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González Abós C, Martínez Escalante E, Salgado Muñoz F, Charles Cantú H, Navarrete Espinosa D, Landi F, Martínez-Mifsud B, Baiges A, Ausania F. Pancreaticoduodenectomy in a patient with severe portal hypertension: the role of preoperative TIPS. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 38685904 DOI: 10.17235/reed.2024.10431/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
The complication rate for Pancreaticoduodenectomy (PD) is 40-50% in most published series and mortality can raise up to 4-5% even in high-volume centers. Severe portal hypertension secondary to liver disease is associated to high perioperative mortality and therefore is considered a contraindication for PD. No standardized management exists for surgically resectable patients with periampullary cancer and severe portal hypertension. The aim of this case study is to analyse the treatment alternatives in patients with periampullary cancer and severe portal hypertension and focus into the surgical treatment of these patients. We present the case of a 67 year-old patient case with a resectable ampullary cancer and portal hypertension managed with Preoperative Transjugular Intrahepatic Portosystemic Shunt (TIPS) to allow a PD. We present a literature review on the use of preoperative TIPS in patients who are candidates to PD. Neoadjuvant TIPS can be safely used in selected patients with severe portal hypertension who need a PD.
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Affiliation(s)
| | | | | | | | | | - Filippo Landi
- Hepatobiliary Surgery and Transplant, Hospital Clínic Barcelona
| | | | - Anna Baiges
- Liver Unit. Hepatology, Hospital Clínic Barcelona
| | - Fabio Ausania
- Hepatobiliary Surgery and Transplant, Hospital Clínic Barcelona
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Rajagopalan A, Aroori S, Russell TB, Labib PL, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh B, Serrablo A, Croagh D. Five-year recurrence/survival after pancreatoduodenectomy for pancreatic adenocarcinoma: does pre-existing diabetes matter? Results from the Recurrence After Whipple's (RAW) study. HPB (Oxford) 2024:S1365-182X(24)01276-0. [PMID: 38755085 DOI: 10.1016/j.hpb.2024.04.010] [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: 09/09/2023] [Revised: 03/27/2024] [Accepted: 04/19/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Diabetes mellitus (DM) has a complex relationship with pancreatic cancer. This study examines the impact of preoperative DM, both recent-onset and pre-existing, on long-term outcomes following pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). METHODS Data were extracted from the Recurrence After Whipple's (RAW) study, a multi-centre cohort of PD for pancreatic head malignancy (2012-2015). Recurrence and five-year survival rates of patients with DM were compared to those without, and subgroup analysis performed to compare patients with recent-onset DM (less than one year) to patients with established DM. RESULTS Out of 758 patients included, 187 (24.7%) had DM, of whom, 47 of the 187 (25.1%) had recent-onset DM. There was no difference in the rate of postoperative pancreatic fistula (DM: 5.9% vs no DM 9.8%; p = 0.11), five-year survival (DM: 24.1% vs no DM: 22.9%; p = 0.77) or five-year recurrence (DM: 71.7% vs no DM: 67.4%; p = 0.32). There was also no difference between patients with recent-onset DM and patients with established DM in postoperative outcomes, recurrence, or survival. CONCLUSION We found no difference in five-year recurrence and survival between diabetic patients and those without diabetes. Patients with pre-existing DM should be evaluated for PD on a comparable basis to non-diabetic patients.
