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Zdanowski AH, Wennerblom J, Rystedt J, Andersson B, Tingstedt B, Williamsson C. Predictive Factors for Delayed Gastric Emptying After Pancreatoduodenectomy: A Swedish National Registry-Based Study. World J Surg 2023; 47:3289-3297. [PMID: 37702776 PMCID: PMC10694105 DOI: 10.1007/s00268-023-07175-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy (PD). DGE causes prolonged hospital stay and a decrease in quality of life. This study analyzes predictive factors for development of DGE after PD, also in the absence of surgical complications. METHOD Data from the Swedish National Pancreatic Cancer Registry for patients undergoing standard and pylorus preserving open PD from January 2010 until June 30, 2018, were collected. Data were analyzed in two groups, no DGE and DGE. A subgroup of patients with DGE but without surgical complications was compared to patients without DGE or any other surgical complication. RESULTS In total, 2503 patients were included, of which 470 (19%) had DGE. In the DGE group, 238 had other coexisting surgical complications and 232 had not. Postoperative pancreatic fistula (OR = 4.22, p < 0.001), surgical infection (OR = 1.44, p = 0.013), heart disease (OR = 1.32, p = 0.023) and medical complications (OR = 1.35, p = 0.025) increased the risk for DGE. A standard PD compared with pylorus preserving resection (OR = 1.69, p = 0.001) and a reconstruction with a pancreaticojejunostomy compared with a pancreaticogastrostomy (OR = 1.83, p < 0.001) increased the risk. For patients without surgical complications, a standard PD and reconstruction with pancreaticojejunostomy still increased the risk for DGE. CONCLUSION DGE is more common after standard PD compared to pylorus preserving PD and after reconstruction with PJ compared to PG in this national cohort, both in the presence of other surgical complications as well as in the absence of other complications.
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Affiliation(s)
- A Hörberg Zdanowski
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - J Wennerblom
- Department of Surgery, Institute of Clinical Sciences Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - J Rystedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - B Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - B Tingstedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - Caroline Williamsson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden.
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2
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Augustinus S, Mackay TM, Andersson B, Beane JD, Busch OR, Gleeson EM, Koerkamp BG, Keck T, van Santvoort HC, Tingstedt B, Wellner UF, Williamsson C, Besselink MG, Pitt HA. Ideal Outcome After Pancreatoduodenectomy: A Transatlantic Evaluation of a Harmonized Composite Outcome Measure. Ann Surg 2023; 278:740-747. [PMID: 37476990 PMCID: PMC10549886 DOI: 10.1097/sla.0000000000006037] [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: 07/22/2023]
Abstract
OBJECTIVE The aim of this study is to define and assess Ideal Outcome in the national or multicenter registries of North America, Germany, the Netherlands, and Sweden. BACKGROUND Assessing outcomes after pancreatoduodenectomy among centers and countries requires a broad evaluation that cannot be captured by a single parameter. Previously, 2 composite outcome measures (textbook outcome and optimal pancreatic surgery) for pancreatoduodenectomy have been described from Europe and the United States. These composites were harmonized into ideal outcome (IO). METHODS This analysis is a transatlantic retrospective study (2018-2020) of patients after pancreatoduodenectomy within the registries from North America, Germany, The Netherlands, and Sweden. After 3 consensus meetings, IO for pancreatoduodenectomy was defined as the absence of all 6 parameters: (1) in-hospital mortality, (2) severe complications-Clavien-Dindo ≥3, (3) postoperative pancreatic fistula-International Study Group of Pancreatic Surgery (ISGPS) grade B/C, (4) reoperation, (5) hospital stay >75th percentile, and (6) readmission. Outcomes were evaluated using relative largest difference (RLD) and absolute largest difference (ALD), and multivariate regression models. RESULTS Overall, 21,036 patients after pancreatoduodenectomy were included, of whom 11,194 (54%) reached IO. The rate of IO varied between 55% in North America, 53% in Germany, 52% in The Netherlands, and 54% in Sweden (RLD: 1.1, ALD: 3%, P <0.001). Individual components varied with an ALD of 2% length of stay, 4% for in-hospital mortality, 12% severe complications, 10% postoperative pancreatic fistula, 11% reoperation, and 9% readmission. Age, sex, absence of chronic obstructive pulmonary disease, body mass index, performance status, American Society of Anesthesiologists (ASA) score, biliary drainage, absence of vascular resection, and histologic diagnosis were associated with IO. In the subgroup of patients with pancreatic adenocarcinoma, country, and neoadjuvant chemotherapy also was associated with improved IO. CONCLUSIONS The newly developed composite outcome measure "Ideal Outcome" can be used for auditing and comparing outcomes after pancreatoduodenectomy. The observed differences can be used to guide collaborative initiatives to further improve the outcomes of pancreatic surgery.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tara M. Mackay
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Joal D. Beane
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas G. Koerkamp
- Department of Surgery, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Tobias Keck
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ulrich F. Wellner
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Henry A. Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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3
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Perri G, van Hilst J, Li S, Besselink MG, Hogg ME, Marchegiani G. Teaching modern pancreatic surgery: close relationship between centralization, innovation, and dissemination of care. BJS Open 2023; 7:zrad081. [PMID: 37698977 PMCID: PMC10496870 DOI: 10.1093/bjsopen/zrad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Pancreatic surgery is increasingly moving towards centralization in high-volume centres, supported by evidence on the volume-outcome relationship. At the same time, minimally invasive pancreatic surgery is becoming more and more established worldwide, and interest in new techniques, such as robotic pancreatoduodenectomy, is growing. Such recent innovations are reshaping modern pancreatic surgery, but they also represent new challenges for surgical training in its current form. METHODS This narrative review presents a chosen selection of literature, giving a picture of the current state of training in pancreatic surgery, together with the authors' own views, and in the context of centralization and innovation towards minimally invasive techniques. RESULTS Centralization of pancreatic surgery at high-volume centres, volume-outcome relationships, innovation through minimally invasive technologies, learning curves in both traditional and minimally invasive surgery, and standardized training paths are the different, but deeply interconnected, topics of this article. Proper training is essential to ensure quality of care, but innovation and centralization may represent challenges to overcome with new training models. CONCLUSION Innovations in pancreatic surgery are introduced with the aim of increasing the quality of care. However, their successful implementation is deeply dependent on dissemination and standardization of surgical training, adapted to fit in the changing landscape of modern pancreatic surgery.
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Affiliation(s)
- Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Shen Li
- Department of Surgical Oncology, University of Chicago, Chicago, Illinois, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Melissa E Hogg
- Department of HPB Surgery, NorthShore Health System, Evanston, Illinois, USA
| | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
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4
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Hemminki K, Försti A, Liska V, Kanerva A, Hemminki O, Hemminki A. Long-term survival trends in solid cancers in the Nordic countries marking timing of improvements. Int J Cancer 2023; 152:1837-1846. [PMID: 36571455 DOI: 10.1002/ijc.34416] [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: 09/26/2022] [Revised: 11/12/2022] [Accepted: 12/19/2022] [Indexed: 12/27/2022]
Abstract
Survival studies are an important indicator of the success of cancer control. We analyzed the 5-year relative survival in 23 solid cancers in Denmark, Finland, Norway and Sweden over a 50-year period (1970-2019) at the NORDCAN database accessed from the International Agency for Research on Cancer website. We plotted survival curves in 5-year periods and showed 5-year periodic survival. The survival results were summarized in four groups: (1) cancers with historically good survival (>50% in 1970-1974) which include melanoma and breast, endometrial and thyroid cancers; (2) cancers which constantly improved survival at least 20% units over the 50 year period, including cancers of the stomach, colon, rectum, kidney, brain and ovary; (3) cancer with increase in survival >20% units with changes taking place in a narrow time window, including oral, oropharyngeal, testicular and prostate cancers; (4) the remaining cancers with <20% unit improvement in survival including lung, esophageal, liver, pancreatic, bladder, soft tissue, penile, cervical and vulvar cancers. For cancers in groups 1 and 2, the constant development implied multiple improvements in therapy, diagnosis and patient care. Cancers in group 3 included testicular cancers with known therapeutic improvements but for the others large incidence changes probably implied that cancer stage (prostate) or etiology (oropharynx) changed into a more tractable form. Group 4 cancers included those with dismal survival 50 years ago but a clear tendency upwards. In 17 cancers 5-year survival reached between 50% and 100% while in only six cancers it remained at below 50%.
