019 from a single center were identified. Patients alive ≥3 years after surgery were considered long-term survivors (LTS). LTS who were alive in June 2022 received a 55-question survey to assess their QOL (EORTC-QLQ-C30) and GI symptoms (EORTC-PAN26 and Problem Areas in Diabetes Questionnaire). Responses were compared against population norms. Clinicodemographic characteristics in LTS versus non-LTS and survey completion were compared. RESULTS Six hundred seventy-two patients underwent pancreatoduodenectomy for pancreatic cancer; 340 were LTS. One hundred thirty-seven patients of the 238 eligible to complete the survey responded (response rate: 58%). Compared to the US general population, LTS reported significantly higher QOL (75 vs 64; P <0.001), less nausea/vomiting, pain, dyspnea, insomnia, appetite loss, and constipation, but more diarrhea (all P <0.001). Most patients (n=136/137, 99%) reported experiencing postoperative GI symptoms related to pancreatic insufficiency (n=71/135, 53%), reflux (n=61/135, 45%), and delayed gastric emptying (n=31/136, 23%). Most patients (n=113/136, 83%) reported that digestive symptoms overall had little to no impact on QOL, and 91% (n=124/136) would undergo surgery again. CONCLUSIONS Despite known long-term complications following pancreatoduodenectomy, cancer survivors appear to have excellent QOL. Specific long-term gastrointestinal symptoms data should be utilized for preoperative education and follow-up planning.
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Affiliation(s)
- Chi Zhang
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester, MN
| | - Andrea Zironda
- Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, MN
| | - Robert A Vierkant
- Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, MN
| | | | - Susanne Warner
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Rory Smoot
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | | | - Sean Cleary
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Mark Truty
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
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Mulliri A, Joubert M, Piquet MA, Alves A, Dupont B. Functional sequelae after pancreatic resection for cancer. J Visc Surg 2023; 160:427-443. [PMID: 37783613 DOI: 10.1016/j.jviscsurg.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
The morbidity and mortality of pancreatic cancer surgery has seen substantial improvement due to the standardization of surgical techniques, the optimization of perioperative multidisciplinary management and the organization of specialized care systems. The identification and treatment of postoperative functional and nutritional sequelae have thereby become major issues in patients who undergo pancreatic surgery. This review addresses the functional sequelae of pancreatic resection for cancerous and pre-cancerous lesions (excluding chronic pancreatitis). Its aim is to specify the prevalence and severity of sequelae according to the type of pancreatic resection and to document, where appropriate, the therapeutic management. Exocrine pancreatic insufficiency (ExPI) is observed in nearly one out of three patients at one year after surgery, and endocrine pancreatic insufficiency (EnPI) is present in one out of five patients after pancreatoduodenectomy (PD) and one out of three patients after distal pancreatectomy (DP). In addition, digestive functional disorders may appear, such as delayed gastric emptying (DGE), which affects 10 to 45% of patients after PD and nearly 8% after DP. Beyond these functional sequelae, pancreatic surgery can also induce nutritional and vitamin deficiencies secondary to a lack of uptake for certain vitamins or to the loss of absorption site in the duodenum. In addition to the treatment of ExPI with oral pancreatic enzymes, nutritional management is based on a high-calorie, high-protein diet with normal lipid intake in frequent small feedings, combined with vitamin supplementation adapted to monitored deficiencies. Better knowledge of the functional consequences of pancreatic cancer surgery can improve the overall management of patients.
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Affiliation(s)
- Andrea Mulliri
- Digestive Surgery Department, University Hospital Center of Caen, Normandie Université, UNICAEN, 14000 Caen, France; Anticipe' U1086 Inserm-UCBN, 'Cancers & Preventions', Registre spécialisé des Tumeurs Digestives du Calvados, Team Labelled 'League Against Cancer', UNICAEN, Normandie Université, 14000 Caen, France
| | - Michael Joubert
- Diabetology-Endocrinology Department, University Hospital Center of Caen Normandie, Normandie Université, UNICAEN, 14000 Caen, France
| | - Marie-Astrid Piquet
- Department of Hepato-Gastroenterology and Nutrition, University Hospital Center of Caen Normandie, Normandie Université, UNICAEN, 14000 Caen, France
| | - Arnaud Alves
- Digestive Surgery Department, University Hospital Center of Caen, Normandie Université, UNICAEN, 14000 Caen, France; Anticipe' U1086 Inserm-UCBN, 'Cancers & Preventions', Registre spécialisé des Tumeurs Digestives du Calvados, Team Labelled 'League Against Cancer', UNICAEN, Normandie Université, 14000 Caen, France
| | - Benoît Dupont
- Anticipe' U1086 Inserm-UCBN, 'Cancers & Preventions', Registre spécialisé des Tumeurs Digestives du Calvados, Team Labelled 'League Against Cancer', UNICAEN, Normandie Université, 14000 Caen, France; Department of Hepato-Gastroenterology and Nutrition, University Hospital Center of Caen Normandie, Normandie Université, UNICAEN, 14000 Caen, France.
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Garay MB, Carbajal-Maldonado ÁL, Rodriguez-Ortiz-DE-Rozas R, Guilabert L, DE-Madaria E. Post-surgical exocrine pancreatic insufficiency. Minerva Surg 2023; 78:671-683. [PMID: 38059441 DOI: 10.23736/s2724-5691.23.10125-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Being an underdiagnosed and under or insufficiently treated condition, surgical pancreatic exocrine insufficiency (PSP) is the condition in which pancreatic enzymes are insufficient for digestion because of gastrointestinal (GI) surgery involving the upper GI tract, biliary ducts, or the pancreas, and and leading to potential malnutrition and deterioration in quality of life. Age, obesity, history of tobacco use, family history of diabetes, surgery due to a malignant tumor, presence of steatorrhea, jaundice, weight loss, and intraoperative findings of hard pancreatic texture have been associated with a higher risk of PSP. Pancreatoduodectomy (PD) has demonstrated an increased risk of developing PSP, with a prevalence between 19-100%. Distal pancreatectomy (DP) and central pancreatectomy (CenP) are associated with less risk of PSP, with a prevalence of 0-82% and 3.66-8.7%, respectively. In patients with chronic pancreatitis (CP), PSP was associated with 80% in Partington-Rochelle procedure, 86% in Frey procedure, 80% in duodenum preserving pancreatic head procedure, >60% in PD and 27.5-63% in DP. Fecal elastase-1 (FE-1) is a generally accepted tool for diagnosis. Treatment is recommended to start as soon as a diagnosis is achieved, or clinical suspicion is high. Pancreatic enzyme replacement therapy improves symptoms of malabsorption, facilitates weight gain, and ultimately improves patients' quality of life. Starting dosage is between 10,000-50,000 units in snacks and 50,000-75,000 units in main meals, administered throughout food intake, though further data specifically on PSP are needed. Follow-up in PSP is recommended on an on-demand basis, where malnutrition should be assessed.
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Affiliation(s)
- Maria B Garay
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Ángela L Carbajal-Maldonado
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Rosario Rodriguez-Ortiz-DE-Rozas
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Lucia Guilabert
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Enrique DE-Madaria
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain -
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Cheung TT, Lee YT, Tang RSY, She WH, Cheng KC, Cheung CC, Chiu KWH, Chok KSH, Chow WS, Lai TW, Seto WK, Yau T. The Hong Kong consensus recommendations on the diagnosis and management of pancreatic cystic lesions. Hepatobiliary Surg Nutr 2023; 12:715-735. [PMID: 37886207 PMCID: PMC10598309 DOI: 10.21037/hbsn-22-471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/10/2023] [Indexed: 10/28/2023]
Abstract
Background The finding of pancreatic cystic lesions (PCL) on incidental imaging is becoming increasingly common. International studies report a prevalence of 2.2-44.7% depending on the population, imaging modality and indication for imaging, and the prevalence increases with age. Patients with PCL are at risk of developing pancreatic cancer, a disease with a poor prognosis. This publication summarizes recommendations for the diagnosis and management of PCL and post-operative pancreatic exocrine insufficiency (PEI) from a group of local specialists. Methods Clinical evidence was consolidated from narrative reviews and consensus statements formulated during two online meetings in March 2022. The expert panel included gastroenterologists, hepatobiliary surgeons, oncologists, radiologists, and endocrinologists. Results Patients with PCL require careful investigation and follow-up due to the risk of malignant transformation of these lesions. They should undergo clinical investigation and pancreas-specific imaging to classify lesions and understand the risk profile of the patient. Where indicated, patients should undergo pancreatectomy to excise PCL. Following pancreatectomy, patients are at risk of PEI, leading to gastrointestinal dysfunction and malnutrition. Therefore, such patients should be monitored for symptoms of PEI, and promptly treated with pancreatic enzyme replacement therapy (PERT). Patients with poor response to PERT may require increases in dose, addition of a proton pump inhibitor, and/or further investigation, including tests for pancreatic function. Patients are also at risk of new-onset diabetes mellitus after pancreatectomy; they should be screened and treated with insulin if indicated. Conclusions These statements are an accurate summary of our approach to the diagnosis and management of patients with PCL and will be of assistance to clinicians treating these patients in a similar clinical landscape.