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Affiliation(s)
| | | | | | - Peter L Labib
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | | | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | | | | | | | | | | | | | - Hassaan Bari
- Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | | | | | | | | | | | - Ismael Dominguez
- Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dhanny Gomez
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Andrea Mingoli
- Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Mavroeidis VK, Knapton J, Saffioti F, Morganstein DL. Pancreatic surgery and tertiary pancreatitis services warrant provision for support from a specialist diabetes team. World J Diabetes 2024; 15:598-605. [PMID: 38680702 PMCID: PMC11045411 DOI: 10.4239/wjd.v15.i4.598] [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: 12/30/2023] [Revised: 01/30/2024] [Accepted: 03/01/2024] [Indexed: 04/11/2024] Open
Abstract
Pancreatic surgery units undertake several complex operations, albeit with considerable morbidity and mortality, as is the case for the management of complicated acute pancreatitis or chronic pancreatitis. The centralisation of pancreatic surgery services, with the development of designated large-volume centres, has contributed to significantly improved outcomes. In this editorial, we discuss the complex associations between diabetes mellitus (DM) and pancreatic/periampullary disease in the context of pancreatic surgery and overall management of complex pancreatitis, highlighting the consequential needs and the indispensable role of specialist diabetes teams in support of tertiary pancreatic services. Type 3c pancreatogenic DM, refers to DM developing in the setting of exocrine pancreatic disease, and its identification and management can be challenging, while the glycaemic control of such patients may affect their course of treatment and outcome. Adequate preoperative diabetes assessment is warranted to aid identification of patients who are likely to need commencement or escalation of glucose lowering therapy in the postoperative period. The incidence of new onset diabetes after pancreatic resection is widely variable in the literature, and depends on the type and extent of pancreatic resection, as is the case with pancreatic parenchymal loss in the context of severe pancreatitis. Early involvement of a specialist diabetes team is essential to ensure a holistic management. In the current era, large volume pancreatic surgery services commonly abide by the principles of enhanced recovery after surgery, with inclusion of provisions for optimisation of the perioperative glycaemic control, to improve outcomes. While various guidelines are available to aid perioperative management of DM, auditing and quality improvement platforms have highlighted deficiencies in the perioperative management of diabetic patients and areas of required improvement. The need for perioperative support of diabetic patients by specialist diabetes teams is uniformly underlined, a fact that becomes clearly more prominent at all different stages in the setting of pancreatic surgery and the management of complex pancreatitis. Therefore, pancreatic surgery and tertiary pancreatitis services must be designed with a provision for support from specialist diabetes teams. With the ongoing accumulation of evidence, it would be reasonable to consider the design of specific guidelines for the glycaemic management of these patients.
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Affiliation(s)
- Vasileios K Mavroeidis
- Department of HPB Surgery, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS2 8HW, United Kingdom
- Department of Gastrointestinal Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, United Kingdom
- Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
| | - Jennifer Knapton
- Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
| | - Francesca Saffioti
- Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, United Kingdom
- UCL Institute for Liver and Digestive Health, University College London, London NW3 2PF, United Kingdom
| | - Daniel L Morganstein
- Department of Endocrinology, Chelsea and Westminster Hospital NHS Foundation Trust, London SW10 9NH, United Kingdom
- Department of Gastrointestinal Unit, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
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Funamizu N, Sakamoto A, Hikida T, Ito C, Shine M, Nishi Y, Uraoka M, Nagaoka T, Honjo M, Tamura K, Sakamoto K, Ogawa K, Takada Y. C-Reactive Protein-to-Albumin Ratio to Predict Tolerability of S-1 as an Adjuvant Chemotherapy in Pancreatic Cancer. Cancers (Basel) 2024; 16:922. [PMID: 38473284 DOI: 10.3390/cancers16050922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/19/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
Adjuvant chemotherapy (AC) with S-1 after radical surgery for resectable pancreatic cancer (PC) has shown a significant survival advantage over surgery alone. Consequently, ensuring that patients receive a consistent, uninterrupted S-1 regimen is of paramount importance. This study aimed to investigate whether the C-reactive protein-to-albumin ratio (CAR) could predict S-1 AC completion in PC patients without dropout due to adverse events (AEs). We retrospectively enrolled 95 patients who underwent radical pancreatectomy and S-1 AC for PC between January 2010 and December 2022. A statistical analysis was conducted to explore the correlation of predictive markers with S-1 completion, defined as continuous oral administration for 6 months. Among the 95 enrolled patients, 66 (69.5%) completed S-1, and 29 (30.5%) failed. Receiver operating characteristic curve analysis revealed 0.05 as the optimal CAR threshold to predict S-1 completion. Univariate and multivariate analyses further validated that a CAR ≥ 0.05 was independently correlated with S-1 completion (p < 0.001 and p = 0.006, respectively). Furthermore, a significant association was established between a higher CAR at initiation of oral administration and acceptable recurrence-free and overall survival (p = 0.003 and p < 0.001, respectively). CAR ≥ 0.05 serves as a predictive marker for difficulty in completing S-1 treatment as AC for PC due to AEs.