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Affiliation(s)
- Kari Hemminki
- Biomedical Center and Faculty of Medicine, Pilsen, Charles University in Prague, Pilsen, Czech Republic.,Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Asta Försti
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany.,Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Vaclav Liska
- Biomedical Center and Faculty of Medicine, Pilsen, Charles University in Prague, Pilsen, Czech Republic.,Department of Surgery, University Hospital Pilsen, Charles University, Pilsen, Czech Republic
| | - Anna Kanerva
- Cancer Gene Therapy Group, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland.,Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Otto Hemminki
- Cancer Gene Therapy Group, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland.,Department of Urology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Akseli Hemminki
- Cancer Gene Therapy Group, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland.,Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
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Masuda H, Kotecha K, Gall T, Gill AJ, Mittal A, Samra JS. Transition from open to robotic distal pancreatectomy in a low volume pancreatic surgery country: a single Australian centre experience. ANZ J Surg 2023; 93:151-159. [PMID: 36511144 DOI: 10.1111/ans.18199] [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: 07/18/2022] [Revised: 10/14/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advances in technology and techniques have allowed for robotic distal pancreatectomies to be readily performed in patients at high volume centres. This study describes the experience of a single surgeon during the learning curve and transition from open to robotic distal pancreatectomy in Australia, a traditionally low volume pancreatic surgery country. METHODS All patients undergoing distal pancreatectomy at an Australian-based tertiary referral centre between 2010 and 2021 were reviewed retrospectively. Demographic, clinicopathologic and survival data were analysed to compare perioperative and oncological outcomes between patients who underwent open, laparoscopic and robotic distal pancreatectomies. RESULTS A total of 178 distal pancreatectomies were identified for analysis during the study period. Ninety-one open distal pancreatectomies (ODP), 48 laparoscopic distal pancreatectomies (LDP), and 39 robotic distal pancreatectomies (RDP) were performed. Robotic distal pancreatectomy was non-inferior with respect to perioperative outcomes and yielded statistically non-significant advantages over LDP and ODP. CONCLUSION RDP is feasible and can be performed safely in well-selected patients during the learning phase at large pancreatic centres in a traditionally low-volume country like Australia. Referral to large pancreatic centres where access to the robotic platform and surgeon experience is not a barrier, and where a robust multidisciplinary team meeting can take place, remains pivotal in the introduction and transition toward the robotic approach for management of patients with pancreatic body or tail lesions.
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Affiliation(s)
- Hiro Masuda
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Tamara Gall
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Anthony J Gill
- Northern Clinical School, University of Sydney, Camperdown, New South Wales, Australia.,NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, Camperdown, New South Wales, Australia.,School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, Camperdown, New South Wales, Australia
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6
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Holmberg M, Radkiewicz C, Strömberg C, Öman M, Ghorbani P, Löhr JM, Sparrelid E. Outcome after surgery for invasive intraductal papillary mucinous neoplasia compared to conventional pancreatic ductal adenocarcinoma - A Swedish nationwide register-based study. Pancreatology 2023; 23:90-97. [PMID: 36522260 DOI: 10.1016/j.pan.2022.12.003] [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: 08/20/2022] [Revised: 10/08/2022] [Accepted: 12/07/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The clinical importance of intraductal papillary mucinous neoplasm (IPMN) have increased last decades. Long-term survival after resection for invasive IPMN (inv-IPMN) compared to conventional pancreatic ductal adenocarcinoma (PDAC) is not thoroughly delineated. OBJECTIVE This study, based on the Swedish national pancreatic and periampullary cancer registry aims to elucidate the outcome after resection of inv-IPMN compared to PDAC. METHODS All patients ≥18 years of age resected for inv-IPMN and PDAC in Sweden between 2010 and 2019 were included. Clinicopathological variables were retrieved from the national registry. The effect on death was assessed in two multivariable Cox regression models, one for patients resected 2010-2015, one for patients resected 2016-2019. Median overall survival (OS) was estimated using the Kaplan-Meier method. RESULTS We included 1909 patients, 293 inv-IPMN and 1616 PDAC. The most important independent predictors of death in multivariable Cox regressions were CA19-9 levels, venous resection, tumour differentiation, as well as T-, N-, M-stage and surgical margin. Tumour type was an independent predictor for death in the 2016-2019 cohort, but not in the 2010-2015 cohort. In Kaplan-Meier survival analysis, inv-IPMN was associated with longer median OS in stage N0-1 and in stage M0 compared to PDAC. However, in stage T2-4 and stage N2 median OS was similar, and in stage M1 even shorter for inv-IPMN compared to PDAC. CONCLUSION In this population-based nationwide study, outcome after resected inv-IPMN compared to PDAC is more favourable in lower stages, and similar to worse in higher.
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Affiliation(s)
- Marcus Holmberg
- Department of Upper Digestive Diseases, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden.
| | - Cecilia Radkiewicz
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Cecilia Strömberg
- Department of Upper Digestive Diseases, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
| | - Mikael Öman
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Sweden
| | - Poya Ghorbani
- Department of Upper Digestive Diseases, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
| | - J-Matthias Löhr
- Department of Upper Digestive Diseases, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
| | - Ernesto Sparrelid
- Department of Upper Digestive Diseases, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
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7
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Sternby H, Andersson B. Nationwide trends and outcomes of neoadjuvant chemotherapy in pancreatic cancer - an analysis of the Swedish national pancreatic cancer registry. Scand J Gastroenterol 2022; 57:1361-1366. [PMID: 35635264 DOI: 10.1080/00365521.2022.2078668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES During the last decade, neoadjuvant therapy (NAT) for pancreatic cancer has become more frequent. Pathological response and overall survival are promising; however, various post-operative complications have been reported. Our primary aim was to compare the complication scenario of patients receiving NAT in borderline resectable and locally advanced disease with those who had upfront pancreatic surgery (UFS) for primarily resectable cancer. METHODS From the Swedish National Pancreatic and Periampullary Cancer Registry, patients resected for pancreatic ductal adenocarcinoma (PDAC) between 2010 and 2018 were identified. Data on patient characteristics, neoadjuvant therapy, post-operative complications and survival were obtained. Comparisons between groups as well as survival analysis were performed. RESULTS Within the total cohort of 13,948 patients, 1894 (median age 69 years, 51% men) were resected for PDAC. Among these, 112 (5.9%) patients received NAT followed by surgery. The patients who received NAT were younger (67 vs 70 years, p < .001), had a lower level of CA19-9 (47 vs 108, p = .001) and had to a larger extent vascular resection (58.9 vs 26.9%, p < .001) and total pancreatectomy performed (23.2 vs 9.1%, p < .001). No difference was found for major post-operative complications and there was no significant change in survival rate between the NAT and UFS groups (median 28 vs 26 months, p = .122). CONCLUSIONS When analyzing data from a national registry, no difference in post-operative complications was found between resected patients receiving UFS and NAT for PDAC. Also, the survival was equal between groups. NAT is a feasible treatment option for patients with potentially curable pancreatic cancer.
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Affiliation(s)
- Hanna Sternby
- Department of Surgery, Institute of Clinical Sciences-Malmö, Lund University, Lund, Sweden
- Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Surgery, Institute of Clinical Sciences-Malmö, Lund University, Lund, Sweden
- Skåne University Hospital, Lund, Sweden
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8
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Hemminki K, Försti A, Hemminki O, Liska V, Hemminki A. Long-term survival trends for primary liver and pancreatic cancers in the Nordic countries. JHEP Rep 2022; 4:100602. [DOI: 10.1016/j.jhepr.2022.100602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/12/2022] [Accepted: 09/21/2022] [Indexed: 11/15/2022] Open
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9
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Complications and chemotherapy have little impact on postoperative quality of life after pancreaticoduodenectomy - a cohort study. HPB (Oxford) 2022; 24:1464-1473. [PMID: 35410782 DOI: 10.1016/j.hpb.2022.02.014] [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: 10/16/2021] [Revised: 01/21/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND With the poor prognosis of pancreatic cancer and the high rate of postoperative complications after pancreaticoduodenectomy, it is important to evaluate how the operation affects patients' quality of life. METHODS This single-centre study included all patients undergoing pancreaticoduodenectomy from 2006 to 2016. Quality of life was measured with two questionnaires preoperatively, and at 6 and 12 months postoperatively. Comparisons between groups were made using a linear mixed models analysis. RESULTS Of 279 patients planned for pancreaticoduodenectomy, 245 underwent the operation. The postoperative response rates were all 80% or more. Differences were found in one domain between the early and late time periods and three domains between patients receiving and not receiving adjuvant chemotherapy. No significant differences were found between patients with and without severe postoperative complications. However, the demographic variables of age group, sex, preoperative diabetes and smoking all exerted a significant impact on postoperative quality of life. CONCLUSION While little or no impact was shown for the factors of postoperative complications, time period and adjuvant chemotherapy, demographic data, such as age, sex, preoperative diabetes and smoking, had considerable impacts on postoperative quality of life after pancreaticoduodenectomy.