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Affiliation(s)
- Tan-To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Yuk Tong Lee
- Gastroenterologist in private practice, Hong Kong, China
| | - Raymond Shing-Yan Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Wong Hoi She
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kai Chi Cheng
- Department of Surgery, Kwong Wah Hospital, Hong Kong, China
| | | | - Keith Wan Hang Chiu
- Department of Radiology & Imaging, Queen Elizabeth Hospital, Hong Kong, China
| | - Kenneth Siu Ho Chok
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Wing Sun Chow
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Tak Wing Lai
- Department of Surgery, Princess Margaret Hospital, Hong Kong, China
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Thomas Yau
- Department of Medicine, The University of Hong Kong, Hong Kong, China
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Maehira H, Iida H, Mori H, Nitta N, Maekawa T, Takebayashi K, Kojima M, Kaida S, Miyake T, Tani M. Clinical impact of postoperative malnutrition after pancreaticoduodenectomy: prediction based on estimated functional remnant pancreatic volume, prognostic nutritional index, and body mass index. HPB (Oxford) 2023; 25:1102-1109. [PMID: 37202228 DOI: 10.1016/j.hpb.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/19/2023] [Accepted: 04/30/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The present study aimed to evaluate the association between estimated functional remnant pancreatic volume (eFRPV) and postoperative malnutrition after pancreaticoduodenectomy (PD). METHODS The medical records of 131 patients who underwent PD and preoperative computed tomography were retrospectively reviewed. Onodera's prognostic nutritional index (PNI) was assessed 6-months after PD. Patients with PNI values of at least 45 were included in the non-malnutrition group, while those with values <45 and <40 were included in the mild and severe malnutrition groups, respectively. Associations between eFRPV and postoperative nutritional status were evaluated to identify factors predictive of severe malnutrition after PD. RESULTS Fifty-three patients (40%) were included in the non-malnutrition group, while 38 (29%) and 40 (31%) were included in the mild and severe malnutrition groups, respectively. Overall survival was significantly shorter in the severe malnutrition group (p < 0.001). The eFRPV was significantly lower in the severe malnutrition group (p = 0.003; Jonckheere-Terpstra trend test, p < 0.001). In the multivariate analysis, eFRPV ≤55.2 mL·HU (odds ratio [OR] = 5.20; p = 0.004), preoperative PNI ≤41.9 (OR = 6.37; p = 0.010), and body mass index ≤19.1 kg/m2 (OR = 3.43; p = 0.031) were independent predictors of severe malnutrition after PD. CONCLUSION The current results indicate that eFRPV may predict low PNI values after PD.
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Affiliation(s)
- Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan.
| | - Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Nobuhito Nitta
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Takeru Maekawa
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | | | - Masatsugu Kojima
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
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Kanwat S, Singh H, Sharma AK, Sharma V, Gupta P, Gupta V, Yadav TD, Gupta R. Pancreatic Dysfunction and Reduction in Quality of Life Is Common After Pancreaticoduodenectomy. Dig Dis Sci 2023:10.1007/s10620-023-07966-6. [PMID: 37160540 DOI: 10.1007/s10620-023-07966-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/02/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Improvements in survival after pancreaticoduodenectomy has increased the number of patients potentially at risk of pancreatic insufficiency. AIMS We studied long-term (> 1 year) pancreatic functions (endocrine and exocrine) after pancreaticoduodenectomy and aimed to recognize the impact of various clinicopathological factors and postoperative complications on pancreatic functions. METHODS All patients who underwent pancreaticoduodenectomy at least 1 year prior were recruited from July 2020 to December 2021. Endocrine function was assessed using HbA1c, fasting blood sugar and postprandial blood sugar levels. Pancreatic exocrine function was assessed clinically with history of steatorrhea and objectively with quantitative estimation of fecal elastase-1 levels in stool samples. Volume of remnant pancreas, parenchymal thickness and duct diameter were assessed by computed tomography. Quality of life assessment was done using SF-36 questionnaire. RESULTS Of the 106 patients assessed, 64 patients met the inclusion criteria. Endocrine insufficiency was noted in 51.6%, and 34.3% had new onset diabetes mellitus. The incidence of pancreatic exocrine insufficiency was 87.5% and severe insufficiency was found in 62.5% of patients. Twenty-nine (45.3%) patients had both exocrine and endocrine insufficiency. Patients with CRPOPF had higher risk of severe exocrine insufficiency (5 vs. 2, OR 1.57(0.28-8.81) p = 0.6). The SF-36 scores were lower than general population especially in role limitation due to physical health, role limitation due to emotional problems, energy/fatigue, general health perception and health change domains. CONCLUSION Post-pancreaticoduodenectomy patients have a high frequency of pancreatic insufficiency and should be screened for same. The post-operative pancreatic fistula increases the risk of pancreatic exocrine insufficiency.
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Affiliation(s)
- Shradha Kanwat
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), F-block, Nehru Hospital, Sector 12, Chandigarh, India.
| | - Arun Kumar Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Gao Y, Guo F, Lu Z, Xi C, Wei J, Jiang K, Miao Y, Wu J, Chen J. Perioperative safety and prognosis following parenchyma-preserving surgery for solid pseudopapillary neoplasm of the pancreas. World J Surg Oncol 2023; 21:119. [PMID: 37004027 PMCID: PMC10064731 DOI: 10.1186/s12957-023-03003-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/22/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND/OBJECTIVES To evaluate perioperative safety and outcome of parenchyma-preserving pancreatectomy and risk factors of metastasis and recurrence for patients with solid pseudopapillary neoplasm (SPN). METHODS Demographic data, operative and pathological parameter, follow-up data of patients with SPN undergoing their first operation were collected in our single center from May 2016 to October 2021 and compared between regular pancreatectomy group and parenchyma-preserving surgery group. Risk factors for metastasis and recurrence were investigated. RESULTS A total of 194 patients were included, 154 of whom were female and the average age of all patients was 33 years old. Most patients were asymptomatic, with the most common complaint being abdominal pain or discomfort. Of them, 62 patients underwent parenchyma-preserving pancreatectomy including middle segment pancreatectomy and enucleation, and 132 patients underwent regular pancreatectomy including pancreaticoduodenectomy, distal pancreatectomy and total pancreatectomy. Patients in the parenchyma-preserving surgery group had a shorter duration of operation, less intraoperative bleeding, and decreased risk of combined organ removal and blood transfusion, with no statistical significance yet. The two groups exhibited a similar incidence of postoperative complications including grade B and C pancreatic fistula, delayed gastric emptying, postoperative pancreatic hemorrhage, and other complications, as well as radiological intervention, relaparotomy and the length of postoperative hospital stay. There were no perioperative deaths. All the patients, except 18 of those who discontinued follow-up, were alive with a median follow-up time of 31 months. Three patients in the regular pancreatectomy group were observed to have liver metastasis, and no metastasis was observed in the parenchyma-preserving surgery group. Significant risk factors for tumor metastasis and recurrence were tumor size, angioinvasion, and nerve infiltration. CONCLUSIONS Parenchyma-preserving surgery did not significantly increase the frequency of perioperative complications or recurrence and might be preferable if comprehensive conditions allow.
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Affiliation(s)
- Yong Gao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, 210029, People's Republic of China
| | - Feng Guo
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, 210029, People's Republic of China
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, 210029, People's Republic of China
| | - Chunhua Xi
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, 210029, People's Republic of China
| | - Jishu Wei
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, 210029, People's Republic of China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, 210029, People's Republic of China
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, 210029, People's Republic of China
- Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu, 210029, People's Republic of China
| | - Junli Wu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, 210029, People's Republic of China.
| | - Jianmin Chen
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, 210029, People's Republic of China.
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Anauth C, Lazarus L, Naidoo R. Anatomical venous landmarks for division of the distal pancreas: Implications for pancreatic resection. TRANSLATIONAL RESEARCH IN ANATOMY 2023. [DOI: 10.1016/j.tria.2023.100241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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10
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Patel V, Shah P, Ludwig DR, Hammill CW, Ashkar M. Development of de novo nonalcoholic fatty liver disease following pancreatectomy. Medicine (Baltimore) 2023; 102:e32782. [PMID: 36705353 PMCID: PMC9875952 DOI: 10.1097/md.0000000000032782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
De novo non-alcoholic fatty liver disease (NAFLD) after pancreatectomy is a recognized phenomenon; however, its pathophysiology is poorly understood. This study aimed to determine the incidence and identify peri-operative risk factors for the development of de novo NAFLD within various pancreatectomy groups. This single-center retrospective cohort study included patients who underwent pancreatectomy between 2000 and 2020. The incidence rate of de novo NAFLD and time to diagnosis were recorded across patients with malignant versus benign indications for pancreatectomy. The overall incidence of de novo NAFLD after pancreatectomy was 17.5% (24/136). Twenty-one percent (20/94) of patients with malignant indications for surgery developed NAFLD compared to 9.5% (4/42) with benign indications (P = .09). Time to development of hepatic steatosis in the malignant group was 26.4 months and was significantly shorter by an average of 6 months when compared to the benign group (32.8 months, P = .03). Higher pre-operative body mass index was associated with new-onset NAFLD (P = .03). Pre-operative body mass index is a significant predictor for de novo NAFLD and highlights a group that should be closely monitored post-operatively, especially after resections for pancreatic malignancy.
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Affiliation(s)
- Vanisha Patel
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Parth Shah
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - Daniel R. Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Chet W. Hammill
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Motaz Ashkar
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
- * Correspondence: Motaz Ashkar, Division of Gastroenterology, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110 (e-mail: )
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11
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Infante M, Ricordi C. The unique pathophysiological features of diabetes mellitus secondary to total pancreatectomy: proposal for a new classification distinct from diabetes of the exocrine pancreas. Expert Rev Endocrinol Metab 2023; 18:19-32. [PMID: 36692892 DOI: 10.1080/17446651.2023.2168645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Diabetes of the exocrine pancreas (DEP; a.k.a. pancreatic diabetes or pancreatogenic diabetes or type 3c diabetes mellitus or T3cDM) refers to different diabetes types resulting from disorders of the exocrine pancreas. DEP is characterized by the structural and functional loss of glucose-normalizing insulin secretion in the context of exocrine pancreatic dysfunction. Among these forms, new-onset diabetes mellitus secondary to total pancreatectomy (TP) has unique pathophysiological and clinical features, for which we propose a new nomenclature such as post-total pancreatectomy diabetes mellitus (PTPDM). AREAS COVERED TP results in the complete loss of pancreatic parenchyma, with subsequent absolute insulinopenia and lifelong need for exogenous insulin therapy. Patients with PTPDM also exhibit deficiency of glucagon, amylin and pancreatic polypeptide. These endocrine abnormalities, coupled with increased peripheral insulin sensitivity, deficiency of pancreatic enzymes and TP-related modifications of gastrointestinal anatomy, can lead to marked glucose variability and increased risk of iatrogenic (insulin-induced) severe hypoglycemic episodes ('brittle diabetes'). EXPERT OPINION We believe that diabetes mellitus secondary to TP should not be included in the DEP spectrum in light of its peculiar pathophysiological and clinical features. Therefore, we propose a new classification for this entity, that would likely provide more accurate prognosis and treatment strategies.