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Affiliation(s)
- Naotake Funamizu
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Akimasa Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Takahiro Hikida
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Chihiro Ito
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Mikiya Shine
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Yusuke Nishi
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Mio Uraoka
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Tomoyuki Nagaoka
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Masahiko Honjo
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Kei Tamura
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Kohei Ogawa
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
| | - Yasutsugu Takada
- Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
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Dumitrascu T. Pancreaticoduodenectomies with Concurrent Colectomies: Indications, Technical Issues, Complications, and Oncological Outcomes. J Clin Med 2023; 12:7682. [PMID: 38137749 PMCID: PMC10744251 DOI: 10.3390/jcm12247682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Multi-visceral resections for colon and pancreatic cancer (PDAC) are feasible, safe, and justified for early and late outcomes. However, the use of pancreaticoduodenectomy (PD) with concurrent colectomies is highly debatable in terms of morbidity and oncological benefits. Based on current literature data, this review assesses the early and long-term outcomes of PD with colectomies. The association represents a challenging but feasible option for a few patients with PDAC or locally advanced right colon cancer when negative resection margins are anticipated because long-term survival can be achieved. Concurrent colectomies during PD should be cautiously approached because they may significantly increase complication rates, including severe ones. Thus, patients should be fit enough to overcome potential severe complications. Patients with PD and colectomies can be classified as borderline resectable, considering the high risk of developing postoperative complications. Carefully selecting patients suitable for PD with concurrent colectomies is paramount to mitigate the potentially severe complications of the two surgical procedures and maximize the oncological benefits. These procedures should be performed at high-volume centers with extensive experience in pancreatectomies and colectomies, and each patient situation should be assessed using a multimodal approach, including high-quality imaging and neoadjuvant therapies, in a multidisciplinary team discussion.
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Affiliation(s)
- Traian Dumitrascu
- Division of Surgical Oncology, Department of General Surgery, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Ausania F, Landi F, González-Abós C, Martinie JB, Vrochides D, Walsh M, Hossain SM, White S, Prabakaran V, Melstrom LG, Fong Y, Valle V, Bing Y, Xiu D, Di Franco G, De' Angelis N, Laurent A, Giuliani G, Pernazza G, Memeo R, Rios J, Coratti A, Morelli L, Giulianotti PC. Robotic versus laparoscopic distal pancreatectomy for pancreatic adenocarcinoma in obese patients. Int J Med Robot 2023:e2596. [PMID: 37937476 DOI: 10.1002/rcs.2596] [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: 08/24/2023] [Revised: 10/08/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Robotic distal pancreatectomy (RDP) is associated with a lower conversion rate and less blood loss than laparoscopic distal pancreatectomy (LDP). LDP has similar oncological outcomes as open surgery in PDAC. The aim of this study was to compare perioperative and oncological outcomes in obese patients with RDP versus LDP for PDAC. MATERIALS AND METHODS Retrospectively, all obese patients who underwent RDP or LDP for PDAC between 2012 and 2022 at 12 international expert centres were included. RESULTS out of 372, 81 patients were included. All baseline features were comparable between the two groups. RDP was associated with decreased blood loss (495mlLDP vs. 188mlRDP; p = 0.003), lower conversion rate (13.5%RDP vs. 36.4%LDP; p = 0.019) and lower rate of Clavien-Dindo ≥3 complications (13.5%RDP vs. 36.4%LDP; p = 0.019). Overall and disease-free survival were comparable. CONCLUSIONS In obese patients with left-sided PDAC, the robotic approach was associated with improved intraoperative outcomes and fewer severe complications.
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Affiliation(s)
- Fabio Ausania
- Department of HBP Surgery and Transplantation, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
| | - Filippo Landi
- Department of HBP Surgery and Transplantation, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
| | - Carolina González-Abós
- Department of HBP Surgery and Transplantation, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
| | - John B Martinie
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Matthew Walsh
- HPB Surgery Department, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shanaz M Hossain
- HPB Surgery Department, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Laleh G Melstrom
- Division of Surgical Oncology, Gastrointestinal Disease Team, City of Hope Medical Center, Duarte, California, USA
| | - Yuman Fong
- Division of Surgical Oncology, Gastrointestinal Disease Team, City of Hope Medical Center, Duarte, California, USA
| | - Valentina Valle
- Department of Surgery, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Yuntao Bing
- Department of General Surgery, Beijing Third Hospital, Beijing, China
| | - Dianrong Xiu
- Department of General Surgery, Beijing Third Hospital, Beijing, China
| | - Gregorio Di Franco
- Division of Translational and New Technologies in Medicine and Surgery, General Surgery Department, University of Pisa, Pisa, Italy
| | - Nicola De' Angelis
- Department of Digestive, HBP Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, Creteil, France
| | - Alexis Laurent
- Department of Digestive, HBP Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, Creteil, France
| | - Giuseppe Giuliani
- Division of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Graziano Pernazza
- General and Robotic Surgery Department, San Giovanni Hospital, Rome, Italy
| | - Riccardo Memeo
- Department of Surgery, Acquaviva delle Fonti Hospital, Bari, Italy
| | - José Rios
- Department of Clinical Pharmacology, Hospital Clinic and Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Andrea Coratti
- Division of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Luca Morelli
- Division of Translational and New Technologies in Medicine and Surgery, General Surgery Department, University of Pisa, Pisa, Italy
| | - Pier C Giulianotti
- Department of Surgery, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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