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10
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de Jong EJM, van der Geest LG, Besselink MG, Bouwense SAW, Buijsen J, Dejong CHC, Koerkamp BG, Heij LR, de Hingh IHJT, Hoge C, Kazemier G, van Laarhoven HWM, de Meijer VE, Stommel MWJ, Tjan-Heijnen VCG, Valkenburg-van Iersel LBJ, Wilmink JW, Geurts SME, de Vos-Geelen J. Treatment and overall survival of four types of non-metastatic periampullary cancer: nationwide population-based cohort study. HPB (Oxford) 2022; 24:1433-1442. [PMID: 35135724 DOI: 10.1016/j.hpb.2022.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/29/2021] [Accepted: 01/17/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Periampullary adenocarcinoma consists of pancreatic adenocarcinoma (PDAC), distal cholangiocarcinoma (DC), ampullary cancer (AC), and duodenal adenocarcinoma (DA). The aim of this study was to assess treatment modalities and overall survival by tumor origin. METHODS Patients diagnosed with non-metastatic periampullary cancer in 2012-2018 were identified from the Netherlands Cancer Registry. OS was studied with Kaplan-Meier analysis and multivariable Cox regression analyses, stratified by origin. RESULTS Among the 8758 patients included, 68% had PDAC, 13% DC, 12% AC, and 7% DA. Resection was performed in 35% of PDAC, 56% of DC, 70% of AC, and 59% of DA. Neoadjuvant and/or adjuvant therapy was administered in 22% of PDAC, 7% of DC, 7% of AC, and 12% of DA. Three-year OS was highest for AC (37%) and DA (34%), followed by DC (21%) and PDAC (11%). Adjuvant therapy was associated with improved OS among PDAC (HR = 0.62; 95% CI 0.55-0.69) and DC (HR = 0.69; 95% CI 0.48-0.98), but not AC (HR = 0.87; 95% CI 0.62-1.22) and DA (HR = 0.85; 95% CI 0.48-1.50). CONCLUSION This retrospective study identified considerable differences in treatment modalities and OS between the four periampullary cancer origins in daily clinical practice. An improved OS after adjuvant chemotherapy could not be demonstrated in patients with AC and DA.
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Affiliation(s)
- Evelien J M de Jong
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Lydia G van der Geest
- Department of Research and Innovation, Netherlands Comprehensive Cancer Organization (IKNL), 3501 DB, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, 1081 HV, Amsterdam, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Jeroen Buijsen
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - C H C Dejong
- Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Bas G Koerkamp
- Department of Surgery, Division of Oncology, Erasmus Medical Center, 3015 GD, Rotterdam, the Netherlands
| | - Lara R Heij
- Department of Surgery, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands; Surgery Aachen: Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, RWTH Aachen University Hospital, Aachen, 52062, Germany; Institute of Pathology, RWTH Aachen University, Aachen, 52062, Germany
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Cancer Institute, 5623 EJ, Eindhoven, the Netherlands; GROW - School for Oncology and Developmental Biology, Maastricht University, PO Box 616, 6200 MD, Maastricht, Netherlands
| | - Chantal Hoge
- Department of Internal Medicine, Division of Gastroenterology, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, 1081 HV, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ, Amsterdam, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, 9713 GZ, Groningen, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Nijmegen Medical Center, 6500 HB, Nijmegen, the Netherlands
| | - Vivianne C G Tjan-Heijnen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Liselot B J Valkenburg-van Iersel
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ, Amsterdam, the Netherlands
| | - Sandra M E Geurts
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands.
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Bereza-Carlson P, Nilsson J, Andersson B. Preoperative Risk Score for Early Mortality After Up-Front Pancreatic Cancer Surgery: A Nationwide Cohort Study. World J Surg 2022; 46:2769-2777. [PMID: 35939088 PMCID: PMC9529690 DOI: 10.1007/s00268-022-06678-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 12/02/2022]
Abstract
Background Pancreatic ductal adenocarcinoma is a highly fatal malignancy. The aim was to identify preoperative factors for early mortality in up-front resectable patients following pancreatoduodenectomy (PD) and develop an early mortality risk score. Methods Patients registered in the Swedish National Registry for Pancreatic and Periampullary Cancer were included. Relevant preoperative factors (n = 21) were investigated. Early mortality was defined as death within 12 months after surgery. Based on the identified risk factor odds ratios (ORs), the Score Predicting Early Mortality (SPEM) was developed.
Results In total, 2183 PDs were performed, and 926 patients met the study criteria. The mean age was 68 (SD ± 8.8) years, and 48% were female. A total of 233 (24%) patients died within 12 months. In the multivariable analyses, age > 75 years (OR 1.7; 95% CI 1.1–2.4; p = 0.008), CRP ≥ 15 mg/L (OR 2.0; 95% CI 1.3–3.1; p = 0.001), CA 19-9 > 500 U/mL (OR 1.8; 95% CI 1.0–3.2; p = 0.040), diabetes mellitus (OR 1.40; 95% CI 1.00–2.1; p = 0.042), and active smoking (OR 1.47; 95%CI 1.00–2.00; p = 0.050) were found to be independent risk factors for early mortality. Conclusion Five independent preoperative risk factors for early mortality following PD were identified and together formed SPEM. The score might be a useful tool in establishing individualized treatment plans.
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Affiliation(s)
- Paulina Bereza-Carlson
- Department of Clinical Sciences Lund, Surgery, Lund University, Lund, Sweden
- Central Hospital of Kristianstad, Kristianstad, Sweden
| | - Johan Nilsson
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University, Lund, Sweden
- Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University, Lund, Sweden.
- Skåne University Hospital, Lund, Sweden.
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12
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Ratnayake B, Pendharkar SA, Connor S, Koea J, Sarfati D, Dennett E, Pandanaboyana S, Windsor JA. Patient volume and clinical outcome after pancreatic cancer resection: A contemporary systematic review and meta-analysis. Surgery 2022; 172:273-283. [PMID: 35034796 DOI: 10.1016/j.surg.2021.11.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/02/2021] [Accepted: 11/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatic cancer remains a highly fatal disease with a 5-year overall survival of less than 10%. In seeking to improve clinical outcomes, there is ongoing debate about the weight that should be given to patient volume in centralization models. The aim of this systematic review is to examine the relationship between patient volume and clinical outcome after pancreatic resection for cancer in the contemporary literature. METHODS The Google Scholar, PubMed, and Cochrane Library databases were systematically searched from February 2015 until June 2021 for articles reporting patient volume and outcomes after pancreatic cancer resection. RESULTS There were 46 eligible studies over a 6-year period comprising 526,344 patients. The median defined annual patient volume thresholds varied: low-volume 0 (range 0-9), medium-volume 9 (range 3-29), high-volume 19 (range 9-97), and very-high-volume 28 (range 17-60) patients. The latter 2 were associated with a significantly lower 30-day mortality (P < .001), 90-day mortality (P < .001), overall postoperative morbidity (P = .005), failure to rescue rate (P = .006), and R0 resection rate (P = .008) compared with very-low/low-volume hospitals. Centralization was associated with lower 30-day mortality in 3 out of 5 studies, while postoperative morbidity was similar in 4 out of 4 studies. Median survival was longer in patients traveling greater distance for pancreatic resection in 2 out of 3 studies. Median and 5-year survival did not differ between urban and rural settings. CONCLUSION The contemporary literature confirms a strong relationship between patient volume and clinical outcome for pancreatic cancer resection despite expected bias toward more complex surgery in high-volume centers. These outcomes include lower mortality, morbidity, failure-to-rescue, and positive resection margin rates.