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Affiliation(s)
- Marco Infante
- Cell Transplant Center, Diabetes Research Institute (DRI), University of Miami Miller School of Medicine, Miami, FL, USA
- Section of Diabetes and Metabolic Disorders, UniCamillus, Saint Camillus International University of Health Sciences, Rome, Italy
- Diabetes Research Institute Federation (DRIF), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Rome, Italy
| | - Camillo Ricordi
- Cell Transplant Center, Diabetes Research Institute (DRI), University of Miami Miller School of Medicine, Miami, FL, USA
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12
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Shah P, Patel V, Ashkar M. De novo non-alcoholic fatty liver disease after pancreatectomy: A systematic review. World J Clin Cases 2022; 10:12946-12958. [PMID: 36569000 PMCID: PMC9782952 DOI: 10.12998/wjcc.v10.i35.12946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/10/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As operative techniques and mortality rates of pancreatectomy have improved, there has been a shift in focus to maintaining and improving the nutritional status of these patients as we continue to learn more about post-operative complications. Although pancreatic endocrine and exocrine insufficiencies are known complications of pancreatectomy, increased longevity of these patients has also led to a higher incidence of de novo fatty liver disease which differs from traditional fatty liver disease given the lack of metabolic syndrome.
AIM To identify and summarize patterns and risk factors of post-pancreatectomy de novo fatty liver disease to guide future management.
METHODS We performed a database search on PubMed selecting papers published between 2001 and 2022 in the English language. PubMed was last accessed 1 June 2022.
RESULTS Various factors influence the development of de novo fatty liver including indication for surgery (benign vs malignant), type of pancreatectomy, amount of pancreas remnant, and peri-operative nutritional status. With an incidence rate up to 75%, de novo non-alcoholic fatty liver disease (NAFLD) can develop within 12 mo after pancreatectomy and various risk factors have been established including pancreatic resection line and remnant pancreas volume, peri-operative malnutrition and weight loss, pancreatic exocrine insufficiency (EPI), malignancy as the indication for surgery, and postmenopausal status.
CONCLUSION Since majority of risk factors leads to EPI and malnutrition, peri-operative focus on nutrition and enzymes replacement is key in preventing and treating de novo NAFLD after pancreatectomy.
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Affiliation(s)
- Parth Shah
- Gastroenterology, Washington University in Saint Louis, Saint Louis, MO 63110, United States
| | - Vanisha Patel
- Internal Medicine, Washington University in Saint Louis, Saint Louis, MO 63110, United States
| | - Motaz Ashkar
- Gastroenterology, Washington University in Saint Louis, Saint Louis, MO 63110, United States
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13
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Budipramana VS, Witarto AP, Witarto BS, Pramudito SL, Ratri LC, Wairooy NAP, Er Putra AJ. Risk factors for exocrine pancreatic insufficiency after pancreatic surgery: a systematic review and meta-analysis. Can J Surg 2022; 65:E770-E781. [PMID: 36384688 PMCID: PMC9671296 DOI: 10.1503/cjs.010621] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Patients should be informed beforehand of the risk factors for exocrine pancreatic insufficiency (ExoPI) after pancreatic surgery; however, there are no clear identified risk factors for this condition. This study aimed to identify the preoperative, perioperative and postoperative risk factors for ExoPI after pancreatic surgery. METHODS We conducted a systematic search of PubMed, Scopus, SAGE, CINAHL Plus and Taylor & Francis from inception to Mar. 7, 2021, for full-text articles that included patients who had undergone pancreatic surgery. The primary outcome was the number of ExoPI events and any risk factors evaluated. We used the Newcastle-Ottawa Scale to assess study quality. RESULTS Twenty studies involving 4131 patients (2312 [52.3%] male, mean age 60.12 [standard deviation 14.07] yr) were included. Of the 4131 patients, 1651 (40.0%) had postoperative ExoPI. Among the 11 factors evaluated, the significant risk factors were preoperative main pancreatic duct (MPD) diameter greater than 3 mm (odds ratio [OR] 4.50, 95% confidence interval [CI] 1.06-19.05), pancreaticoduodenectomy (PD) as the surgical treatment procedure (OR 3.31, 95% CI 1.92-5.68), pancreaticogastrostomy (PG) as the anastomotic procedure (OR 3.13, 95% CI 1.83-5.35), hard pancreatic texture (OR 2.93, 95% CI 1.99-4.32) and adjuvant chemotherapy (OR 2.50, 95% CI 1.54-4.04). Gender, history of diabetes mellitus or endocrine pancreatic insufficiency (EndoPI), underlying diseases, de novo diabetes or EndoPI, pylorus-preserving PD and postoperative pancreatic fistula were not risk factors for ExoPI after pancreatic surgery. CONCLUSION Preoperative MPD diameter greater than 3 mm, PD, PG reconstruction, hard pancreatic texture and adjuvant chemotherapy were risk factors for the development of ExoPI after pancreatic surgery. The findings should provide useful information for patients to reduce postoperative dissatisfaction and improve quality of life.
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Affiliation(s)
- Vicky S Budipramana
- From the Division of Digestive Surgery, Department of Surgery, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (Budipramana); and the Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (A. Witarto, B. Witarto, Pramudito, Ratri, Wairooy, Putra)
| | - Andro Pramana Witarto
- From the Division of Digestive Surgery, Department of Surgery, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (Budipramana); and the Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (A. Witarto, B. Witarto, Pramudito, Ratri, Wairooy, Putra)
| | - Bendix Samarta Witarto
- From the Division of Digestive Surgery, Department of Surgery, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (Budipramana); and the Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (A. Witarto, B. Witarto, Pramudito, Ratri, Wairooy, Putra)
| | - Shidi Laras Pramudito
- From the Division of Digestive Surgery, Department of Surgery, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (Budipramana); and the Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (A. Witarto, B. Witarto, Pramudito, Ratri, Wairooy, Putra)
| | - Lintang Cahyaning Ratri
- From the Division of Digestive Surgery, Department of Surgery, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (Budipramana); and the Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (A. Witarto, B. Witarto, Pramudito, Ratri, Wairooy, Putra)
| | - Nabilah Azzah Putri Wairooy
- From the Division of Digestive Surgery, Department of Surgery, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (Budipramana); and the Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (A. Witarto, B. Witarto, Pramudito, Ratri, Wairooy, Putra)
| | - Achmad Januar Er Putra
- From the Division of Digestive Surgery, Department of Surgery, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (Budipramana); and the Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (A. Witarto, B. Witarto, Pramudito, Ratri, Wairooy, Putra)
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Maekawa T, Maehira H, Iida H, Mori H, Nitta N, Tokuda A, Kaida S, Miyake T, Takebayashi K, Tani M. Impact of Preoperative Muscle Mass Maintenance and Perioperative Muscle Mass Loss Prevention After Pancreatectomy: Association Between Perioperative Muscle Mass and Postoperative Nutritional Status. Pancreas 2022; 51:1179-1185. [PMID: 37078943 DOI: 10.1097/mpa.0000000000002168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
OBJECTIVES We investigated how preoperative sarcopenia and perioperative muscle mass changes affect postoperative nutritional parameters in patients undergoing pancreatectomy. METHODS This study included 164 patients undergoing pancreatectomy between January 2011 and October 2018. Skeletal muscle area was measured by computed tomography before and 6 months after surgery. Sarcopenia was defined as the lowest sex-specific quartile, and patients with muscle mass ratios less than -10% were classified into the high-reduction group. We examined the relationship between perioperative muscle mass and postoperative nutritional parameters 6 months after pancreatectomy. RESULTS There were no significant differences in nutritional parameters between the sarcopenia and nonsarcopenia groups at 6 months after surgery. In contrast, albumin (P < 0.001), cholinesterase (P < 0.001), and prognostic nutritional index (P < 0.001) were lower in the high-reduction group. According to each surgical procedure, albumin (P < 0.001), cholinesterase (P = 0.007), and prognostic nutritional index (P < 0.001) were lower in the high-reduction group of pancreaticoduodenectomy. In distal pancreatectomy cases, only cholinesterase (P = 0.005) was lower. CONCLUSIONS Postoperative nutritional parameters were correlated with muscle mass ratios but not with preoperative sarcopenia in patients undergoing pancreatectomy. Improvement and maintenance of perioperative muscle mass are important to maintain good nutritional parameters.
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Affiliation(s)
- Takeru Maekawa
- From the Department of Surgery, Shiga University of Medical Science, Shiga, Japan
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15
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Klatte DCF, Boekestijn B, Wasser MNJM, Feshtali Shahbazi S, Ibrahim IS, Mieog JSD, Luelmo SAC, Morreau H, Potjer TP, Inderson A, Boonstra JJ, Dekker FW, Vasen HFA, van Hooft JE, Bonsing BA, van Leerdam ME. Pancreatic Cancer Surveillance in Carriers of a Germline CDKN2A Pathogenic Variant: Yield and Outcomes of a 20-Year Prospective Follow-Up. J Clin Oncol 2022; 40:3267-3277. [PMID: 35658523 DOI: 10.1200/jco.22.00194] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/30/2022] [Accepted: 04/26/2022] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Pancreatic cancer surveillance in high-risk individuals may lead to detection of pancreatic ductal adenocarcinoma (PDAC) at an earlier stage and with improved survival. This study evaluated the yield and outcomes of 20 years of prospective surveillance in a large cohort of individuals with germline pathogenic variants (PVs) in CDKN2A. METHODS Prospectively collected data were analyzed from individuals participating in pancreatic cancer surveillance. Surveillance consisted of annual magnetic resonance imaging with magnetic resonance cholangiopancreatography and optional endoscopic ultrasound. RESULTS Three hundred forty-seven germline PV carriers participated in surveillance and were followed for a median of 5.6 (interquartile range 2.3-9.9) years. A total of 36 cases of PDAC were diagnosed in 31 (8.9%) patients at a median age of 60.4 (interquartile range 51.3-64.1) years. The cumulative incidence of primary PDAC was 20.7% by age 70 years. Five carriers (5 of 31; 16.1%) were diagnosed with a second primary PDAC. Thirty (83.3%) of 36 PDACs were considered resectable at the time of imaging. Twelve cases (12 of 36; 33.3%) presented with stage I disease. The median survival after diagnosis of primary PDAC was 26.8 months, and the 5-year survival rate was 32.4% (95% CI, 19.1 to 54.8). Individuals with primary PDAC who underwent resection (22 of 31; 71.0%) had an overall 5-year survival rate of 44.1% (95% CI, 27.2 to 71.3). Nine (2.6%; 9 of 347) individuals underwent surgery for a suspected malignant lesion, which proved to not be PDAC, and this included five lesions with low-grade dysplasia. CONCLUSION This long-term surveillance study demonstrates a high incidence of PDAC in carriers of a PV in CDKN2A. This provides evidence that surveillance in such a high-risk population leads to detection of early-stage PDAC with improved resectability and survival.
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Affiliation(s)
- Derk C F Klatte
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bas Boekestijn
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Martin N J M Wasser
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Isaura S Ibrahim
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Saskia A C Luelmo
- Department of Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans Morreau
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas P Potjer
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans F A Vasen
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bert A Bonsing
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
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16
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Thomas AS, Huang Y, Kwon W, Schrope BA, Sugahara K, Chabot JA, Wright JD, Kluger MD. Prevalence and Risk Factors for Pancreatic Insufficiency After Partial Pancreatectomy. J Gastrointest Surg 2022; 26:1425-1435. [PMID: 35318597 DOI: 10.1007/s11605-022-05302-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/11/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND This study aimed to determine the rate, timing, and predictors of diabetes and exocrine pancreatic insufficiency after pancreatectomy in order to inform preoperative patient counseling and risk management strategies. METHODS Using prescription claims as a surrogate for disease prevalence, IBM Watson Health MarketScan was queried for claims patterns pre- and post-pancreatectomy. Multivariable models explored associations between clinical characteristics and medication use within 2 years of surgery. RESULTS In total, 18.96% of 2,848 pancreaticoduodenectomy (PD) patients and 18.95% of 1,858 distal pancreatectomy (DP) patients had preoperative diabetic medication prescription claims. Fewer (6.6% and 3.88%, respectively) had pancreatic enzyme replacement therapy (PERT) claims. Diabetic medication claims increased to 28.69% after PD and 38.59% after DP [adjusted relative risk (aRR) = 1.36 (95% CI 1.27, 1.46)]. Other associated factors included age > 45, medical comorbidity, and obesity. The incidence of new diabetic medication claims among medication naïve patients was 13.78% for PD and 24.7% for DP (p < 0.001) with a median 4.7 and 4.9 months post-operatively. The prevalence of PERT claims was 55.97% after PD and 17.06% after DP [aRR = 0.32 (0.29, 0.36)]. The incidence of postoperative PERT claims 53.98% (PD) and 14.84% (DP) (p < 0.0001). The median time to new PERT claim was 3.0 (PD) and 3.2 (DP) months, respectively. Claims for both diabetic medications and PERT rose sharply after surgery and plateaued within 6 months. CONCLUSIONS This study defines prevalence, timing, and predictors for post-pancreatectomy insufficiency to inform preoperative counseling, risk modification strategies, and interventions related to quality of life.
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Affiliation(s)
- Alexander S Thomas
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA.
| | - Yongmei Huang
- Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Wooil Kwon
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Beth A Schrope
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA
| | - Kazuki Sugahara
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA
| | - John A Chabot
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA
| | - Jason D Wright
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Michael D Kluger
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA
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17
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Janssen QP, Gorris M, van den Broek BLJ, Besselink MG, Busch OR, van Eijck CHJ, Groot Koerkamp B, van Hooft JE, van Driel LMJW. Endoscopic ultrasonography as additional preoperative workup is valuable in half of the patients with a pancreatic body or tail lesion. HPB (Oxford) 2022; 24:809-816. [PMID: 34732301 DOI: 10.1016/j.hpb.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/05/2021] [Accepted: 10/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The management of pancreatic body and tail lesions is underexposed. It remains unclear whether endoscopic ultrasonography (EUS) increases the accuracy of the preoperative workup. This study assessed the diagnostic value and safety of EUS in addition to cross-sectional imaging in a surgical cohort of patients with pancreatic body or tail lesions. METHODS A multicenter retrospective cohort study was performed of patients who underwent distal pancreatectomy from 2010 to 2017. The composite primary outcome was the additional value of EUS, defined as: (a) EUS confirmed an uncertain diagnosis on cross-sectional imaging, (b) EUS was correct in case of discrepancy with cross-sectional imaging, or (c) EUS provided tissue diagnosis for neoadjuvant treatment. Furthermore, serious adverse events and needle tract seeding were assessed. RESULTS In total, 181 patients were included, of whom 123 (68%) underwent EUS besides cross-sectional imaging. Postoperative pathology was heterogeneous: 91 was malignant, 49 premalignant, 41 benign. Most lesions were solid (n = 117). EUS had additional value in 59/123 (48%) patients; 27/50 (54%) of cystic and 32/73 (44%) of solid lesions. No serious adverse event or needle tract seeding following EUS occurred. CONCLUSION EUS had additional value besides cross-sectional imaging in half of the patients and showed low associated risks.
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Affiliation(s)
- Quisette P Janssen
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Myrte Gorris
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Bram L J van den Broek
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Lydi M J W van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
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Shikata M, Chujo D, Enkaku A, Takikawa-Nishida A, Honoki H, Yamada-Matsukoshi S, Nakagawa-Yokoyama M, Kamigishi M, Inagawa S, Fujisaka S, Yagi K, Shibuya K, Fujii T, Tobe K. Perioperative C-peptide index is associated with the status of diabetes management after pancreatectomy. J Diabetes Investig 2022; 13:1685-1694. [PMID: 35638355 PMCID: PMC9533048 DOI: 10.1111/jdi.13861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/08/2022] [Accepted: 05/27/2022] [Indexed: 11/30/2022] Open
Abstract
Aims/Introduction This study aimed to identify the clinical factors affecting postoperative residual pancreatic β‐cell function, as assessed by the C‐peptide index (CPI), and to investigate the association between perioperative CPI and the status of diabetes management after pancreatectomy. Materials and Methods The associations between perioperative CPI and clinical background, including surgical procedures of pancreatectomy, were analyzed in 47 patients who underwent pancreatectomy, and were assessed for pre‐and postoperative CPI. The association between perioperative CPI and glycemic control after pancreatectomy was investigated. Results The low postoperative CPI group (CPI <0.7) had longer duration of diabetes (17.5 ± 14.5 vs 5.5 ± 11.0 years, P = 0.004), a higher percentage of sulfonylurea users (41.7 vs 8.7%, P = 0.003) and a greater number of drug categories used for diabetes treatment (1.9 ± 1.1 vs 0.8 ± 0.8, P <0.001) than did the high postoperative CPI group. Postoperative CPI was higher (1.4 ± 1.2 vs 0.7 ± 0.6, P = 0.039) in patients with low glycosylated hemoglobin (<7.0%) at 6 months after pancreatectomy; preoperative (2.0 ± 1.5 vs 0.7 ± 0.5, P = 0.012) and postoperative CPI (2.5 ± 1.4 vs 1.4 ± 1.1, P = 0.020) were higher in non‐insulin users than in insulin users at 6 months after surgery. Conclusions The duration of diabetes and preoperative diabetes treatment were associated with residual pancreatic β‐cell function after pancreatectomy. Furthermore, perioperative β‐cell function as assessed by CPI was associated with diabetes management status after pancreatectomy.
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Affiliation(s)
- Masataka Shikata
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Daisuke Chujo
- First Department of Internal Medicine, University of Toyama, Toyama, Japan.,Center for Clinical Research, Toyama University Hospital, Toyama, Japan
| | - Asako Enkaku
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | | | - Hisae Honoki
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | | | | | - Miki Kamigishi
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Shinya Inagawa
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Shiho Fujisaka
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kunimasa Yagi
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
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Firkins SA, Hart PA, Porter K, Chiang C, Cloyd J, Dillhoff M, Lara LF, Manilchuk A, Papachristou GI, Pawlik TM, Tsung A, Conwell DL, Krishna SG. Incidence and Risk Factors for New-Onset Diabetes Mellitus After Surgical Resection of Pancreatic Cystic Lesions: A MarketScan Study. Pancreas 2022; 51:427-434. [PMID: 35858183 PMCID: PMC9388590 DOI: 10.1097/mpa.0000000000002054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES There is a paucity of literature evaluating new-onset diabetes mellitus (NODM) after resection of pancreatic cystic lesions (PCLs). We sought to characterize the incidence and risk factors associated with NODM after partial pancreatectomy for PCLs. METHODS We utilized the IBM MarketScan Database (2012-2018) to identify all nondiabetic adults who underwent partial pancreatectomy for PCLs. Patients with any other pancreatic disease were excluded. We performed Kaplan-Meier analysis and multivariable Cox proportional hazards regression to define the incidence and risk factors of postoperative NODM. RESULTS Among 311 patients, the overall risk (95% confidence interval) of NODM was 9.1% (6.3-12.9%), 15.1% (11.3-20.2%), and 20.2% (15.3-26.4%) at 6, 12 and 24 months, respectively. Multivariable analysis (adjusted hazard ratio; 95% confidence interval) revealed that older age (1.97; 1.04-3.72; 55-64 vs 18-54 years), obesity (2.63; 1.35-5.12), hypertension (1.79; 1.01-3.17), and cardiovascular disease (2.54; 1.02-6.28) were independent predictors of NODM. Rates of NODM were similar after distal pancreatectomy versus pancreaticoduodenectomy. CONCLUSIONS Within 2 years, 1 in 5 patients without any other pancreatic disease will develop NODM after partial pancreatectomy for PCLs. Those with advanced age, metabolic syndrome features, and/or cardiovascular disease may benefit from preoperative counseling and intensive postoperative monitoring, education, and treatment for diabetes mellitus.