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Affiliation(s)
- Bathiya Ratnayake
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand; HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand. https://twitter.com/ProfJohnWindsor
| | - Sayali A Pendharkar
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - Saxon Connor
- Department of Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Jonathan Koea
- Upper GI Unit, Northshore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Diana Sarfati
- Department of Public Health, University of Otago, Dunedin, New Zealand; Cancer Control Agency, Te Aho O Te Kahu, Ministry of Health, New Zealand
| | - Elizabeth Dennett
- Cancer Control Agency, Te Aho O Te Kahu, Ministry of Health, New Zealand
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK; Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand; HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand.
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13
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Sahlström E, Bereza-Carlson P, Nilsson J, Tingstedt B, Andersson B. Risk factors and outcomes for patients with pancreatic cancer undergoing surgical exploration without resection due to metastatic disease: A national cohort study. Hepatobiliary Pancreat Dis Int 2022; 21:279-284. [PMID: 35248479 DOI: 10.1016/j.hbpd.2022.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 02/08/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Unresectable disease is sometimes diagnosed during surgery in patients with pancreatic ductal adenocarcinoma (PDAC). This study aimed to identify preoperative risk factors for metastatic disease diagnosed at surgical exploration and to investigate and compare survival in resected and non-resected patients. METHODS Patients were identified from the Swedish National Pancreatic and Periampullary Cancer Registry 2010-2018. Predictors of metastatic disease were evaluated with a multivariable logistic regression model, and survival was evaluated with Kaplan-Meier estimates and log-rank tests. RESULTS In total, 1938 patients with PDAC were scheduled for surgery. An unresectable situation was diagnosed intraoperatively in 399 patients (20.6%), including 234 (12.1%) with metastasized disease. Independent risk factors for metastasis were involuntary weight loss (OR = 1.72; 95% CI: 1.27-2.33) and elevated carbohydrate antigen 19-9 (CA19-9) (35-599 U/mL, OR = 1.79, 95% CI: 1.11-2.89; ≥ 600 U/mL, OR = 3.24, 95% CI: 2.04-5.17). Overall survival was lower among patients with metastasized disease than that among patients with a resectable tumor (P < 0.001). CONCLUSIONS Involuntary weight loss and an elevation of CA19-9 are preoperative risk factors for diagnosing metastasized disease during surgical exploration.
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Affiliation(s)
- Emil Sahlström
- Department of Clinical Sciences Lund, Surgery, Lund University, Sweden
| | - Paulina Bereza-Carlson
- Department of Clinical Sciences Lund, Surgery, Lund University, Sweden; Department of Surgery, Central Hospital Kristianstad, Sweden
| | - Johan Nilsson
- Department of Translational Medicine, Cardiothoracic surgery and bioinformatics, Lund University, Sweden; Department of Thoracic and vascular surgery, Skåne University hospital, Lund, Sweden
| | - Bobby Tingstedt
- Department of Clinical Sciences Lund, Surgery, Lund University, Sweden; Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University, Sweden; Department of Surgery, Skåne University Hospital, Lund, Sweden.
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14
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Johansen K, Khodakaram K, Lundgren L, Hasselgren K, Gasslander T, Sandström P, Bratlie SO, Björnsson B. Preoperative Biliary Drainage Does Not Independently Reduce Survival After Pancreaticoduodenectomy Among Patients With Pancreatic Ductal Adenocarcinoma: A National Registry Study. ANNALS OF SURGERY OPEN 2021; 2:e090. [PMID: 37635825 PMCID: PMC10455057 DOI: 10.1097/as9.0000000000000090] [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: 07/12/2021] [Accepted: 07/18/2021] [Indexed: 11/26/2022] Open
Abstract
Objective This study aimed to explore a possible relationship between preoperative biliary drainage (PBD) and overall survival in a national cohort of Swedish patients who underwent pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). Background PBD has been shown to increase postoperative complications after PD, but its use is steadily increasing. There are a few small studies that have indicated that PBD might in itself negatively affect overall survival after PD. Methods Patients from the Swedish National Registry for tumors in the pancreatic and periampullary region diagnosed from 2010 to 2019 who underwent PD for PDAC were included. Kaplan-Meier curves, log-rank tests and Cox proportional hazards analyses were performed to investigate survival. Results Out of 15,818 patients in the registry, 3113 had undergone PD, of whom 1471 had a histopathological diagnosis of PDAC. Patients who had undergone PBD had significantly worse survival, but the effect of PBD disappeared in the multivariable analysis when elevated bilirubin at any time was included. Conclusions PBD does not independently influence survival after PD for PDAC, but this study implies that even a nominally increased preoperative bilirubin level might impair long-term survival.
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Affiliation(s)
- Karin Johansen
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Kaveh Khodakaram
- Department of Gastrosurgical Research, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Linda Lundgren
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Kristina Hasselgren
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thomas Gasslander
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Per Sandström
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Svein Olav Bratlie
- Department of Gastrosurgical Research, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bergthor Björnsson
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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15
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Ullgren H, Fransson P, Olofsson A, Segersvärd R, Sharp L. Health care utilization at end of life among patients with lung or pancreatic cancer. Comparison between two Swedish cohorts. PLoS One 2021; 16:e0254673. [PMID: 34270589 PMCID: PMC8284833 DOI: 10.1371/journal.pone.0254673] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/30/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives The purpose was to analyze trends in intensity of care at End-of-life (EOL), in two cohorts of patients with lung or pancreatic cancer. Setting We used population-based registry data on health care utilization to describe proportions and intensity of care at EOL comparing the two cohorts (deceased in the years of 2010 and 2017 respectively) in the region of Stockholm, Sweden. Primary and secondary outcomes Main outcomes were intensity of care during the last 30 days of life; systemic anticancer treatment (SACT), emergency department (ED) visits, length of stay (LOS) > 14 days, intensive care (ICU), death at acute care hospital and lack of referral to specialized palliative care (SPC) at home. The secondary outcomes were outpatient visits, place of death and hospitalizations, as well as radiotherapy and major surgery. A multivariable logistic regression analysis was used for associations. A moderation variable was added to assess for the effect of SPC at home between the cohorts. Results Intensity of care at EOL increased over time between the cohorts, especially use of SACT, increased with 10%, p<0.001, (n = 102/754 = 14% to n = 236/972 = 24%), ED visits with 7%, p<0.001, (n = 25/754 = 3% to n = 100/972 = 10%) and ICU care, 2%, p = 0.04, (n = 12/754 = 2% to n = 38/972 = 4%). High intensity of care at EOL were more likely among patients with lung cancer. The difference in use of SACT between the years, was moderated by SPC, with an increase of SACT, unstandardized coefficient β; 0.87, SE = 0.27, p = 0.001, as well as the difference between the years in death at acute care hospitals, that decreased (β = 0.69, SE = 0.26, p = 0.007). Conclusion These findings underscore an increase of several aspects regarding intensity of care at EOL, and a need for further exploration of the optimal organization of EOL care. Our results indicate fragmentation of care and a need to better organize and coordinate care for vulnerable patients.
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Affiliation(s)
- Helena Ullgren
- Department of Nursing, Umeå University, Umeå, Sweden
- Regional Cancer Center, Stockholm, Gotland, Sweden
- Theme cancer, Karolinska University Hospital, Stockholm, Sweden
- * E-mail:
| | - Per Fransson
- Department of Nursing, Umeå University, Umeå, Sweden
| | | | - Ralf Segersvärd
- Regional Cancer Center, Stockholm, Gotland, Sweden
- Department of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Lena Sharp
- Regional Cancer Center, Stockholm, Gotland, Sweden
- Department of Innovative Care, LIME, Karolinska Institutet, Stockholm, Sweden
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16
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Johansen K, Lundgren L, Gasslander T, Hasselgren K, Sandström P, Björnsson B. High resection rate improves overall survival in elderly patients with pancreatic head cancer – A cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Abstract
OBJECTIVE This analysis aimed to compare failure to rescue (FTR) after pancreatoduodenectomy across the Atlantic. SUMMARY BACKGROUND DATA FTR, or mortality after development of a major complication, is a quality metric originally created to compare hospital results. FTR has been studied in North American and Northern European patients undergoing pancreatoduodenectomy (PD). However, a direct comparison of FTR after PD between North America and Northern Europe has not been performed. METHODS Patients who underwent PD in North America, the Netherlands, Sweden and Germany (GAPASURG dataset) were identified from their respective registries (2014-17). Patients who developed a major complication defined as Clavien-Dindo ≥3 or developed a grade B/C postoperative pancreatic fistula (POPF) were included. Preoperative, intraoperative, and postoperative variables were compared between patients with and without FTR. Variables significant on univariable analysis were entered into a logistic regression for FTR. RESULTS Major complications occurred in 6188 of 22,983 patients (26.9%) after PD, and 504 (8.1%) patients had FTR. North American and Northern European patients with complications differed, and rates of FTR were lower in North America (5.4% vs 12%, P < 0.001). Fourteen factors from univariable analysis contributing to differences in patients who developed FTR were included in a logistic regression. On multivariable analysis, factors independently associated with FTR were age, American Society of Anesthesiology ≥3, Northern Europe, POPF, organ failure, life-threatening complication, nonradiologic intervention, and reoperation. CONCLUSIONS Older patients with severe systemic diseases are more difficult to rescue. Failure to rescue is more common in Northern Europe than North America. In stable patients, management of complications by interventional radiology is preferred over reoperation.