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Affiliation(s)
- Stephen A. Firkins
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kyle Porter
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - ChienWei Chiang
- Social and Behavioral Sciences, Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Jordan Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Luis F. Lara
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Andrei Manilchuk
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Georgios I. Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M. Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Allan Tsung
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
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Gupta V, Bhandare MS, Chaudhari V, Parray A, Shrikhande SV. Organ preserving pancreatic resections offer better long-term conservation of pancreatic function at the expense of high perioperative major morbidity: a fair trade-off for benign or low malignant potential pancreatic neoplasms-a single-center experience. Langenbecks Arch Surg 2022; 407:1507-1515. [PMID: 35298681 DOI: 10.1007/s00423-022-02491-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 03/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Standard pancreatic resections (SPRs) might have long-term deleterious effects on pancreatic function, without added oncological advantage in low malignant potential (LMP) or benign neoplasms. This study aimed to evaluate outcomes following organ-preserving pancreatic resections (OPPARs) and SPRs. METHOD Post hoc analysis of patients undergoing OPPAR or SPR for benign or LMP pancreatic tumors from January 2011 to January 2020 at Tata Memorial Hospital, Mumbai. RESULTS Thirty-six and 114 patients were identified in OPPAR and SPR groups respectively. The overall morbidity (58.3% vs 43.9%, p-0.129) was comparable. Major morbidity (41.7% vs 21.9%, p-0.020), post-operative pancreatic fistula (POPF) (63.9% vs 35.1%, p-0.002), and clinically relevant POPF (41.7% vs 20.2%, p-0.010) were significantly higher with OPPAR. Post-operative endocrine insufficiency (14.9% vs 11.1%, p-0.567), exocrine insufficiency (19.3% vs 0%, p-0.004), and requirement of long-term pancreatic enzyme replacement (17.5% vs 0%, p-0.007) were higher in SPRs. Comparing left-sided and right-sided resections in the entire cohort, incidence of endocrine insufficiency was 17.1% vs 11.2% (p-0.299) and that of exocrine insufficiency was 8.6% vs 20% (p-0.048) respectively. CONCLUSION OPPAR is associated with high post-operative major morbidity and pancreatic fistula rate but offers long-term benefit due to better preservation of pancreatic function than SPR. The incidence of exocrine insufficiency is higher in right sided as compared to left-sided pancreatic resections.
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Affiliation(s)
- Vikas Gupta
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India.
| | - Vikram Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Amir Parray
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
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21
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Shen X, Yang X. Comparison of Outcomes of Enucleation vs. Standard Surgical Resection for Pancreatic Neoplasms: A Systematic Review and Meta-Analysis. Front Surg 2022; 8:744316. [PMID: 35155544 PMCID: PMC8825491 DOI: 10.3389/fsurg.2021.744316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/09/2021] [Indexed: 01/04/2023] Open
Abstract
Background With advancement in health technology, the detection rate of pancreatic neoplasms is increasing. Tissue sparing surgery (enucleation) as well as standard surgical resection are two commonly used modalities of management. There are studies comparing clinical outcomes between these two modalities; however, there is lack of studies that systematically pool the available findings to present conclusive and reliable evidence. Methods A systematic search was conducted using the PubMed, Scopus, and Google Scholar databases. Studies that were randomised controlled trials or cohort based or analysed retrospective data were considered for inclusion. Studies should have been done in adult patients with pancreatic neoplasms and should have examined the outcomes of interest by the two management modalities i.e., enucleation and standard surgical resection. Statistical analysis was performed using STATA software. Results A total of 20 studies were included in the meta-analysis. The operation time (in minutes) (WMD −78.20; 95% CI: −89.47, −66.93) and blood loss (in ml) (WMD −204.30; 95% CI: −281.70, −126.90) for enucleation was significantly lesser than standard surgical resection. The risk of endocrine (RR 0.32; 95% CI: 0.18, 0.56) and exocrine insufficiency (RR 0.16; 95% CI: 0.07, 0.34) was lower whereas the risk of post-operative pancreatic fistula (RR 1.46; 95% CI: 1.22, 1.75) was higher in enucleation, compared to standard surgical resection group. There were no differences in the risk of reoperation, readmission, recurrence, mortality within 90 days and 5-years overall mortality between the two groups. Conclusions Enucleation, compared to standard surgical resection, was associated with better clinical outcomes and therefore, might be considered for selected pancreatic neoplasms. There is a need for randomised controlled trials to document the efficacy of these two management techniques.
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22
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Kawai M. Understanding the Onset and Mechanism of Occurrence of Post-Pancreatectomy Diabetes. J Am Coll Surg 2021; 233:762-763. [PMID: 34823682 DOI: 10.1016/j.jamcollsurg.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 10/19/2022]
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23
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Latenstein AEJ, Blonk L, Tjahjadi NS, de Jong N, Busch OR, de Hingh IHJT, van Hooft JE, Liem MSL, Molenaar IQ, van Santvoort HC, de van der Schueren MAE, DeVries JH, Kazemier G, Besselink MG. Long-term quality of life and exocrine and endocrine insufficiency after pancreatic surgery: a multicenter, cross-sectional study. HPB (Oxford) 2021; 23:1722-1731. [PMID: 34001452 DOI: 10.1016/j.hpb.2021.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/05/2021] [Accepted: 04/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Data regarding long-term quality of life and exocrine and endocrine insufficiency after pancreatic surgery for premalignant and benign (non-pancreatitis) disease are lacking. METHODS This cross-sectional study included patients ≥3 years after pancreatoduodenectomy or left pancreatectomy in six Dutch centers (2006-2016). Outcomes were measured with the EQ-5D-5L, the EORTC QLQ-C30, an exocrine and endocrine pancreatic insufficiency questionnaire, and PAID20. RESULTS Questionnaires were completed by 153/183 patients (response rate 84%, median follow-up 6.3 years). Surgery related complaints were reported by 72/153 patients (47%) and 13 patients (8.4%) would not undergo this procedure again. The VAS (EQ-5D-5L) was 76 ± 17 versus 82 ± 0.4 in the general population (p < 0.001). The mean global health status (QLQ-C30) was 78 ± 17 versus 78 ± 17, p = 1.000. Fatigue, insomnia, and diarrhea were clinically relevantly worse in patients. Exocrine pancreatic insufficiency was reported by 62 patients (41%) with relieve of symptoms by enzyme supplementation in 48%. New-onset diabetes mellitus was present in 22 patients (14%). The median PAID20 score was 6.9/20 (IQR 2.5-17.8). CONCLUSION Although generic quality of life after pancreatic resection for pre-malignant and benign disease was similar to the general population and diabetes-related distress was low, almost half suffered from a range of symptoms highlighting the need for long-term counseling.
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Affiliation(s)
- Anouk E J Latenstein
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Lotte Blonk
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands; Department of Nutrition and Dietetics, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Nic S Tjahjadi
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Nenke de Jong
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Isaaq Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Marian A E de van der Schueren
- Department of Nutrition and Health, HAN University of Applied Sciences, Nijmegen, the Netherlands; Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, the Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands.
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Abstract
The most common complications after a pancreaticoduodenectomy are delayed gastric emptying, pancreatic fistulae, hemorrhage, chyle leaks, endocrine and exocrine pancreatic insufficiency, and surgical site infections. Understanding the potential complications and recognizing them are imperative to taking great care of these complex patients. Taking care of these patients postoperatively requires a team approach including experienced nursing staff combined with robust gastroenterology and interventional radiology.
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Affiliation(s)
- Robert Simon
- General Surgery, Department of Hepatopancreaticobiliary Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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25
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Moore JV, Tom S, Scoggins CR, Philips P, Egger ME, Martin RCG. Exocrine Pancreatic Insufficiency After Pancreatectomy for Malignancy: Systematic Review and Optimal Management Recommendations. J Gastrointest Surg 2021; 25:2317-2327. [PMID: 33483914 DOI: 10.1007/s11605-020-04883-1] [Citation(s) in RCA: 12] [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: 10/05/2020] [Accepted: 11/12/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Exocrine pancreatic insufficiency (EPI) occurs when pancreatic enzyme activity in the intestinal lumen is insufficient for normal digestion to occur. The true incidence and diagnosis of EPI after pancreatectomy has not been fully understood and optimized. The aim of this study was to present incidence and diagnostic criteria for EPI after pancreatectomy for cancer and provide a guide for management and optimal therapy in pancreatectomy patients with cancer. METHODS A comprehensive review of the literature with publication dates from 2014 to 2019 was performed. A comprehensive diagnostic and treatment algorithm was then created based on literature review and current treatment options. RESULTS In total, 30 studies were included, 19 combined both pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), 9 for central pancreatectomy, and 2 others. EPI was defined subjectively without definitive testing using any of the established diagnostic studies in the majority of studies 23 (76%). Preoperative EPI was calculated to be 11.52%. Most studies assessed exocrine function at least 6 months postoperatively with four studies extending the follow-up period beyond 12 months. EPI diagnosed postoperatively at 1 month (40.27%), 3 months (30.94%), 6 months (36.06%), and 12 months (34.69%). After PD, the median prevalence of postoperative EPI was 43.14%, CP, the median prevalence was 4.85%, DP, median prevalence of postoperative EPI of 11.94%. CONCLUSION EPI is a frequent outcome that is often misdiagnosed or under-reported by the patient post-pancreatectomy. Given the increasing overall survival in pancreatectomy patients for cancer, surgeon awareness and assessment is critical to improving patients' overall quality of life.
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Affiliation(s)
| | - Stephanie Tom
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway #311, Louisville, KY, 40202, USA
| | - Charles R Scoggins
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway #311, Louisville, KY, 40202, USA
| | - Prejesh Philips
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway #311, Louisville, KY, 40202, USA
| | - Michael E Egger
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway #311, Louisville, KY, 40202, USA
| | - Robert C G Martin
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway #311, Louisville, KY, 40202, USA.
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26
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Uemura M, Ohgi K, Sugiura T, Okamura Y, Ito T, Yamamoto Y, Ashida R, Aramaki T, Notsu A, Kawabata T, Uesaka K. Changes in the body composition and nutritional status after total pancreatectomy. Langenbecks Arch Surg 2021; 406:1909-1916. [PMID: 34021413 DOI: 10.1007/s00423-021-02185-x] [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: 01/30/2021] [Accepted: 05/02/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to evaluate changes in the body composition and nutritional status after total pancreatectomy (TP). METHODS Consecutive 45 patients underwent TP between February 2003 and July 2018. Among them, 32 had computed tomography images available before TP and at 6 and 12 months after TP. The skeletal muscle index (SMI), visceral fat tissue index (VFI), and subcutaneous fat tissue index (SFI) were measured using images at each time. Body mass index (BMI), serum albumin levels (Alb), hemoglobin A1c levels (HbA1c), and daily insulin use were also recorded. RESULTS There were significant reductions in SMI (median, 38.7 vs. 36.6 cm2/m2, P = 0.030), VFI (12.4 vs. 5.1 cm2/m2, P < 0.001), SFI (26.5 vs. 9.2 cm2/m2, P < 0.001), BMI (20.3 vs. 18.7 kg/m2, P < 0.001), and Alb (4.2 vs. 3.7 g/dL, P = 0.031) at 6 months after TP compared with preoperative period. HbA1c significantly increased at 6 months after TP compared with postoperative discharge (6.7 vs. 7.3%, P < 0.001). The daily insulin use significantly increased at 12 months after TP compared with 6 months after TP (22 vs. 26 units/day, P < 0.001), whereas there were no significant changes in other parameters. CONCLUSIONS Significant losses in fat and skeletal muscle mass as well as the BMI and Alb occurred within the first 6 months after TP. A subsequent increase in the daily insulin use occurred during the next six months, which helped preserve the body composition.
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Affiliation(s)
- Masao Uemura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Takeshi Aramaki
- Division of Interventional Radiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Akifumi Notsu
- Clinical Research Center, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
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Ravi PK, Singh SR, Mishra PR. Redefining the tail of pancreas based on the islets microarchitecture and inter-islet distance: An immunohistochemical study. Medicine (Baltimore) 2021; 100:e25642. [PMID: 33907122 PMCID: PMC8084047 DOI: 10.1097/md.0000000000025642] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/17/2021] [Accepted: 03/20/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Researchers divided the pancreas distal to the neck into 2 equal parts as the body and tail region by an arbitrary line. Surgeons considered the part of the pancreas, left to the aorta as the tail region. We performed this study to identify the transition zone of low-density to high-density islet cells for redefining the tail region.We quantified islets area proportion, beta-cell area proportion, and inter-islet distance in 9 Indian-adult-human non-diabetic pancreases from autopsy by using anti-synaptophysin and anti-insulin antibodies. Data were categorized under 3 regions like the proximal body, distal body, and distal part of the pancreas.Islet and beta-cell area proportion are progressively increased from head to tail region of the pancreas with a significant reduction in inter-islet distance and beta-cell percentage distal to the aorta. There is no significant difference in inter-islet distance and beta-cell percentage of the distal part of the body and tail region.Crowding of islets with intermingled microarchitecture begins in the pancreas distal to the aorta, which may be the beginning of the actual tail region. This study will provide insight into the preservation of islets-rich part of the pancreas during pancreatectomy and future prediction of new-onset diabetes.
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Affiliation(s)
- Praveen Kumar Ravi
- Department of Anatomy, Trichy SRM Medical College Hospital & Research Centre, Tiruchirappalli, Tamil Nadu
| | | | - Pravash Ranjan Mishra
- Department of Anatomy, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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28
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Kim MS, Park H, Lee S, Yoo SY, Cho SY, Lee SK, Jin DK. Clinical characteristics, treatment outcomes, and occurrence of diabetes mellitus after pancreatic resection of solid pseudopapillary tumor in children and adolescents: A single institution experience with 51 cases. Pancreatology 2021; 21:509-514. [PMID: 33509684 DOI: 10.1016/j.pan.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/25/2020] [Accepted: 01/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Solid pseudopapillary tumors (SPTs) are rare, but they comprise the majority of pediatric pancreatic neoplasms. However, studies on these conditions in pediatric patients are lacking. The aim of this study was to investigate the clinical characteristics and treatment outcomes in children and adolescents with SPTs. METHODS This retrospective study included 51 patients with SPTs who had undergone pancreatic tumor resection before the age of 19 years at Samsung Medical Center in Korea (from November 1994 to August 2020). We investigated the postoperative outcomes. RESULTS Of the 51 patients with SPTs (female, 88.2%), the median age at diagnosis was 14 years (range, 8-19). The most common symptom was abdominal pain (60.8%), and 14 patients (27.5%) were asymptomatic. The median maximal tumor diameter was 7 cm (range, 1.4-14), and the pancreatic body and/or tail were involved in 68.6% of patients. The short-term complication rate was 21.5%, and the recurrence rate was 5.9%. New-onset diabetes mellitus (NODM) occurred in four patients. CONCLUSIONS The ideal treatment for SPTs is complete resection of the tumor; however, long-term postoperative complications including NODM should be monitored carefully, particularly in children and adolescents.
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Affiliation(s)
- Min-Sun Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyojung Park
- Department of Pediatrics, Seongnam Citizens Medical Center, Gyeonggi-do, Republic of Korea
| | - Sanghoon Lee
- Department of Pediatric Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - So Young Yoo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Yoon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Suk-Koo Lee
- Department of Pediatric Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong-Kyu Jin
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Khodr J, Truant S, El Amrani M. Surgical ampullectomy with resection of the common bile duct for biliary papillomatosis. J Gastrointest Surg 2021; 25:1087-1088. [PMID: 33237486 DOI: 10.1007/s11605-020-04851-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/27/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intraductal papillary neoplasm of the bile duct (IPNB) or biliary papillomatosis is a precursor lesion of papillary cholangiocarcinoma.1 IPNB is recognized as a biliary counterpart of IPMN (pancreatic intraductal papillary mucinous neoplasm). IPNB is a rare disease involving entire (diffuse type) or one part (localized type) of biliary tree. Patients without distant metastasis are considered for surgical resection. For patients with distal bile duct papillomatosis, pancreaticoduodenectomy (PD) is recommended for patients with invasive distal bile duct IPNB. PD is a high complex procedure associated with the deterioration of endocrine and exocrine functions leading to a significant impact on quality of life.2 Some authors have reported a new surgical approach leading to a complete resection of the common bile duct without pancreatectomy.3 METHODS: We report the case of a 71-year-old female presented to our department with jaundice. At endoscopic ultrasound with cholangioscopy and CT scan, 2-cm distal bile duct mass tumor with villous component was seen. All needle biopsies were benign, and no distant disease was found. According to the risk of degeneration of this tumor, a surgical resection was decided. RESULTS Intraoperative frozen section assessed the benignity of peripancreatic lymph nodes. We performed surgical ampullectomy with resection of the common bile duct. The intrapancreatic common bile duct was completely mobilized between the ampullectomy area and the upper edge of the pancreas. Frozen sections on distal and proximal margins of common bile duct were performed to discard malignancy. Finally, reconstruction consisted on the main pancreatic duct reimplantation to the duodenum and choledochoduodenostomy. The histological analysis confirmed the diagnosis of biliary papillomatosis with low-grade dysplasia. CONCLUSION This procedure allows complete resection of benign tumors with endobiliary extension and preserve intestinal continuity and pancreatic parenchyma.
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Affiliation(s)
- Justine Khodr
- Department of Digestive Surgery and Transplantation, Lille University Hospital, Rue Michel Polonovski, 59037, Lille, France.,University of Lille, Lille, France
| | - Stéphanie Truant
- Department of Digestive Surgery and Transplantation, Lille University Hospital, Rue Michel Polonovski, 59037, Lille, France.,University of Lille, Lille, France
| | - Mehdi El Amrani
- Department of Digestive Surgery and Transplantation, Lille University Hospital, Rue Michel Polonovski, 59037, Lille, France. .,University of Lille, Lille, France.
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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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31
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Oh MY, Kim EJ, Kim H, Byun Y, Han Y, Choi YJ, Kang JS, Kwon W, Jang JY. Changes in postoperative long-term nutritional status and quality of life after total pancreatectomy. Ann Surg Treat Res 2021; 100:200-208. [PMID: 33854989 PMCID: PMC8019983 DOI: 10.4174/astr.2021.100.4.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/14/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Quality of life (QoL) is widely known to be poor after total pancreatectomy (TP) due to the loss of pancreatic function and poor nutritional status, but prospective studies on changes in QoL over time are lacking. The aim of this study was to prospectively evaluate the short- and long-term consequences of pancreatic exocrine insufficiency, changes in nutritional status, and their associated effects on QoL after TP. Methods Prospective data were collected from patients who underwent TP between 2008 and 2018. Validated questionnaires (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ] Core 30, EORTC QLQ-pancreatic cancer module, and the Mini Nutritional Assessment), measured frequency of bowel movement, relative body weight (RBW), triceps skinfold thickness (TSFT), and serum levels of protein, albumin, transferrin, and hemoglobin A1c were collected serially for 1 year. Results Thirty patients who underwent TP were eligible for the study. Bowel movement frequency increased over time, and the RBW and TSFT were lowest by 1 year. The global health status score showed no significant difference over time. At 3 months, physical and role function scores as well as symptoms of fatigue, constipation, and digestive difficulties worsened significantly. Most indices recovered after 1 year, but poorer physical function scores, digestive difficulties, and altered bowel habits persisted. Conclusion Because some symptoms do not recover over time, careful follow-up and supportive postoperative management are needed for TP patients, including nutritional support with pancreatic enzyme replacement and education about medication adherence and diet.
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Affiliation(s)
- Moon Young Oh
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Joo Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoonhyeong Byun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo Jin Choi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Wei Q, Qi L, Lin H, Liu D, Zhu X, Dai Y, Waldron RT, Lugea A, Goodarzi MO, Pandol SJ, Li L. Pathological Mechanisms in Diabetes of the Exocrine Pancreas: What's Known and What's to Know. Front Physiol 2020; 11:570276. [PMID: 33250773 PMCID: PMC7673428 DOI: 10.3389/fphys.2020.570276] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 10/07/2020] [Indexed: 12/17/2022] Open
Abstract
The clinical significance of diabetes arising in the setting of pancreatic disease (also known as diabetes of the exocrine pancreas, DEP) has drawn more attention in recent years. However, significant improvements still need to be made in the recognition, diagnosis and treatment of the disorder, and in the knowledge of the pathological mechanisms. The clinical course of DEP is different from type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). DEP develops in patients with previous existing exocrine pancreatic disorders which damage both exocrine and endocrine parts of pancreas, and lead to pancreas exocrine insufficiency (PEI) and malnutrition. Therefore, damage in various exocrine and endocrine cell types participating in glucose metabolism regulation likely contribute to the development of DEP. Due to the limited amount of clinical and experimental studies, the pathological mechanism of DEP is poorly defined. In fact, it still not entirely clear whether DEP represents a distinct pathologic entity or is a form of T2DM arising when β cell failure is accelerated by pancreatic disease. In this review, we include findings from related studies in T1DM and T2DM to highlight potential pathological mechanisms involved in initiation and progression of DEP, and to provide directions for future research studies.