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18
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Öman M, Wettergren Y, Odin E, Westermark S, Naredi P, Hemmingsson O, Taflin H. Pharmacokinetics of preoperative intraperitoneal 5-FU in patients with pancreatic ductal adenocarcinoma. Cancer Chemother Pharmacol 2021; 88:619-631. [PMID: 34132895 PMCID: PMC8367903 DOI: 10.1007/s00280-021-04318-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim was to investigate the pharmacokinetics of preoperatively administered intraperitoneal (IP) 5-FU in patients with resectable pancreatic ductal adenocarcinoma (PDAC) by analyzing levels of 5-FU and target metabolites in peritoneal fluid, plasma, liver, lymph nodes, pancreatic tumour, and pancreatic tissue. These results were correlated to expression of genes encoding enzymes of the 5-FU pathway and cell membrane transporters of 5-FU and FdUMP. METHODS Twenty-two patients with PDAC were treated with IP 5-FU before surgery. The postoperative treatment followed a routine clinical protocol. 5-FU and its metabolites were analyzed by LC-MS/MS. The expression of genes encoding enzymes and transporters in the 5-FU pathway was analyzed by qPCR. RESULTS After IP treatment, 5-FU could be detected in plasma, lymph nodes, liver, pancreatic tumour, and pancreatic tissue. The highest 5-FU concentration was found in the liver, also expressing high levels of the 5-FU transporter OAT2. 5-FU was converted to active FdUMP in all tissues and the highest concentration was measured in lymph nodes, liver and pancreatic tumour (18.5, 6.1 and 6.7 pmol/g, respectively). There was a correlation between the FdUMP and dUr levels in lymph nodes (r = 0.70, p = 0.0076). In tumours, there was an association between OAT2 expression and FdUMP concentration. CONCLUSION The study shows uptake of IP 5-FU and drug metabolism to active FdUMP in pancreatic tumour, liver, and lymph nodes. Extended studies are warranted to evaluate the IP route for 5-FU administration in PDAC patients.
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Affiliation(s)
- Mikael Öman
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University Faculty of Medicine, Umeå University, 90185, Umeå, Sweden.
| | - Yvonne Wettergren
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital/Östra, 41345, Göteborg, Sweden
| | - Elisabeth Odin
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital/Östra, 41345, Göteborg, Sweden
| | - Sofia Westermark
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University Faculty of Medicine, Umeå University, 90185, Umeå, Sweden.,Department of Surgery, Örnsköldsviks sjukhus, 89135, Örnsköldsvik, Sweden
| | - Peter Naredi
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital/Östra, 41345, Göteborg, Sweden
| | - Oskar Hemmingsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University Faculty of Medicine, Umeå University, 90185, Umeå, Sweden
| | - Helena Taflin
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital/Östra, 41345, Göteborg, Sweden
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19
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Williamsson C, Rystedt J, Andersson B. An analysis of gender differences in treatment and outcome of periampullary tumours in Sweden - A national cohort study. HPB (Oxford) 2021; 23:847-853. [PMID: 33339715 DOI: 10.1016/j.hpb.2020.11.1145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/11/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little is known of possible gender differences in treatment of periampullary tumours and outcome after pancreatoduodenectomy (PD), and the aim of this study was therefore to investigate any variances from national multicentre perspective. METHODS Data from the Swedish National Registry for Pancreatic and Periampullary Cancer for all patients diagnosed with a periampullary tumour from 2012 throughout 2017 was collected. The material was analysed in two groups, men and women, for palliative treatment and curative intended resection. RESULTS A total of 5677 patients were included, 2906 (51%) men and 2771 (49%) women. Women were older than men, 72 (65-78) years vs. 70 (64-76), p < 0.001. A lesser proportion of women were planned for resection (1131 (41%) vs. 1288 (44%), p = 0.008), but after adjusting for age and tumour location no difference was seen. Postoperative morbidity was equal, but women had significantly better long-term survival than men. The survival was equal for palliative men and women. CONCLUSION No gender bias could be established when analysing treatment for periampullary tumours in Sweden, even though less women were offered surgery. Data suggest that even though women were older they tolerate surgery well and hence offering PD at a higher age for women could be suggested.
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Affiliation(s)
- Caroline Williamsson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden.
| | - Jenny Rystedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
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20
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Haraldsson E, Halimi A, Rangelova E, Valente R, Löhr JM, Arnelo U. Adenomatous neoplasia in the papilla of Vater endoscopic and/or surgical resection? Surg Endosc 2021; 36:2401-2411. [PMID: 33942182 DOI: 10.1007/s00464-021-08521-y] [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: 01/13/2021] [Accepted: 04/17/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Adenomatous neoplasia in the papilla of Vater needs to be resected in order not to progress. It can be challenging to distinguish between early ampullary malignant lesions and non-invasive adenomas, due to the overlap in symptoms and radiological findings. This retrospective study describes the different findings and treatment decisions taken prior to endoscopic and/or surgical resection of ampullary adenomatous lesions. MATERIALS AND METHODS Patients treated with endoscopic and/or surgical resection for suspected or verified ampullary adenomatous neoplasia, between January 2006 and July 2018, where pre-interventional cross-sectional imaging could not discern an obvious invasive, malignant tumor, were included. Findings were compared against the final diagnosis of the histopathological analysis on the resected specimen. RESULTS In total, 172 met the inclusion criteria. Patients were treated with either surgical resection (n = 96), endoscopic papillectomy (EP) (n = 55) or both (n = 21). The final diagnosis was in 48% ampullary adenocarcinoma, and the remaining had either ampullary adenoma (38%) or non-neoplastic lesions (14%). In patients where symptoms and cross-sectional imaging were suspicious for malignancy, but with no tissue samples that confirmed neoplasia prior to surgical resection, only 47% had adenocarcinoma. The remaining had either adenoma (9%) or non-neoplastic lesions (44%). Adenocarcinoma was revealed in 27% of the patients where endoscopic biopsies had shown adenoma. Patients with adenoma, treated with EP, were cured in 59%. However, 28% were after EP sent for further surgery due to ductal invasion or a finding of adenocarcinoma. CONCLUSIONS In patients with a suspicion of ampullary neoplasia on imaging, attempts should be made to get endoscopic tissue samples before deciding on a treatment strategy. If biopsies show ampullary adenoma, patients should be considered for EP, unless there are clear radiologic or endoscopic signs of malignancy. Patients with adenocarcinoma on endoscopic biopsies should undergo surgical resection.
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Affiliation(s)
- Erik Haraldsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden. .,Department of Surgery, Skaraborg Hospital, Skövde, Sweden.
| | - Asif Halimi
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Elena Rangelova
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Section for Upper Abdominal Surgery at the Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roberto Valente
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - J Matthias Löhr
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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21
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Partelli S, Sclafani F, Barbu ST, Beishon M, Bonomo P, Braz G, de Braud F, Brunner T, Cavestro GM, Crul M, Trill MD, Ferollà P, Herrmann K, Karamitopoulou E, Neuzillet C, Orsi F, Seppänen H, Torchio M, Valenti D, Zamboni G, Zins M, Costa A, Poortmans P. European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Pancreatic Cancer. Cancer Treat Rev 2021; 99:102208. [PMID: 34238640 DOI: 10.1016/j.ctrv.2021.102208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 12/14/2022]
Abstract
European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Pancreatic cancer is an increasing cause of cancer mortality and has wide variation in treatment and care in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must be carried out only in pancreatic cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.