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Affiliation(s)
- Qiong Wei
- Department of Endocrinology, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, China.,Institute of Pancreas, Southeast University, Nanjing, China
| | - Liang Qi
- Department of Endocrinology, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Hao Lin
- Institute of Pancreas, Southeast University, Nanjing, China.,Department of Clinical Science and Research, ZhongDa Hospital, Southeast University, Nanjing, China
| | - Dechen Liu
- Institute of Pancreas, Southeast University, Nanjing, China.,Department of Clinical Science and Research, ZhongDa Hospital, Southeast University, Nanjing, China
| | - Xiangyun Zhu
- Department of Endocrinology, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, China.,Institute of Pancreas, Southeast University, Nanjing, China
| | - Yu Dai
- Nanjing Foreign Language School, Nanjing, China
| | - Richard T Waldron
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Aurelia Lugea
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Mark O Goodarzi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Stephen J Pandol
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Ling Li
- Department of Endocrinology, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, China.,Institute of Pancreas, Southeast University, Nanjing, China
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Para-aortic lymph node metastasis detected intraoperatively by systematic frozen section examination in pancreatic head adenocarcinoma: is resection improving the prognosis? HPB (Oxford) 2020; 22:1604-1612. [PMID: 32179009 DOI: 10.1016/j.hpb.2020.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/16/2020] [Accepted: 02/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to evaluate the controversial benefit of a pancreaticoduodenectomy (PD) in patients with PALN metastasis intraoperatively detected by systematic frozen section examination in pancreatic adenocarcinoma. METHODS PALN intraoperative examination by frozen section was systematically performed from January 2006 to February 2018 prior to performing PD for pancreatic adenocarcinoma. Until June 2012, PALN + patients still underwent PD (PALN+/PD group) in the framework of a prospective study. Since July 2012, PALN+ was considered as contraindicating the planned PD (PALN+/No-PD group). Post-operative morbidity and survival were compared between these two groups. RESULTS Of the 32 PALN + patients intraoperatively detected, the first 13 underwent a PD, while the last 19 did not undergo resection. Seven patients (54%) among 13 PALN+/PD patients developed a post-operative complication against 3 (16%) among 19 PALN+/No-PD patients (p = 0.049). The median length of stay was 5 days longer for PALN+/PD patients (p = 0.001). The median survival did not differ between PALN+/No-PD and PALN+/PD groups (respectively 13.4 months (95%CI:7.6-19.3) and 11.5 months (95%CI:5.9-17.1), p = 0.471). No patient was alive 4 years after surgery in both the PALN+/No-PD or PALN+/PD groups. CONCLUSION In case of PALN detected intraoperatively in pancreatic adenocarcinoma, PD does not improve survival compared to current palliative treatment.
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Collard MK, Lefevre JH, Ahmed O, Voron T, Balladur P, Paye F, Parc Y. Ten-year impact of pancreaticoduodenectomy on bowel function and quality of life of patients with ileal pouch-anal anastomosis for familial adenomatous polyposis. HPB (Oxford) 2020; 22:1402-1410. [PMID: 32019738 DOI: 10.1016/j.hpb.2020.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/04/2019] [Accepted: 01/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with familial adenomatous polyposis (FAP) carry a risk of duodenal adenocarcinoma. These patients, who already have an ileal pouch-anal anastomosis (IPAA), sometimes require pancreaticoduodenectomy (PD). This work aims to evaluate the long-term consequences of the combination of PD + IPAA. METHODS All patients with IPAA due to FAP who underwent PD from 1991 to 2017 were included (PD + IPAA group). Patients were matched 1:1 according to age, sex, ASA score and presence of colorectal cancer. Fecal continence and quality of life (QoL) were assessed using the Wexner score and the EORTC-QLQ-C30 questionnaire. RESULTS Thirty-two PD + IPAA patients were matched with thirty-two IPAA-only patients. In each group, the response rate to the questionnaire was 78% (25/32). No differences were noted between PD + IPAA and IPAA-only groups in terms of daytime fecal frequency (6.0 vs 6.0; p = 0.362), Wexner score (3/20 vs 4/20; p = 0.984) and global QoL score (83.3/100 vs 83.3/100; p = 0.401). In the PD + IPAA group, 26% of patients developed diabetes a median period of 10.0 years after PD. The global QoL for these patients was significantly altered (p = 0.011), while daytime fecal frequency was unaffected (p = 0.092) as fecal continence (p = 0.475). CONCLUSION In FAP patients with IPAA, PD does not affect bowel function or QoL.
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Affiliation(s)
- Maxime K Collard
- Department of Digestive Surgery, Saint Antoine Hospital, AP-HP, Paris, France
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Saint Antoine Hospital, AP-HP, Paris, France; Sorbonne Université, Paris, France.
| | - Omar Ahmed
- Department of Digestive Surgery, Saint Antoine Hospital, AP-HP, Paris, France
| | - Thibault Voron
- Department of Digestive Surgery, Saint Antoine Hospital, AP-HP, Paris, France
| | - Pierre Balladur
- Department of Digestive Surgery, Saint Antoine Hospital, AP-HP, Paris, France; Sorbonne Université, Paris, France
| | - François Paye
- Department of Digestive Surgery, Saint Antoine Hospital, AP-HP, Paris, France; Sorbonne Université, Paris, France
| | - Yann Parc
- Department of Digestive Surgery, Saint Antoine Hospital, AP-HP, Paris, France; Sorbonne Université, Paris, France
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McDonald JD, Gupta S, Shindorf ML, Copeland A, Good ML, Sadowski SM, Nilubol N. Pancreatic insufficiency following pancreatectomy: Does underlying tumor syndrome confer a greater risk? Am J Surg 2020; 221:465-471. [PMID: 32943182 DOI: 10.1016/j.amjsurg.2020.08.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/06/2020] [Accepted: 08/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The risk of postoperative pancreatic exocrine insufficiency (PPEI) is unknown in patients with multiple endocrine neoplasia type I (MEN1) and von Hippel-Lindau (VHL) who require resection of pancreatic neuroendocrine tumors (PNETs). METHODS A retrospective review of patients who underwent resection of PNETs at the National Institutes of Health from 2007 to 2019 was performed. RESULTS Our cohort included 82 patients (VHL n = 25, MEN1 n = 20, sporadic n = 37), 6 of whom developed PPEI. While VHL compared to all non-VHL patients (p = 0.046), non-functional PNETs (p = 0.050), and pancreaticoduodenectomy (PD) (p=<0.001) were associated with higher rates of PPEI on univariate analysis, only PD was found to be an independent predictor of PPEI on multivariate analysis (OR 14.43, 95% CI 1.43-145.8, p = 0.024). CONCLUSIONS The rate of PPEI in patients with hereditary tumor syndromes was similar to that of sporadic PNETs. PD was independently associated with PPEI, and this increased risk should be included in preoperative counseling.
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Affiliation(s)
- James D McDonald
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Shreya Gupta
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Mackenzie L Shindorf
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Amy Copeland
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Meghan L Good
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Samira M Sadowski
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Naris Nilubol
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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Lee CYC, Depczynski B, Poynten A, Haghighi KS. Diabetes-related outcomes after pancreatic surgery. ANZ J Surg 2020; 90:2004-2010. [PMID: 32691521 DOI: 10.1111/ans.16129] [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: 01/17/2020] [Revised: 06/01/2020] [Accepted: 06/16/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The development of pancreatogenic diabetes mellitus (PDM) is a common complication post-pancreatectomy; however, its prevalence has not been described in Australia. We aimed to describe the glycaemic status pre- and post-pancreatectomy, compare patients' clinical characteristics, group according to pre- and post-pancreatectomy diabetes mellitus (DM) status and identify predictors of post-operative PDM. METHODS We retrospectively reviewed the medical records of patients admitted for pancreatic resection at a single institution from 2011 to 2017. Post-operative DM status was determined at the time of discharge or at 30 days post-operation. Longer term DM onset was as documented in medical record subsequent to admission for pancreatic surgery. RESULTS A total of 137 cases were analysed; 13.3% and 24.8% of patients developed post-operative PDM within 30 days and at median of 1 year (range 1-4 years) follow-up, respectively. All patients with pre-existing DM continued to have DM post-operatively. Patients with pre-existing DM were older (P = 0.004) and had a family history of DM (P = 0.020); 8.3% of patients who had undergone pancreaticoduodenectomy versus 17.1% of patients who had undergone distal pancreatectomy developed PDM (P = 0.318). A lower estimated glomerular filtration rate (P = 0.033) was significantly associated with post-operative PDM development. No independent predictors for post-operative PDM were identified. CONCLUSIONS The new development of DM within 30 days post-pancreatectomy occurs in approximately one in seven persons. No patients with pre-existing DM demonstrated a remission of DM post-pancreatectomy. These findings suggest that all patients should be screened for DM pre-operatively and followed up post-operatively, particularly those with pre-existing impaired renal function.
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Affiliation(s)
| | - Barbara Depczynski
- Department of Endocrinology, Prince of Wales Hospital and Community Health Services, Sydney, New South Wales, Australia
| | - Ann Poynten
- Department of Endocrinology, Prince of Wales Hospital and Community Health Services, Sydney, New South Wales, Australia
| | - Koroush S Haghighi
- Department of General Surgery, Prince of Wales Hospital and Community Health Services, Sydney, New South Wales, Australia
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Gianotti L, Sandini M, Hackert T. Preoperative carbohydrates: what is new? Curr Opin Clin Nutr Metab Care 2020; 23:262-270. [PMID: 32412978 DOI: 10.1097/mco.0000000000000661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to give an overview of recently published articles covering preoperative carbohydrate loading in surgical patients. RECENT FINDINGS Between January 1, 2017, and December 31, 2019, 26 publications addressing the effect of carbohydrate load were retrieved through a systematic search. Seventeen were randomized clinical trials, three prospective observational studies and six retrospective series with case-control comparison. Most of the studies were underpowered, addressed surrogate endpoints, and variability among dose and timing of carbohydrate (CHO) treatment was high. The most recent literature endorses preoperative carbohydrate loading up to 2 h before operations as a safe treatment. The new evidence confirm that this strategy is effective in reducing perioperative insulin resistance and the proportion of hyperglycemia episodes, and improving patient well-being and comfort but without affecting surgery-related morbidity. SUMMARY Further properly designed randomized clinical trials, addressing more clinically relevant endpoints such as length of hospitalization and morbidity rate, are warrant.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, Milano - Bicocca University
- Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Marta Sandini
- School of Medicine and Surgery, Milano - Bicocca University
- Department of Surgery, San Gerardo Hospital, Monza, Italy
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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González IA, Kang LI, Williams GA, Liu J, DeNardo DG, Hawkins WG, Chatterjee D. Tumor-insular Complex in Neoadjuvant Treated Pancreatic Ductal Adenocarcinoma Is Associated With Higher Residual Tumor. Am J Surg Pathol 2020; 44:817-825. [PMID: 32091434 PMCID: PMC7225071 DOI: 10.1097/pas.0000000000001454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The tumor microenvironment in pancreatic ductal adenocarcinoma (PDAC) plays a vital role in treatment response, and therefore, patient survival. We and others have observed an intimate association of neoplastic ductal cells with non-neoplastic islet cells, recapitulating the ductoinsular complex. We define this phenomenon as tumor-insular complex (TIC). Herein, we describe the clinicopathologic characteristics of TIC in neoadjuvant treated PDAC cases for the first time. We retrospectively reviewed the pathology of 105 cases of neoadjuvant treated PDAC resected at our institution. TIC was noted in 35 cases (33.3%), the mean tumor bed size was 2.7±1.0 cm, mean percentage of residual tumor 40±28% and mean Residual Tumor Index (RTI) (an index previously established as a prognostic parameter by our group) was 1.1±1.0. TIC was significantly associated with perineural invasion (P=0.001), higher tumor bed size (P=0.007), percentage of residual tumor (P=0.009), RTI (P=0.001), ypT stage (P=0.045), and poor treatment response, grouped by a previously established criteria (P=0.010). Using our prior binary reported prognostic cutoff for RTI of ≤0.35 and >0.35, TIC was associated with a RTI >0.35 (P=0.002). Moreover, patients who did not receive neoadjuvant radiation were associated with a higher frequency of TIC (P=0.003). In this cohort, RTI but not TIC was also shown to be a significant independent prognosticator for recurrence-free survival and overall survival on multivariate analysis. In conclusion, TIC is significantly associated with a more aggressive neoplasm which shows a poor treatment response. Further studies will be needed to better understand the tumor biology of TICs.
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Affiliation(s)
- Iván A. González
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
| | - Liang-I Kang
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
| | - Gregory A. Williams
- Division of HPB and GI surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Jingxia Liu
- Division of Public Health, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - David G. DeNardo
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - William G. Hawkins
- Division of HPB and GI surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Deyali Chatterjee
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
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de Mestier L, Védie AL, Faron M, Cros J, Rebours V, Hentic O, Do Cao C, Bardet P, Lévy P, Sauvanet A, Ruszniewski P, Hammel P. The Postoperative Occurrence or Worsening of Diabetes Mellitus May Increase the Risk of Recurrence in Resected Pancreatic Neuroendocrine Tumors. Neuroendocrinology 2020; 110:967-976. [PMID: 31791037 DOI: 10.1159/000505158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 11/29/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The goal of this retrospective study was to investigate the potential link between diabetes mellitus (DM) and the recurrence of pancreatic neuroendocrine tumors (PanNET) following curative intent surgery. METHODS We included patients who underwent surgical resection of nonmetastatic well-differentiated PanNET. Exacerbation of DM was defined as the postoperative occurrence of DM or worsening of preexisting DM. We explored the variables associated with PanNET recurrence-free survival (RFS). RFS was compared in a subset of patients with and without DM operated on by anatomical resection, after matching for the main prognostic factors. The impact of antidiabetic therapy on RFS was assessed. RESULTS A total of 268 patients (median age 54.7, 40% men) were included. Most PanNET were sporadic (85%), G1 (61%), pT1/pT2 (79%), and pN0 (76%). Postoperative DM exacerbation occurred in 38 patients (14%), including 27 with new-onset DM. On multivariable analysis, DM exacerbation was independently associated with an increased risk of PanNET recurrence (HR 2.35, 95% CI [1.24-4.47], p = 0.009) after adjustment for age, multiplicity of tumors, grade, pT, and pN stages. Similar results were found when 27 patients with and 48 patients without DM exacerbation, matched for grade, pT stage and pN stage, were compared (HR 3.03, 95% CI [1.05-8.77], p = 0.032). The postoperative use of metformin tended to decrease the risk of recurrence (HR 0.59, 95% CI 0.24-1.47, p = 0.26). CONCLUSION Patients with postoperative DM exacerbation may have an increased risk of PanNET recurrence. Closer follow-up might be beneficial in these patients. The protective role of metformin should be further explored.
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Affiliation(s)
- Louis de Mestier
- Department of Gastroenterology and Pancreatology, ENETS Centre of Excellence, Beaujon Hospital (APHP), Clichy, France,
- Université de Paris, Paris, France,
- INSERM U1149, Centre de Recherche sur l'Inflammation, Clichy/Paris, France,
| | - Anne-Laure Védie
- Department of Gastroenterology and Pancreatology, ENETS Centre of Excellence, Beaujon Hospital (APHP), Clichy, France
- Université de Paris, Paris, France
| | - Matthieu Faron
- Department of Surgical Oncology and Department of Biostatistics and Epidemiology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Jérôme Cros
- Université de Paris, Paris, France
- INSERM U1149, Centre de Recherche sur l'Inflammation, Clichy/Paris, France
- Department of Pathology, ENETS Centre of Excellence, Beaujon/Bichat Hospitals (APHP), Clichy/Paris, France
| | - Vinciane Rebours
- Department of Gastroenterology and Pancreatology, ENETS Centre of Excellence, Beaujon Hospital (APHP), Clichy, France
- Université de Paris, Paris, France
- INSERM U1149, Centre de Recherche sur l'Inflammation, Clichy/Paris, France
| | - Olivia Hentic
- Department of Gastroenterology and Pancreatology, ENETS Centre of Excellence, Beaujon Hospital (APHP), Clichy, France
| | - Christine Do Cao
- Department of Endocrinology, Diabetology and Metabolism, Lille University Hospital, Lille, France
| | - Pascal Bardet
- Department of Gastroenterology and Pancreatology, ENETS Centre of Excellence, Beaujon Hospital (APHP), Clichy, France
| | - Philippe Lévy
- Department of Gastroenterology and Pancreatology, ENETS Centre of Excellence, Beaujon Hospital (APHP), Clichy, France
- Université de Paris, Paris, France
| | - Alain Sauvanet
- Université de Paris, Paris, France
- Department of Hepato-Bilio-Pancreatic Surgery, ENETS Centre of Excellence, Beaujon/Bichat Hospitals (APHP), Clichy, France
| | - Philippe Ruszniewski
- Department of Gastroenterology and Pancreatology, ENETS Centre of Excellence, Beaujon Hospital (APHP), Clichy, France
- Université de Paris, Paris, France
- INSERM U1149, Centre de Recherche sur l'Inflammation, Clichy/Paris, France
| | - Pascal Hammel
- Université de Paris, Paris, France
- Department of Digestive Oncology, ENETS Centre of Excellence, Beaujon Hospital (APHP), Clichy, France
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Dragomir MP, Sabo AA, Petrescu GED, Li Y, Dumitrascu T. Central pancreatectomy: a comprehensive, up-to-date meta-analysis. Langenbecks Arch Surg 2019; 404:945-958. [PMID: 31641855 DOI: 10.1007/s00423-019-01829-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 09/23/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Central pancreatectomy (CP) is the alternative to distal pancreatectomy (DP) for specific pathologies of the mid-pancreas. However, the benefits of CP over DP remain controversial. This study aims to compare the two procedures by conducting a meta-analysis of all published papers. METHODS A systematic search of original studies comparing CP vs. DP was performed using PubMed, Scopus, and Cochrane Library databases up to June 2018. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was followed. RESULTS Twenty-one studies were included (596 patients with CP and 1070 patients with DP). Compared to DP, CP was associated with significantly higher rates of overall and severe morbidity (p < 0.0001), overall and clinically relevant pancreatic fistula (p < 0.0001), postoperative hemorrhage (p = 0.02), but with significantly lower incidences of new-onset (p < 0.0001) and worsening diabetes mellitus (p = 0.004). Furthermore, significantly longer length of hospital stay (p < 0.0001) was observed for CP patients. CONCLUSIONS CP is superior to DP regarding the preservation of pancreatic functions, but at the expense of significantly higher complication rates and longer hospital stay. Proper selection of patients is of utmost importance to maximize the benefits and mitigate the risks of CP.
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Affiliation(s)
- Mihnea P Dragomir
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of General Surgery and Liver Transplantation, Division of Surgical Oncology, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, 258 Fundeni Street, 022328, Bucharest, Romania.,Department of Experimental Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexandru A Sabo
- Department of Pediatrics, "Marie S. Curie" Emergency Clinical Hospital for Children, Bucharest, Romania
| | | | - Yongfeng Li
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
| | - Traian Dumitrascu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. .,Department of General Surgery and Liver Transplantation, Division of Surgical Oncology, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, 258 Fundeni Street, 022328, Bucharest, Romania.
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Andreasi V, Partelli S, Capurso G, Muffatti F, Balzano G, Crippa S, Falconi M. Long-Term Pancreatic Functional Impairment after Surgery for Neuroendocrine Neoplasms. J Clin Med 2019; 8:jcm8101611. [PMID: 31623399 PMCID: PMC6832294 DOI: 10.3390/jcm8101611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/23/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022] Open
Abstract
Radical surgery represents the only curative treatment for pancreatic neuroendocrine neoplasms (PanNEN). The aim of this study was to evaluate the postoperative onset of diabetes mellitus (DM) and/or pancreatic exocrine insufficiency (PEI) in surgically treated PanNEN. Consecutive PanNEN patients, without preoperative DM, who underwent partial pancreatic resection, were included. After a median follow-up of 72 months, overall 68/276 patients (24%) developed DM. Patients who developed DM were significantly older (p = 0.002) and they had a higher body mass index (BMI) (p < 0.0001) than those who did not; they were more frequently male (p = 0.017) and with nonfunctioning neoplasms (p = 0.019). BMI > 25 Kg/m2 was the only independent predictor of DM (p = 0.001). Overall, 118/276 patients (43%) developed a PEI, which was significantly more frequent after pancreaticoduodenectomy (p < 0.0001) and in patients with T3-T4 tumors (p = 0.001). Pancreaticoduodenectomy was the only independent predictor of PEI (p < 0.0001). Overall, 54 patients (20%) developed disease progression. Patients with and without DM had similar progression free survival (PFS), whereas patients without PEI had better five-year-PFS (p = 0.002), although this association was not confirmed in multivariate analysis. The risk of DM and PEI after surgery for PanNEN is relatively high but it does not affect PFS. BMI and pancreatic head resection are independent predictors of DM and PEI, respectively.
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Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Gabriele Capurso
- Biliopancreatic Endoscopy Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
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