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Affiliation(s)
- Stefano Partelli
- European Society of Surgical Oncology (ESSO); IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Sclafani
- European Organisation for Research and Treatment of Cancer (EORTC); Institut Jules Bordet, Brussels, Belgium
| | - Sorin Traian Barbu
- Pancreatic Cancer Europe (PCE); Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Marc Beishon
- Cancer World, European School of Oncology (ESO), Milan, Italy
| | - Pierluigi Bonomo
- Flims Alumni Club (FAC); Careggi University Hospital, Florence, Italy
| | - Graça Braz
- European Oncology Nursing Society (EONS); Portuguese Oncology Institute, Porto, Portugal
| | - Filippo de Braud
- Organisation of European Cancer Institutes (OECI); IRCCS Foundation National Cancer Institute of Milan, Milan, Italy
| | - Thomas Brunner
- European Society for Radiotherapy and Oncology (ESTRO); Otto von Guericke University, Magdeburg, Germany
| | - Giulia Martina Cavestro
- European Hereditary Tumour Group (EHTG); IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mirjam Crul
- European Society of Oncology Pharmacy (ESOP); Amsterdam University Medical Centre, Netherlands
| | - Maria Die Trill
- International Psycho-Oncology Society (IPOS); ATRIUM: Psycho-Oncology & Clinical Psychology, Madrid, Spain
| | - Piero Ferollà
- International Neuroendocrine Cancer Alliance (INCA); Umbria Regional Cancer Network, Perugia, Italy
| | - Ken Herrmann
- European Association of Nuclear Medicine (EANM); University Hospital Essen, Essen, Germany
| | - Eva Karamitopoulou
- European Society of Pathology (ESP); Institute of Pathology, University of Bern, Bern, Switzerland
| | - Cindy Neuzillet
- International Society of Geriatric Oncology (SIOG), Institut Curie, Saint-Cloud, France
| | - Franco Orsi
- Cardiovascular and Interventional Radiological Society of Europe (CIRSE); European Institute of Oncology, Milan, Italy
| | - Hanna Seppänen
- Association of European Cancer Leagues (ECL); Helsinki University Hospital, Helsinki, Finland
| | - Martina Torchio
- Organisation of European Cancer Institutes (OECI); IRCCS Foundation National Cancer Institute of Milan, Milan, Italy
| | - Danila Valenti
- European Association for Palliative Care (EAPC); Palliative Care Network, AUSL Bologna, Bologna, Italy
| | - Giulia Zamboni
- European Society of Oncologic Imaging (ESOI); University Hospital Verona, Verona, Italy
| | - Marc Zins
- European Society of Radiology (ESR); Groupe hospitalier Paris Saint-Joseph, Paris, France
| | | | - Philip Poortmans
- European Cancer Organisation (ECCO); Iridium Kankernetwerk and University of Antwerp, Wilrijk-Antwerp, Belgium
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22
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Latenstein AEJ, Mackay TM, Beane JD, Busch OR, van Dieren S, Gleeson EM, Koerkamp BG, van Santvoort HC, Wellner UF, Williamsson C, Tingstedt B, Keck T, Pitt HA, Besselink MG. The use and clinical outcome of total pancreatectomy in the United States, Germany, the Netherlands, and Sweden. Surgery 2021; 170:563-570. [PMID: 33741182 DOI: 10.1016/j.surg.2021.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/16/2021] [Accepted: 02/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Total pancreatectomy has high morbidity and mortality and differences among countries are currently unknown. This study compared the use and postoperative outcomes of total pancreatectomy among 4 Western countries. METHODS Patients who underwent one-stage total pancreatectomy were included from registries in the United States, Germany, the Netherlands, and Sweden (2014-2018). Use of total pancreatectomy was assessed by calculating the ratio total pancreatectomy to pancreatoduodenectomy. Primary outcomes were major morbidity (Clavien Dindo ≥3) and in-hospital mortality. Predictors for the primary outcomes were assessed in multivariable logistic regression analyses. Sensitivity analysis assessed the impact of volume (low-volume <40 or high-volume ≥40 pancreatoduodenectomies annually; data available for the Netherlands and Germany). RESULTS In total, 1,579 patients underwent one-stage total pancreatectomy. The relative use of total pancreatectomy to pancreatoduodenectomy varied up to fivefold (United States 0.03, Germany 0.15, the Netherlands 0.03, and Sweden 0.15; P < .001). Both the indication and several baseline characteristics differed significantly among countries. Major morbidity occurred in 423 patients (26.8%) and differed (22.3%, 34.9%, 38.3%, and 15.9%, respectively; P < .001). In-hospital mortality occurred in 85 patients (5.4%) and also differed (1.8%, 10.2%, 10.8%, 1.9%, respectively; P < .001). Country, age ≥75, and vascular resection were predictors for in-hospital mortality. In-hospital mortality was lower in high-volume centers in the Netherlands (4.9% vs 23.1%; P = .002), but not in Germany (9.8% vs 10.6%; P = .733). CONCLUSION Considerable differences in the use of total pancreatectomy, patient characteristics, and postoperative outcome were noted among 4 Western countries with better outcomes in the United States and Sweden. These large, yet unexplained, differences require further research to ultimately improve patient outcome.
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Affiliation(s)
- Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands. https://twitter.com/anouklatenstein
| | - Tara M Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands. https://twitter.com/tarammackay
| | - Joal D Beane
- Department of Surgical Oncology, Ohio State University, Columbus, OH
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Susan van Dieren
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, 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, the Netherlands
| | - Ulrich F Wellner
- DGAV StuDoQ
- Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Sweden
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Sweden
| | - Tobias Keck
- DGAV StuDoQ
- Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Henry A Pitt
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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23
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Johansen KU, Lundgren LM, Gasslander TR, Sandström P, Björnsson B. There Is No Increase in Perioperative Mortality After Pancreaticoduodenectomy in Octogenarians: Results From the Swedish National Registry for Tumors in the Pancreatic and Periampullary Region. ANNALS OF SURGERY OPEN 2020; 1:e015. [PMID: 37637454 PMCID: PMC10455282 DOI: 10.1097/as9.0000000000000015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/25/2020] [Indexed: 11/25/2022] Open
Abstract
Objective The aim of this observational study was to compare postoperative mortality and complications between octogenarians and younger patients following pancreaticoduodenectomy (PD). Summary Background Data With the growing elderly population and improved operative and postoperative results, PD is performed more frequently in octogenarians. Despite recent studies, it is uncertain whether elderly patients experience worse postoperative outcomes than younger patients. Methods All patients registered in the Swedish National Registry for tumors in the pancreatic and periampullary region from 2010 to 2018 who underwent PD were included in the analysis. Results Out of 13,936 patients included in the registry, 2793 patients underwent PD and were divided into the following age groups: <70 (n = 1508), 70-79 (n = 1137), and ≥80 (n = 148) years old. There was no significant difference in in-hospital, 30- or 90-day mortality among groups. The 2 older groups had a higher rate of medical and some surgical complications but not a significantly higher rate of complications ≥IIIa according to the Clavien-Dindo classification system. The 2 older groups had lower body mass index, higher American Society of Anesthesiologists and Eastern Cooperative Oncology Group scores, lower smoking rates, and a higher rate of preoperative biliary drainage than the <70-year-old group (all P < 0.001). The operation time was shorter in the oldest group. Conclusions Despite the worse preoperative condition of octogenarians than younger patients, short-term mortality and serious complications were not increased. The shorter operation time, however, may indicate that patients in the oldest group were more strictly selected. With careful preoperative consideration, especially regarding cardiovascular morbidity, more octogenarians can potentially be safely offered PD.
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Affiliation(s)
- Karin U. Johansen
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Linda M. Lundgren
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thomas R. Gasslander
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Per Sandström
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Bergthor Björnsson
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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24
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Williamsson C, Stenvall K, Wennerblom J, Andersson R, Andersson B, Tingstedt B. Predictive Factors for Postoperative Pancreatic Fistula-A Swedish Nationwide Register-Based Study. World J Surg 2020; 44:4207-4213. [PMID: 32816084 PMCID: PMC7599162 DOI: 10.1007/s00268-020-05735-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND A serious complication after pancreatoduodenectomy (PD) is postoperative pancreatic fistula (POPF). The aim of this study was to analyse the incidence and predictive factors for POPF by using a large nationwide cohort. METHODS Data from the Swedish National Registry for Pancreatic and Periampullary Cancer for all patients undergoing a PD from 2010 until 30th June 2018 were collected. The material was analysed in two groups, no POPF and clinically relevant (grade B and C) POPF. RESULTS A total of 2503 patients underwent PD, of which 245 (10%) developed POPF. Patients with POPF had significantly more overall complications (Clavien Dindo ≥3a, 75% vs. 21%, p < 0.001) and longer hospital stay (median 23 [16-35] vs. 11 [8-15], p < 0.001) than patients without POPF. The risk of POPF was higher with increased BMI (OR 1.08, p < 0.001). Preoperative presence of diabetes (OR 0.52, p = 0.012) and preoperative biliary drainage (OR 0.34, p < 0.001) reduced the risk of POPF. Reconstruction with pancreaticojejunostomy caused a more than two folded increase in POPF compared with pancreaticogastrostomy (OR 2.41, p < 0.001). Weight gain ≥2 kg on postoperative day 1 was also a risk factor (OR 1.76, p < 0.001). CONCLUSION A high BMI, a pancreaticojejunostomy and postoperative weight gain were risk factors for developing POPF. Diabetes or preoperative biliary drainage was protective.
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Affiliation(s)
- C Williamsson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden.
| | - K Stenvall
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - J Wennerblom
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - R Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - B Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - B Tingstedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
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25
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Ullgren H, Sharp L, Olofsson A, Fransson P. Factors associated with healthcare utilisation during first year after cancer diagnose-a population-based study. Eur J Cancer Care (Engl) 2020; 30:e13361. [PMID: 33216423 PMCID: PMC8047913 DOI: 10.1111/ecc.13361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 08/24/2020] [Accepted: 10/14/2020] [Indexed: 12/24/2022]
Abstract
Background Improved cancer treatments and models of care (such as early palliative care) has developed during recent years. Aspects of healthcare utilisation—unplanned care have been used for evaluation of coordination and quality. The aim was to explore factors associated with cancer healthcare utilisation, during the first year after a cancer diagnosis. Methods Population‐based registry and patient‐reported data, (The European Organisation of Research and Treatment of Cancer (EORTC), QLQ‐ C30 questionnaire and study‐specific questions) were collected. Descriptive statistics and multivariate regression models were performed. Results The sample consists of 1718 patients (haematological, gynaecological, upper gastrointestinal and head and neck cancers). Living alone were associated with unplanned hospital admissions (OR 1.35; 95% CI [1.15, 1.59], p < 0.001). Patients with specialised palliative home care had a higher likelihood of unplanned hospital admissions, (OR 4.35; 95% CI [3.22‐5.91], p < 0.001) and re‐admissions within 30 days, (OR, 5.8; 95% CI [4.12‐8.19], p < 0.001). Conclusions Sociodemographic and clinical factors, such as living alone and disease stage, is associated with healthcare utilisation. Patients with specialised palliative home care report lower levels of HRQoL and higher levels of unplanned care, and our findings stresses the importance of a holistic view when planning care.
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Affiliation(s)
- Helena Ullgren
- Department of nursing, Umeå University, Umeå, Sweden.,Regional Cancer Center, Stockholm-Gotland, Sweden.,Head & Neck, Lung -and Skin cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Sharp
- Regional Cancer Center, Stockholm-Gotland, Sweden.,Department of Innovative Care, LIME, Innovative care, Stockholm, Sweden
| | | | - Per Fransson
- Department of nursing, Umeå University, Umeå, Sweden
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26
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Nymo LS, Kleive D, Waardal K, Bringeland EA, Søreide JA, Labori KJ, Mortensen KE, Søreide K, Lassen K. Centralizing a national pancreatoduodenectomy service: striking the right balance. BJS Open 2020; 4:904-913. [PMID: 32893988 PMCID: PMC7528527 DOI: 10.1002/bjs5.50342] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/23/2020] [Accepted: 07/20/2020] [Indexed: 12/19/2022] Open
Abstract
Background Centralization of pancreatic surgery is currently called for owing to superior outcomes in higher‐volume centres. Conversely, organizational and patient concerns speak for a moderation in centralization. Consensus on the optimal balance has not yet been reached. This observational study presents a volume–outcome analysis of a complete national cohort in a health system with long‐standing centralization. Methods Data for all pancreatoduodenectomies in Norway in 2015 and 2016 were identified through a national quality registry and completed through electronic patient journals. Hospitals were dichotomized (high‐volume (40 or more procedures/year) or medium–low‐volume). Results Some 394 procedures were performed (201 in high‐volume and 193 in medium–low‐volume units). Major postoperative complications occurred in 125 patients (31·7 per cent). A clinically relevant postoperative pancreatic fistula occurred in 66 patients (16·8 per cent). Some 17 patients (4·3 per cent) died within 90 days, and the failure‐to‐rescue rate was 13·6 per cent (17 of 125 patients). In multivariable comparison with the high‐volume centre, medium–low‐volume units had similar overall complication rates, lower 90‐day mortality (odds ratio 0·24, 95 per cent c.i. 0·07 to 0·82) and no tendency for a higher failure‐to‐rescue rate. Conclusion Centralization beyond medium volume will probably not improve on 90‐day mortality or failure‐to‐rescue rates after pancreatoduodenectomy.
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Affiliation(s)
- L S Nymo
- Department of Gastrointestinal Surgery, University Hospital of North, Tromsø, Norway.,Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
| | - D Kleive
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - K Waardal
- Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - E A Bringeland
- Department of Gastrointestinal Surgery, St Olav Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - J A Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - K J Labori
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - K E Mortensen
- Department of Gastrointestinal Surgery, University Hospital of North, Tromsø, Norway.,Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
| | - K Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - K Lassen
- Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway.,Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway
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27
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Mackay TM, Gleeson EM, Wellner UF, Williamsson C, Busch OR, Groot Koerkamp B, Keck T, van Santvoort HC, Tingstedt B, Pitt HA, Besselink MG. Transatlantic registries of pancreatic surgery in the United States of America, Germany, the Netherlands, and Sweden: Comparing design, variables, patients, treatment strategies, and outcomes. Surgery 2020; 169:396-402. [PMID: 32868111 DOI: 10.1016/j.surg.2020.07.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/06/2020] [Accepted: 07/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Registries of pancreatic surgery have become increasingly popular as they facilitate both quality improvement and clinical research. We aimed to compare registries for design, variables collected, patient characteristics, treatment strategies, clinical outcomes, and pathology. METHODS Registered variables and outcomes of pancreatoduodenectomy (2014-2017) in 4 nationwide or multicenter pancreatic surgery registries from the United States of America (American College of Surgeons National Surgical Quality Improvement Program), Germany (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie - Studien-, Dokumentations- und Qualitätszentrum), the Netherlands (Dutch Pancreatic Cancer Audit), and Sweden (Swedish National Pancreatic and Periampullary Cancer Registry) were compared. A core registry set of 55 parameters was identified and evaluated using relative and absolute largest differences between extremes (smallest versus largest). RESULTS Overall, 22,983 pancreatoduodenectomies were included (15,224, 3,558, 2,795, and 1,406 in the United States of America, Germany, the Netherlands, and Sweden). Design of the registries varied because 20 out of 55 (36.4%) core parameters were not available in 1 or more registries. Preoperative chemotherapy in patients with pancreatic ductal adenocarcinoma was administered in 27.6%, 4.9%, 7.0%, and 3.4% (relative largest difference 8.1, absolute largest difference 24.2%, P < .001). Minimally invasive surgery was performed in 7.8%, 4.5%, 13.5%, and unknown (relative largest difference 3.0, absolute largest difference 9.0%, P < .001). Median length of stay was 8.0, 16.0, 12.0, and 11.0 days (relative largest difference 2.0, absolute largest difference 8.0, P < .001). Reoperation was performed in 5.7%, 17.1%, 8.7%, and 11.2% (relative largest difference 3.0, absolute largest difference 11.4%, P < .001). In-hospital mortality was 1.3%, 4.7%, 3.6%, and 2.7% (relative largest difference 3.6, absolute largest difference 3.4%, P < .001). CONCLUSION Considerable differences exist in the design, variables, patients, treatment strategies, and outcomes in 4 Western registries of pancreatic surgery. The absolute largest differences of 24.3% for the use of preoperative chemotherapy, 9.0% for minimally invasive surgery, 11.4% for reoperation rate, and 3.4% for in-hospital mortality require further study and improvement. This analysis provides 55 core parameters for pancreatic surgery registries.
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Affiliation(s)
- Tara M Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Elizabeth M Gleeson
- Department of Surgery, Hahnemann University Hospital and Drexel University College of Medicine, Philadelphia, PA
| | - Ulrich F Wellner
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Tobias Keck
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, the Netherlands
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Henry A Pitt
- Temple University Health System, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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28
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Abstract
BACKGROUND Textbook outcome (TO) is a multidimensional measure for quality assurance, reflecting the "ideal" surgical outcome. METHODS Post-hoc analysis of patients who underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between 2014 and 2017, queried from the nationwide prospective Dutch Pancreatic Cancer Audit. An international survey was conducted among 24 experts from 10 countries to reach consensus on the requirements for TO in pancreatic surgery. Univariable and multivariable logistic regression was performed to identify TO predictors. Between-hospital variation in TO rates was compared using observed-versus-expected rates. RESULTS Based on the survey (92% response rate), TO was defined by the absence of postoperative pancreatic fistula, bile leak, postpancreatectomy hemorrhage (all ISGPS grade B/C), severe complications (Clavien-Dindo ≥III), readmission, and in-hospital mortality. Overall, 3341 patients were included (2633 (79%) PD and 708 (21%) DP) of whom 60.3% achieved TO; 58.3% for PD and 67.4% for DP. On multivariable analysis, ASA class 3 predicted a worse TO rate after PD (ASA 3 OR 0.59 [0.44-0.80]), whereas a dilated pancreatic duct (>3 mm) and pancreatic ductal adenocarcinoma (PDAC) were associated with a better TO rate (OR 2.22 [2.05-3.57] and OR 1.36 [1.14-1.63], respectively). For DP, female sex and the absence of neoadjuvant therapy predicted better TO rates (OR 1.38 [1.01-1.90] and OR 2.53 [1.20-5.31], respectively). When comparing institutions, the observed-versus-expected rate for achieving TO varied from 0.71 to 1.46 per hospital after casemix-adjustment. CONCLUSIONS TO is a novel quality measure in pancreatic surgery. TO varies considerably between pancreatic centers, demonstrating the potential benefit of quality assurance programs.
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29
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Sahlström E, Nilsson J, Tingstedt B, Bergenfeldt M, Andersson R, Andersson B. Surgical exploration without resection in pancreatic and periampullary tumors: Report from a national database. Scand J Surg 2020; 110:344-350. [PMID: 32299289 PMCID: PMC8551431 DOI: 10.1177/1457496920913669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background and objective: Pancreatic and periampullary cancers are sometimes found to have a too advanced disease during surgery to allow resection. The aim was to describe characteristics, treatment, outcome, and time trends for patients that were planned for pancreatic surgery but found unresectable during surgery. Methods: Data from the Swedish National Pancreatic and Periampullary Cancer Registry were used. All patients registered between January 2010 and August 2018 were included. The patient cohort was divided in two halves based on year of diagnosis. Results: In total, 12,377 patients were included in the registry and finally 4568 patients were scheduled for surgery. During surgical exploration, 3879 (84.9%) patients underwent pancreatic resection, 658 (14.4%) patients were found unresectable, and 31 (0.7%) had no pancreatic resection due to other reasons (e.g. benign lesion, comorbidity). More patients underwent surgical exploration and resection during the second time period, but exploration without resection was unchanged (15.7% vs 13.7%; p = 0.062). Survival rates were lower among the unresectable patients with pancreatic and periampullary tumors compared to the resectable patients, including 30-day mortality (n = 17 (3.5%) vs n = 39 (1.6%), p = 0.004) and 90-day mortality (n = 72 (15.0%) vs n = 70 (2.8%), p < 0.001). Palliative surgery became less common during the second half of the time period (p < 0.001). Conclusions: Unresectability is associated with an unfavorable prognosis. The frequency did not decrease during the study period, but palliative surgical procedures became less common.
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Affiliation(s)
- Emil Sahlström
- Department of Clinical Sciences, Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Johan Nilsson
- Department of Clinical Sciences, Lund, Cardiothoracic Surgery Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Bobby Tingstedt
- Department of Clinical Sciences, Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Magnus Bergenfeldt
- Department of Clinical Sciences, Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Roland Andersson
- Department of Clinical Sciences, Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Surgery, Clinical Sciences, Lund, Lund University and Skåne University Hospital, Lund, SE-221 85, Sweden
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30
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Björnsson B, Larsson AL, Hjalmarsson C, Gasslander T, Sandström P. Comparison of the duration of hospital stay after laparoscopic or open distal pancreatectomy: randomized controlled trial. Br J Surg 2020; 107:1281-1288. [DOI: 10.1002/bjs.11554] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/13/2019] [Accepted: 01/21/2020] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Studies have suggested that laparoscopic distal pancreatectomy (LDP) is advantageous compared with open distal pancreatectomy (ODP) regarding hospital stay, blood loss and recovery. Only one randomized study is available, which showed enhanced functional recovery after LDP compared with ODP.
Methods
Consecutive patients evaluated at a multidisciplinary tumour board and planned for standard distal pancreatectomy were randomized prospectively to LDP or ODP in an unblinded, parallel-group, single-centre superiority trial. The primary outcome was postoperative hospital stay.
Results
Of 105 screened patients, 60 were randomized and 58 (24 women, 41 per cent) were included in the intention-to-treat analysis; there were 29 patients of mean age 68 years in the LDP group and 29 of mean age 63 years in the ODP group. The main indication was cystic pancreatic lesions, followed by neuroendocrine tumours. The median postoperative hospital stay was 5 (i.q.r. 4–5) days in the laparoscopic group versus 6 (5–7) days in the open group (P = 0·002). Functional recovery was attained after a median of 4 (i.q.r. 2–6) versus 6 (4–7) days respectively (P = 0·007), and duration of surgery was 120 min in both groups (P = 0·482). Blood loss was less with laparoscopic surgery: median 50 (i.q.r. 25–150) ml versus 100 (100–300) ml in the open group (P = 0·018). No difference was found in the complication rates (Clavien–Dindo grade III or above: 4 versus 8 patients respectively). The rate of delayed gastric emptying and clinically relevant postoperative pancreatic fistula did not differ between the groups.
Conclusion
LDP is associated with shorter hospital stay than ODP, with shorter time to functional recovery and less bleeding. Registration number: ISRCTN26912858 (www.isrctn.com).
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Affiliation(s)
- B Björnsson
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - A Lindhoff Larsson
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - C Hjalmarsson
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - T Gasslander
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - P Sandström
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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31
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Åkerberg D, Ansari D, Bergenfeldt M, Andersson R, Tingstedt B. Early postoperative fluid retention is a strong predictor for complications after pancreatoduodenectomy. HPB (Oxford) 2019; 21:1784-1789. [PMID: 31164275 DOI: 10.1016/j.hpb.2019.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/29/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perioperative fluid overload has been reported to increase complications after a variety of operative procedures. This study was conducted to investigate the incidence of fluid retention after pancreatic resection and its association with postoperative complications. METHODS Data from 1174 patients undergoing pancreatoduodenectomy between 2010 and 2016 were collected from the Swedish National Pancreatic and Periampullary Cancer Registry. Early postoperative fluid retention was defined as a weight gain ≥2 kg on postoperative day 1. Outcome measures were overall complications, as well as procedure-specific complications. RESULTS The weight change on postoperative day 1 ranged from -1 kg to +9 kg. A total of 782 patients (66.6%) were considered to have early fluid retention. Patients with fluid retention had significantly higher rates of total complications (p = 0.002), surgical complications (p = 0.001), pancreatic anastomotic leakage (p = 0.018) and wound infection (p = 0.023). Multivariable logistic regression confirmed early fluid retention as an independent risk factor for total complications (OR 1.46; p = 0.003), surgical complications (OR 1.49; p = 0.002), pancreatic anastomotic leakage (OR 1.48; p = 0.027) and wound infection (OR 1.84; p = 0.023). CONCLUSIONS Fluid retention is common after elective pancreatic resection, and its associated with an increased rate of postoperative complications.
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Affiliation(s)
- Daniel Åkerberg
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Daniel Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Magnus Bergenfeldt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Roland Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden.
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Søreide K, Nymo LS, Lassen K. Centralization of Pancreatic Surgery in Europe: an Update. J Gastrointest Surg 2019; 23:2322-2323. [PMID: 31485907 DOI: 10.1007/s11605-019-04383-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/27/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Tromsø, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Kristoffer Lassen
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway.,Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway
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